Heterotopic pregnancy after assisted reproductive techniques with favorable outcome of the intrauterine pregnancy:A case report

BACKGROUND Heterotopic pregnancy(HP)is a rare condition in which both ectopic and intrauterine pregnancies occur.HP is uncommon after natural conception but has recently received more attention due to the widespread use of assisted reproductive techniques(ART)such as ovulation promotion therapy.CASE SUMMARY Here,we describe a case of HP that occurred after ART with concurrent tubal and intrauterine singleton pregnancies.This was treated successfully with surgery to preserve the intrauterine pregnancy,resulting in the birth of a low-weight premature infant.This case report aims to increase awareness of the possibility of HP during routine first-trimester ultrasound examinations,especially in pregnancies resulting from ART and even if multiple intrauterine pregnancies are present.CONCLUSION This case alerts us to the importance of comprehensive data collection during regular consultations.It is important for us to remind ourselves of the possibility of HP in all patients presenting after ART,especially in women with an established and stable intrauterine pregnancy that complain of constant abdominal discomfort and also in women with an unusually raised human chorionic gonadotropin level compared with simplex intrauterine pregnancy.This will allow symptomatic and timeous treatment of patients with better results.

Giant cyst in heterotopic pregnancy:A case report

BACKGROUND The coexistence of a heterotopic pregnancy with a giant ovarian cyst is an incredibly rare abnormal pregnancy in cases of natural conception.The incidence of this condition has increased significantly as a result of the continuous development of assisted reproductive technologies.When this type of pregnancy occurs,both the continuation of intrauterine pregnancy and the life of the pregnant woman are severely threatened.Early diagnosis and treatment using safe and effective methods are paramount in this situation.CASE SUMMARY A 30-year-old primigravida at a gestation age determined as 8 wk 4 d by scan was admitted to the hospital with heterotopic pregnancy and a right ovarian cyst.Laparoscopic resection of the ectopic pregnancy was performed,but the intrauterine pregnancy and ovarian cyst were preserved.CONCLUSION The approach to a patient with heterotopic pregnancy and a giant ovarian cyst is individualized base on the fertility requirements.We recommend the following:(1)If the patient satisfies parity and has no fertility requirement,a laparoscopic salpingectomy should be performed and the giant ovarian cyst and intrauterine pregnancy removed;(2)If the patient has fertility requirements wishes to have more children in the future,laparoscopic salpingectomy or salpingostomy should be performed and the intrauterine pregnancy preserved.Serial ovarian cyst aspiration can be performed under ultrasound and resection can be done after delivery;and(3)Heterotopic pregnancy should be diagnosed early by active surveillance during antenatal visits using ultra sound as this is important for the avoidance of catastrophic complications.

Successfully Man aging Cornual Heterotopic Pregnancy: A Case Report and Literature Review

Cornual heterotopic pregnancy is an extremely rare,life-threatening complication during pregnancy.Here,we report a 33-year-old woman who suffered cornual heterotopic pregnancy after in vitro fertilization embryo transfer.To prevent rupture during heterotopic pregnancy,she received laparoscopic surgery to remove the ectopic gestational sac at 7^(+2) weeks of gestation.Ultimately,she delivered a healthy boy at 38^(+3) weeks of gestation.Here,we also review the clinical presentations,risk factors,treatment options and outcomes of cornual heterotopic pregnancy.

Post-salpingectomy interstitial heterotopic pregnancy after in vitro fertilization and embryo transfer:A case report

BACKGROUND Heterotopic pregnancy(HP)refers to the coexistence of ectopic pregnancy and intrauterine pregnancy.Salpingectomy is proposed as a pretreatment before in vitro fertilization and embryo transfer(IVF-ET)to reduce the risk of HP.HP after IVF-ET occurs in women who had already underwent bilateral salpingectomy,even though it is extremely rare.CASE SUMMARY A case of a 29-year-old woman with recurrent interstitial HP after IVF-ET following salpingectomy is presented.The main symptom was a sudden and worsening pelvic pain.Physical examinations revealed signs of peritoneal bleeding and irritation with stable vital signs.Transvaginal ultrasound showed a live intrauterine pregnancy and another live embryo with cardiac activity in the left cornu extending beyond the lateral edge of the uterus.Her hemoglobin concentration was 8.0 g/dL,and serum human chorionic gonadotropin value was 171116.9 mIU/mL.With the diagnosis of ruptured HP with internal bleeding,an emergency laparoscopic resection of left cornu was performed.The interstitial pregnancy was removed with caution to protect the intrauterine pregnancy.After the surgical treatment,the intrauterine pregnancy continued with no complications.A healthy baby was delivered by caesarean section at 39 wk.Outcomes of another three cases are further summarized.CONCLUSION Post-salpingectomy HP is a rare but challenging condition.Surgical treatment is preferred in the case with a viable intrauterine pregnancy.

Heterotopic Pregnancy: Challenges in Diagnosis and Management

Objectives: 1) To study the obstetric outcome in two women with heterotopic pregnancy, 2) To report the challenges faced during management of these pregnancies. Design: Case study of two heterotopic pregnancies managed by us. Setting: RL Jalappa Hospital and Research Hospital. Patients: Two women with heterotopic pregnancy. Interventions: Laparotomy and management of ectopic component. Main Outcome Measures: Pregnancy outcomes following surgery. Results: Both pregnancies continued with one live birth at 36 weeks and one preterm delivery at 29 weeks with neonatal death subsequently. Conclusion: Pregnancy outcome after surgery for heterotopic pregnancy is guarded and is at high risk for preterm birth. Salpingostomy is a good option when faced with dilemma of whether it is hematosalpinx or ectopic pregnancy instead of salpingectomy.

Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy:A case report

BACKGROUND Heterotopic cesarean scar pregnancy(HCSP)is very rare and has a high risk of massive uterine bleeding.Preservation of concurrent intrauterine pregnancy(IUP)is one of the great challenges in the management of HCSP.No universal treatment protocol has been established when IUP is desired to be preserved.CASE SUMMARY We report a case of HCSP at 8+wk gestation in a 34-year-old woman with stable hemodynamics.A two-step intervention was applied.Selective embryo aspiration was performed first,and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later.Both steps were performed under ultrasound guidance.The patient had an uneventful course,and a healthy baby was delivered at 34+6 wk gestation.CONCLUSION Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP.This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.

Ectopic Molar Pregnancy with Coexistent Normal Intrauterine Pregnancy: A Report of an Unusual Diagnosis managed in Yaoundé Gyneco-Obstetric and Pediatric Hospital, Cameroon

Background: Heterotopic pregnancy is a very rare event in a natural cycle. Its incidence is rising mostly due to induction of ovulation or Assisted Reproductive Technique. Most ectopic in heterotopic pregnancies are localized in the fallopian tubes. The occurrence of molar tubal ectopic pregnancy coexisting with intrauterine pregnancy is uncommon and consequently not often considered a diagnostic possibility. Case Report: We report the case of a 25-year-old woman, gravida 4 para 1, who complained of vaginal spotting and lower abdominal pain after 6 weeks of amenorrhea following clomiphene citrate ovarian stimulation. Transvaginal Ultrasonography revealed an intrauterine pregnancy and an unruptured left tubal ectopic pregnancy. She underwent successful laparoscopic salpingectomy while the intra-uterine pregnancy was allowed to continue. The ectopic pregnancy tissue histology reported an ectopic partial molar pregnancy. She subsequently had a normal vaginal delivery at 39 weeks and 3 days and her follow-up was uneventful. Conclusion: Heterotopic pregnancy is a rare but life-threatening condition. It should be suspected in a pregnant woman with a risk factor of multiple gestations who presents vaginal bleeding and lower abdominal pain in the context of early pregnancy. Laparoscopic surgery is effective for confirming the diagnosis and treating the ectopic component. Routine histological examination of tubal specimens must be taken very seriously because some findings like molar pregnancies may require specific management.

Misdiagnosis and Delayed Diagnosis for Ectopic and Heterotopic Pregnancies after In Vitro Fertilization and Embryo Transfer

This study examined the misdiagnosis and delayed diagnosis factors for ectopic pregnancy（EP） and heterotopic pregnancy（HP） after in vitro fertilization and embryo transfer（IVF-ET） in an attempt to reduce the diagnostic error. Clinical data of patients who underwent IVF-ET treatment and had clinical pregnancy from 12463 cycles were retrospectively analyzed. Their findings of serum β-hCG test and transvaginal ultrasonography were also obtained during follow-up. These patients were divided into two groups according to the diagnosis accuracy of EP/HP： early diagnosis and misdiagnosis/delayed diagnosis. The results showed that the incidence of EP and HP was 3.8%（125/3286） and 0.8%（27/3286） respectively for IVF/ICSI-ET cycle, and 3.8%（55/1431） and 0.7%（10/1431） respectively for frozen-thawed embryo transfer（FET） cycle. Ruptured EP occurred in 28 patients due to initial misdiagnosis or delayed diagnosis. Related factors fell in 3 categories：（1） clinician factors： misunderstanding of patients＇ medical history, insufficient training in ultrasonography and unawareness of EP and HP;（2） patient factors： noncompliance with medical orders and lack of communication with clinicians;（3） complicated conditions of EP： atypical symptoms, delayed elevation of serum β-hCG level, early rupture of cornual EP, asymptomatic in early gestation and pregnancy of unknown location. All the factors were interwoven, contributing to the occurrence of EP and HP. It was concluded that complicated conditions are more likely to affect the diagnosis accuracy of EP/HP after IVF-ET. Transvaginal ultrasonography should be performed at 5 weeks of gestation. Intensive follow-up including repeated ultrasonography and serial serum β-hCG tests should be performed in patients with a suspicious diagnosis at admission.

Expectant management of heterotopic cesarean scar pregnancy

Background Heterotopic cesarean scar pregnancy （HCSP） is a very rare but life-threatening entity and there is no optimal management strategy. Here we report a successfully managed case of HCSP with expectant treatment in a tertiary referral hospital. Methods A woman with HCSP after in vitro fertilization-embryo transfer opted for expectant treatment after five days of mild bleeding and ultrasound demonstrated cardiac activity disappearance of the scar pregnancy at 8＋4 weeks of gestation. Results The patient had mild to moderate bleeding during close monitoring. Three days later, speculum examination revealed the gestational mass was partly protruding at the os of the cervix and it was removed with forceps without massive hemorrhage. A healthy male baby was delivered by cesarean section at gestational age of 36＋4 weeks. Conclusions The expectant method might be an alternative option for a HCSP with loss of cardiac activity of the scar pregnancy, when applied under supportive management and with available emergency surgery facilities.

Efficacy of local aspiration in the conservative treatment of live interstitial pregnancy coexisting with live intrauterine pregnancy after in vitro fertilization and embryo transfer

Background Heterotopic pregnancy （HP） is defined as a pregnancy in which one or more embryos is viably implanted in the uterus while the other is implanted elsewhere as an ectopic pregnancy. The occurrence of HP rises dramatically with the increased use of assisted reproductive technology. HP of interstitial pregnancy is one special situation which needs more concern. Here we evaluate the efficacy of local aspiration and instillation of hyperosmolar glucose in the treatment of live interstitial pregnancy complicated with live intrauterine pregnancy after in vitro fertilization and embryo transfer. Methods Five female patients were diagnosed with live interstitial pregnancies complicated with intrauterine pregnancies. They were treated with transvaginal ultrasound-guided aspiration of interstitial pregnancy and instillation of hyperosmolar glucose at the Center for Reproductive Medicine of Peking University Third Hospital from January 1st, 2008 to May 30th, 2011. Results Gemmule embryos in all 5 cases were aspirated successfully and there was no abdominal hemorrhage, threatened abortion or infection in any of the cases. The sac of interstitial pregnancy continued to progress after aspiration and stopped growing between 11 to 20 weeks. By the 30th week of pregnancy, 80% of the interstitial masses had disappeared. Four cases have delivered and one is still in on-going pregnancy. All of the four cases underwent cesarean section and there were nothing special detected in the corner of the uterus. Conclusion Local aspiration and instillation of hyperosmolar glucose may be an effective way to treat live interstitial pregnancy when coexisting with a live intrauterine pregnancy.

Clinical Analysis on Laparoscopic Salpingectomy for Ectopic Pregnancy Following IVF/ICSI-ET

Objective To investigate whether laparoscopic surgery is valuable during early pregnancy and its influence on delivery outcome of the patients.Methods A retrospective analysis was undertaken of 14 heterotopic pregnancies conceived by IVF/ICSI-ET and underwent laparoscopic salpingectomy from December 2001 to September 2009.Results The mean age of 14 patients was 29 ± 5.3 years with range of 21-39 years.The ectopic pregnancy was located in the ampulla（11 patients,78.57%） and isthmus（3 patients,21.43%）.All 14 patients underwent successful laparoscopic salpingectomy without complications.Eleven（78.57%） patients delivered live singleton infants at full term via caesarean section while 3（21.43%） had spontaneous abortion.The birth weight of viable newborns ranged from 2 600 g to 3 720 g and had a high Apgar score.Conclusion During early pregnancy,the heterotopic pregnancy should be diagnosed and treated early and laparoscopic salpingectomy can be a safe and effective choice.The well experienced surgeons and accessibility of the modern equipments are mandatory.