Spontaneous Heterotopic Pregnancy with a Favorable Perinatal Outcome, Case Report, and Literature Review
Abstract
Heterotopic pregnancy (HP) involves multiple gestations in which one embryo is implanted within the uterine cavity and another elsewhere, such as an ectopic pregnancy (EP). A spontaneous pregnancy has an incidence of one in 30.000 pregnancies, and with assisted reproduction techniques (ART) up to one in a hundred. Its early diagnosis allows to reduce morbidity and mortality and improve the prognosis for intrauterine pregnancy. The article aims to perform a review of the literature on HP and present a clinical case. A search was conducted on Pubmed and Medline databases, using combinations with Boolean operators of the terms MESH: heterotopic pregnancy, ectopic pregnancy, therapy, risk factors and prognosis. The search limits were: full-text articles, Spanish and English languages, published in the last ten years. 275 titles were obtained; after eliminating duplicates and abstract evaluation, 27 references were used. We present a case of a pregnant patient 2, records of broken EP, with spontaneous hp and rupture of tubal gestation; their management and the perinatal results are described. The HP may have tubal implantation (more frequent) or in any other location. The diagnosis should focus on risk factors and ultrasound criteria; the management can be expectant, medical, or surgical, having with the first the worst maternal prognosis, with the second lower rates of gestational loss and better maternal outcomes, and with the latter higher abortion rates. The diagnosis of HP is performed by transvaginal ultrasound; according to each case, the treatment is oriented. The surgical approach is the first line in the acute presentation. Expectant management or ultrasound-guided aspiration are reasonable options in the stable patient. More cohorts of patients are needed to evaluate management outcomes in our environment.
Downloads
References
Talbot K, Simpson R, Price N, Jackson SR. Heterotopic pregnancy. J Obstet Gynaecol. 2011 en;31(1):7-12. DOI: https://doi.org/10.3109/01443615.2010.522749
Wu Z, Zhang X, Xu P, Huang X. Clinical analysis of 50 patients with heterotopic pregnancy after ovulation induction or embryo transfer. Eur J Med Res. 2018 dic;23(1):17. DOI: https://doi.org/10.1186/s40001-018-0316-y
Li J-B, Kong L-Z, Yang J-B, Niu G, Fan L, Huang J-Z, et al. Management of Heterotopic Pregnancy: Experience From 1 Tertiary Medical Center. Medicine (Balti- more). 2016 feb;95(5):e2570. DOI: https://doi.org/10.1097/MD.0000000000002570
Liu M, Zhang X, Geng L, Xia M, Zhai J, Zhang W, et al. Risk Factors and Early Predictors for Heterotopic Pregnancy after In Vitro Fertilization. Sun Q-Y, editor. plos one. 2015 oct;10(10):e0139146. DOI: https://doi.org/10.1371/journal.pone.0139146
Lu D, Tang JJ, Zakashansky K, Berkowitz RS, Kalir T, Liu Y. Heterotopic Pregnancy Including Intrauterine Normal Gestation and Tubal Complete Hydatidiform Mole: A Case Report and Review of the Literature. Int J Gynecol Pathol. 2017 sep;36(5):428-32. DOI: https://doi.org/10.1097/PGP.0000000000000347
Xiao S, Mo M, Hu X, Zhang H, Xu S, Wang Z, et al. Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles and frozen-thawed cycles. J Assist Reprod Genet. 2018 apr;35(4):677-81. DOI: https://doi.org/10.1007/s10815-017-1109-x
Pratilas GC, Chatzis P, Panteleris N, Chatzistamatiou K, Zeipiridis L, Dinas K. Concealed heterotopic pregnancy at 12 weeks, with no coexisting risk factors: Lessons to be learned: Concealed heterotopic pregnancy at 12/40. J Obstet Gynaecol Res. 2017 en;43(1):228-31. DOI: https://doi.org/10.1111/jog.13157
Yu Y, Xu W, Xie Z, Huang Q, Li S. Management and outcome of 25 heterotopic pregnancies in Zhejiang, China. Eur J Obstet Gynecol Reprod Biol. 2014 sep;180:157-61. DOI: https://doi.org/10.1016/j.ejogrb.2014.04.046
O'Donnell R, Siacunco E, Quesada D, Barkataki K, Aguìñiga-Navarrete P. Early Diagnosis of Heterotopic Pregnancy in a Primigravid Without Risk Factors in the Emergency Department. Clin Pract Cases Emerg Med. 2019 feb;3(2):162-3. DOI: https://doi.org/10.5811/cpcem.2019.1.41312
Panelli DM, Phillips CH, Brady PC. Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. Fertil Res Pract. 2015 dic;1(1):15. DOI: https://doi.org/10.1186/s40738-015-0008-z
Perkins KM, Boulet SL, Kissin DM, Jamieson DJ. Risk of Ectopic Pregnancy Associated With Assisted Reproductive Technology in the United States, 2001- 2011: Obstet Gynecol. 2015 en;125(1):70-8. DOI: https://doi.org/10.1097/AOG.0000000000000584
Noor N, Parveen S, Bano I. Heterotopic pregnancy with successful pregnancy outcome. J Hum Reprod Sci. 2012;5(2):213. DOI: https://doi.org/10.4103/0974-1208.101024
Ciebiera M, Słabuszewska-Jóźwiak A, Zaręba K, Jakiel G. Heterotopic pregnancy how easily you can go wrong in diagnosing? A case study. Journal of ultrasoNography. 2018;18(75):355-358. DOI: https://doi.org/10.15557/JoU.2018.0052
Tingi E, Rowland J, Hanna L. A case of heterotopic pregnancy following spontaneous conception. J Obstet Gynaecol. 2015 may;35(4):430-1. DOI: https://doi.org/10.3109/01443615.2014.958445
Li XH, Ouyang Y, Lu GX. Value of transvaginal sonography in diagnosing heterotopic pregnancy after in-vitro fertilization with embryo transfer: tvs for diagnosis of heterotopic pregnancy. Ultrasound Obstet Gynecol. 2013 may;41(5):563-9. DOI: https://doi.org/10.1002/uog.12341
Altıntaş E, Yuksel B, Tok S, Hatipoglu H, Aslan F. Heterotopic pregnancy identified in the postpartum period. Int J Gynecol Obstet. 2015 sept;130(3):287-8. DOI: https://doi.org/10.1016/j.ijgo.2015.02.025
Sarmiento A, Silva LE, Jordán A, Carrillo M. Embarazo heterotópico: Presentación de un caso. Rev Colomb Obstet Ginecol. 1996 sept;47(3):203-5. DOI: https://doi.org/10.18597/rcog.1451
Mihmanli V, Kilickaya A, Cetinkaya N, Karahisar G, Uctas H. Spontaneous Heterotopic Pregnancy Presenting with Hemoperitoneum. J Emerg Med. 2016 en;50(1):44-6. DOI: https://doi.org/10.1016/j.jemermed.2015.02.050
Chukus A, Tirada N, Restrepo R, Reddy NI. Un- common Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass. Radio- Graphics. 2015 may;35(3):946-59. DOI: https://doi.org/10.1148/rg.2015140202
Holley I, Stickles S. Heterotopic Pregnancy Diagnosed with Point-of-care Ultrasound in the Emergency Department: A Case Report. Clin Pract Cases Emerg Med. 2020 abr;4(2):178-80. DOI: https://doi.org/10.5811/cpcem.2020.2.45933
Brown J, Wittich A. Spontaneous Heterotopic Pregnancy Successfully Treated via Laproscopic Surgery With Subsequent Viable Intrauterine Pregnancy: A Case Report. Mil Med. 2012 oct;177(10):1227-30. DOI: https://doi.org/10.7205/MILMED-D-11-00457
Subedi J, Xue M, Sun X, Xu D, Deng X, Yu K, et al. Hysteroscopic Management of a Heterotopic Pregnancy Following Uterine Artery Embolization: A Case Re- port. J Med Case Reports. 2016 dic;10(1):324. DOI: https://doi.org/10.1186/s13256-016-1109-y
Li J, Luo X, Yang J, Chen S. Treatment of Tubal Heterotopic Pregnancy with Viable Intrauterine Pregnancy: Analysis Of 81 Cases From one Tertiary Care Center. Eur J Obstet Gynecol Reprod Biol. 2020 sep;252:56-61. DOI: https://doi.org/10.1016/j.ejogrb.2020.06.005
Liu F, Liu YF, Liu J, Huang Y, Xu GF, Cai J, et al. Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies. Int J Obstet Anesth. 2018 may;34:73-8. DOI: https://doi.org/10.1016/j.ijoa.2017.12.001
Guan Y, Ma C. Clinical Outcomes of Patients with Heterotopic Pregnancy After Surgical Treatment. J Minim Invasive Gynecol. 2017 nov;24(7):1111-5. DOI: https://doi.org/10.1016/j.jmig.2017.03.003
Mendivil C, Silva G. Embarazo heterotópico: diagnóstico ecográfico temprano, manejo con laparoscopia. Reporte de un caso y revisión de la literatura. Rev Colomb Obstet Ginecol. en 2011;62(1):98-103. DOI: https://doi.org/10.18597/rcog.248
Castaño L. Embarazo combinado o heterotópico. Rev Colomb Obstet Ginecol. 1994;45(3):257-8. DOI: https://doi.org/10.18597/rcog.813