International Journal of Women’s Health Care A Ruptured Spontaneous Heterotopic Tubal Pregnancy With a Viable Intrauterine Pregnancy Case Report Volume 2 | Issue 2 | 1 of 3 Int J Women’s Health Care, 2017 Ashley Wiltshire 1* , Diane Goh 1 , Chukwuma I. Onyeije 1 and Veena N. Rao 1 2 * Corresponding author Ashley Wiltshire, Department of Obstetrics and Gynecology, Morehouse School of Medicine, 720 Westview Drive Atlanta, GA 30310 USA. Submitted: 20 July 2017; Accepted: 27 July 2017; Published: 05 Aug 2017 1 Department of Obstetrics and Gynecology. 2 Cancer Biology program, Morehouse School of Medicine, Georgia Cancer Center for Excellence, Atlanta, Ga. USA. Introduction An ectopic pregnancy is a pregnancy located outside of the intrauterine cavity.They comprise 1-2% of all frst trimester pregnancies and 6% of pregnancy related deaths in the United States [1]. Ectopic pregnancies most commonly occur in the fallopian tube but can also implant in other locations, including the ovaries, peritoneal cavity, cesarean section scars and the cervix [2]. Heterotopic pregnancy A heterotopic pregnancy is when an intrauterine pregnancy and an extra uterine pregnancy occur simultaneously. Ninety percent involve simultaneous intrauterine and tubal gestations [2]. Spontaneous or naturally occurring heterotopic pregnancies are rare and are estimated to occur in 1:30,000 pregnancies [3]. For pregnancies conceived following ovulation induction, heterotopy is much more common at 0.5-1% [1]. The incidence of heterotopy for all pregnancies, naturally conceived and those utilizing artifcial reproductive technology combined is approximately 1:7,000 [3]. Besides ART and ovulation induction, another common risk factor for ectopic pregnancies includes tubal disease. Tubal disease can be secondary to a history of sexually transmitted infections, such as chlamydia and gonorrhea, which are notoriously associated with pelvic infammatory disease. There are also congenital anomalies, such as those related to DES exposure in utero, that are associated with malformed tubes [2]. Other abdominopelvic infammatory conditions, such as endometriosis, appendicitis, peritonitis, and Crohns disease, can also lead to anatomical distortion of the fallopian tubes via progression of infammation and adhesion formation. Lastly, prior surgical manipulation of the fallopian tubes through tubal sterilization, tubal sterilization reversal, and salpingostomy orsalpingoplasty for ectopic treatment can also increase the risk of ectopic pregnancy [1]. Due to its extreme rarity, heterotopic pregnancies are often very diffcult to diagnose, especially when the patient lacks or denies risk factors. If the patient is hemodynamically stable, once an intrauterine pregnancy (IUP) is visualized the working diagnosis of a heterotopic pregnancy is commonly and quickly dismissed. This is consistent with many published suggested algorithms for the work up of a suspected ectopic pregnancy [1]. Unfortunately, symptoms of an un-ruptured heterotopic gestation can be masked by other seemingly more likely diagnoses such as round ligament pain, threatened/missed abortion, and cervicitis. Often times, it is not until there is tubal rupture when hemodynamic instability presents, adding concrete direction in the assessment and diagnosis of an early heterotopic pregnancy. Approximately 70% of heterotopic pregnancies are diagnosed between 5-8 weeks, 20% between 9-10 weeks, and 10% after 11 weeks gestation [4]. Case The clinical case is of a ruptured spontaneous heterotopic tubal pregnancy of a 30 year old G5P4004. The patient initially presented to the emergency department (ED) with severe and diffuse post-coital lower abdominal pain for 3-4 hours.She also endorsed shortness of breath, lightheadedness and persistent nausea and vomiting during the 4 days leading up to presentation. She was unsure of the date of her last menstrual period, but noted that she may have skipped 1-2 cycles. During the initial assessment, the patient was noted to be intermittently hypotensive (108-97/61-50), tachycardic (120s-130s bpm), diaphoretic, with worsening pallor and fuctuating mental status. AFocused Assessment with Sonography for Trauma scan revealedhemoperitoneum and an IUP with fetal cardiac activity [5].Leukocytosis was noted at 20.7 K/mcL. Initial hemoglobin and hematocrit was 10.9 g/dL and 32.6%, respectively The differential diagnosis at this time included ruptured tubal heterotopic pregnancy vs. an acute abdomen due to gastroentrologic or vascular etiologies. All possible diagnoses were deemed highly unlikely by respective medical teams.A bedside trans-vaginal ultrasound and repeat abdominal US revealed an intrauterine gestational sac with a fetal pole measuring approximately 6 weeks, a yolk sac, fetal cardiac activity, free fuid in the pelvic cavity and free fuid in all abdominal quadrants up to the liver edge. Due to the patients worsening hemodynamic stability, CT imaging was bypassed and the patient was taken straight to the operating room for exploratory laparotomy. The patient received 2 units of packed red blood cells (PRBCs) preoperatively. Surgical fndings included 1,000 cc of hemoperitoneum, a ruptured left fallopian tube, a gravid uterus measuring approximately 6-8 week size, normal appearing right fallopian tube, and normal appearing bilateral ovaries and no evidence of adhesive disease. Total left salpingectomy was performed (Fig 1-2). Pathology analysis confrmed products of conception within the surgical specimen (Fig. 3-4).