Afzal Safdar Bukhari, Shazia Bukhari.
Heterotopic Pregnancy- A Report of 2 Cases in Women Without Risk Factors.
J Ayub Med Coll Abottabad Jan ;13(2):45-8.

Two cases of heterotopic pregnancy are reported. The cases emphasize that co incident pregnancies may occur in women who are without risk of ectopic pregnancy or multiple gestation. The cases describe the complexities of diagnosis and management.

PATIENT 1: A 25-year old woman, G3P1A1 was admitted to the emergency unit of NHM with a history of vomiting, lower abdominal pain and mild vaginal bleeding. Emergency department assessment revealed that she had a vacuum aspiration done, 3 weeks before for a missed abortion diagnosed on ultrasonography (USG). Both the USG and histopathology report of the aspirated tissue confirmed the diagnosis of a missed abortion 3 weeks ago. On further history taking, it was found that she had her cycles occurring regularly. She was not taking any contraception. Her sexual history was uncomplicated by sexually transmitted diseases (STDs) or any type of pelvic infection. She had never been on fertility enhancing drugs. She had an alive baby girl from the first pregnancy. She, now, had a continuing feeling of pregnancy and gave history of breast tenderness. Rest everything was unremarkable. Her physical examination revealed a pulse rate of above 90 beats per minute. She was pale. No other abnormality was detected on general physical examination (GPE). Her abdominal examination showed generalized lower abdominal tenderness. Pelvic examination revealed a pinkish vaginal discharge, a bulky uterus with bilateral adnexal tenderness and an adnexal mass on the left side of approximately 5x6 cm size. There was fullness in Pouch of Douglas Beta human chorionic gonadotrophin (B-HCG) levels were found to be 600 mlU/ml Sonogram showed a mass in the left adnexa of 6x7 cm with empty uterus. Fluid was seen in the Pouch of Douglas (POD). A laparotomy confirmed a left tubal ectopic which was ruptured at the ampullary end. There were multiple left tubal adhesions. Left salpingectomy with adhesiolysis was done followed by peritoneal lavage. The histopathological examination of tissue confirmed the presence of chorionic villi. The patient`s post-operative period was uneventful and she was discharged on the 5th postoperative day.

PATIENT 2: 29-year old lady, G5P3A1, was admitted to the emergency ward via antenatal clinic. She had a history of 22 days of amenorrhoea. She had pain lower abdomen and vaginal bleeding off and on. She had been married for the last 10 years and was mother of 3 alive and healthy children. Her cycle had always been regular and the couple never used any contraception except condoms occasionally. Though she belonged to the low socioeconomic class, she took care of her hygiene. There was nothing in the history suggestive of STD or pelvic inflammatory disease (PID). She had never used fertility enhancing drugs. There was nothing remarkable in systematic inquiry. On examination, her GPE and systemic examination were unremarkable. Pelvic examination revealed bleeding per vaginum, a bulky uterus with cervical os, which was 2 finger open. After 4 hours of fasting, evacuation was done for inevitable (incomplete) abortion. The histopathology confirmed the removed tissue to be products of conception (POCs). Post operatively, the patient kept on complaining of lower abdominal pain. B-HCG, a couple of days later was found to be 600mlU/ml. A transvaginal scan was done to rule out incomplete removal of POCs. It showed the uterus to be empty but a complex mass of mixed echogenicity was observed in the right adnexa measuring 4x4 cm. Pelvic examination had failed to reveal it because the examination had to be abandoned because of marked tenderness in the fornices. Ectopic was suspected and consents for laparotomy and tubal ligation were taken. Per operatively, there was right tubal incomplete abortion with old blood in the peritoneal cavity. There were 2 corpora lutea with a slightly bulky uterus and left tubal congestion. Right salpingectomy with left tubal ligation was done. Histopathology report confirmed the presence of placental villi. Post-operative period was uneventful.

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