CASE REPORT
Spontaneous heterotopic triplet pregnancy
Haitham Torky 1, 2  
,   Amr Abo El-Elaa 2, 3
 
More details
Hide details
1
Department of Obstetrics and Gynecology, Faculty of Medicine, October 6 University, Cairo, Egypt
2
Department of Obstetrics and Gynecology, As-Salam International Hospital, Cairo, Egypt
3
Department of General Surgery, Al-Sahel Teaching Hospital, Cairo, Egypt
CORRESPONDING AUTHOR
Haitham Torky   

6th October, Cairo, Egypt. Tel.: +20 1001230161; fax: +20 225240066.
Submission date: 2016-03-22
Acceptance date: 2016-06-21
Online publication date: 2016-08-25
Publication date: 2020-03-22
 
Pol. Ann. Med. 2017;24(2):221–223
 
KEYWORDS
ABSTRACT
Introduction:
Heterotopic pregnancy is a rare condition characterized by the occurrence of two or more simultaneous pregnancies in two or more implantation sites.

Aim:
To report a case of spontaneous ectopic pregnancy co-existing with twin living intrauterine pregnancies of 10 weeks gestation.

Case study:
A 29-years-old woman 10-weeks pregnant presented to the emergency department with acute abdomen. Transvaginal ultrasound revealed di-amniotic intrauterine living twins and right adnexal mass inseparable from the ovary. Laparoscopy revealed intact right tubal pregnancy managed by salpingostomy.

Results and discussion:
Diagnosis of heterotopic ectopic is difficult as we cannot depend on bsubunit of human chorionic gonadotropin level because of the presence of a co-existent intrauterine pregnancy which affects the hormonal level and the false sense of security that may be present on visualizing an intrauterine pregnancy by ultrasonography (USG), therefore, it is important to visualize the adnexa even in the presence of an intrauterine pregnancy to avoid missing a possible co-existent ectopic pregnancy. Surgery is the gold standard treatment. Other treatment modalities as laparoscopic or transvaginal USG guided injection of hyperosmolar glucose or potassium chloride have less success rates.

Conclusions:
It is important to scan the adnexa even in the presence of an intrauterine pregnancy to avoid missing a possible co-existent ectopic pregnancy. Surgery is the gold standard treatment, however, other modalities were described with less success.

ACKNOWLEDGEMENTS
Authors declare that they neither have a conflict of interest nor received any financial support.
CONFLICT OF INTEREST
None declared.
 
REFERENCES (16)
1.
Talbot K, Simpson R, Price N, Jackson SR. Heterotopic pregnancy. J Obstet Gynaecol. 2011;31(1):7–12.
 
2.
Varras M, Akrivis C, Hadjopoulos G, Antoniou N. Heterotopic pregnancy in a natural conception cycle presenting with tubal rupture: a case report and review of the literature. Eur J Obstet Gynaecol Reprod Biol. 2003;106(1):79–82.
 
3.
Bello GV, Schonolz D, Moshirpur J, Jeng DY, Berkowitz RL. Combined pregnancy: the Mount Sinai experience. Obstet Gynecol Surv. 1986;41(10):603–613.
 
4.
Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update. 2014;20(2):250–261.
 
5.
Simsek T, Dogan A, Simsek M, Pestereli E. Heterotopic triplet pregnancy (twin tubal) in a natural cycle with tubal rupture: case report and review of literature. J Obstet Gynaecol Res. 2008;34(4 Pt 2):759–762.
 
6.
Inion I, Gerris J, Joostens M, De Vree B, Kockx M, Verdonk P. An unsuspected triplet heterotopic pregnancy after replacement of two embryos. Hum Reprod. 1998;13(7):1999–2001.
 
7.
Strandell A, Thornburn J, Hamberger L. Risk factors for ectopic pregnancy in assisted reproduction. Fertil Steril. 1999;71(2):282–286.
 
8.
Marcus SF, Macnamee M, Brindsen P. Heterotopic pregnancies after in-vitro fertilisation and embryo transfer. Hum Reprod. 1995;10(5):1232–1236.
 
9.
Ludwig M, Kaisi M, Bauer O, Diedrich K. Heterotopic pregnancy in a spontaneous cycle: do not forget about it!. Eur J Obstet Gynecol Reprod Biol. 1999;87(1):91–103.
 
10.
Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: a literature review from 1971 to 1993. Fertil Steril. 1996;66(1):1–12.
 
11.
Jerrard D, Tso E, Salik R, Barish RA. Unsuspected heterotopic pregnancy in a woman without risk factors. Am J Emerg Med. 1992;10(1):58–60.
 
12.
Bugatto F, Quintero-Prado R, Kirk-Grohar J, Melero-Jiménez V, Hervías-Vivancos B, Bartha JL. Heterotopic triplets: tubal ectopic and twin intrauterine pregnancy. A review of obstetric outcomes with a case report. Arch Gynecol Obstet. 2010;282(6):601–606.
 
13.
Li XH, Ouyang Y, Lu GX. Value of transvaginal sonography in diagnosing heterotopic pregnancy after in-vitro fertilisation with embryo transfer. Ultrasound Obstet Gynecol. 2013;41(5):563–569.
 
14.
Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Transvaginal sonography and human chorionic gonadotrophin measurements in suspected ectopic pregnancy: a detailed analysis of a diagnostic approach. Hum Reprod. 1993;8(8):1307–1311.
 
15.
Umranikar S, Umranikar A, Rafi J, et al. Acute presentation of a heterotopic pregnancy following spontaneous conception: a case report. Cases J. 2009;2:9369.
 
16.
Goldstein JS, Ratts VS, Philpott T, Dahan MH. Risk of surgery after use of potassium chloride for treatment of tubal heterotopic pregnancy. Obstet Gynecol. 2006;107(2 Pt 2):506–508.