IJG-08291; No of Pages 2 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Heterotopic pregnancy identified in the postpartum period Ertunc Altıntaş a, Beril Yuksel b,⁎, Sermin Tok c, Himmet Hatipoglu b, Figen Aslan d a
Department of General Surgery, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey Department of Obstetrics and Gynecology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey c Department of Radiology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey d Department of Pathology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey b
a r t i c l e
i n f o
Article history: Received 8 January 2015 Received in revised form 2 February 2015 Accepted 2 April 2015 Keywords: Acute abdominal pain Ectopic pregnancy Heterotopic pregnancy Postpartum period
Women with a heterotopic pregnancy have an ectopic pregnancy and an intrauterine pregnancy simultaneously. One in 30 000 pregnancies conceived spontaneously are heterotopic [1,2]. Heterotopic pregnancies are usually located in the uterine tubes and are diagnosed between 5 and 8 weeks of pregnancy [3]. Only 10% of heterotopic pregnancies are diagnosed after 11 weeks [3]. The aim of the present report is to describe a case of heterotopic pregnancy diagnosed after a cesarean delivery at term. Informed consent was obtained from the patient for publication of the present report. In March 2014, a woman aged 36 years presented to the Evliya Celebi Research and Education Hospital, Kutahya, Turkey, with acute abdominal pain. She had had a cesarean delivery 3 days previously and had been discharged from hospital the day before presentation. She had had one previous ectopic pregnancy. The patient reported nausea and blunt abdominal pain on the right side since her discharge. Fever, diarrhea, and dysuria were not reported. She had a body temperature of 37 °C, a blood pressure of 110/70 mm Hg, a pulse of 80 beats per minute, and a respiratory rate of 18 breaths per minute. Her lungs were clear. Rebound tenderness and distention of the abdomen were reported, along with decreased bowel sounds, suggesting paralytic ileus. The initial laboratory tests revealed an elevated white blood cell
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, 43600, Kutahya, Turkey. Tel.: +90 530 885 26 52. E-mail address: [email protected] (B. Yuksel).
count (15 000) and an increased concentration of C-reactive protein (190.1 nmol/L), although these values are not unusual after a cesarean. Other laboratory tests, including urine analysis, were normal. Computed tomography showed a hypodense mass with clear boundaries adjacent to the cecum (Fig. 1). The mass was deemed to be an abscess or a gossypiboma. In view of the imaging findings and physical examinations, a diagnostic laparotomy was performed. During this procedure, the cystic mass was located in the right paracolic region, originating from the right lobe of the liver and extending to the right pelvic area. Adhesions with the liver, peritoneum, and right colon were noted. The mass was dissected and excised. The surgery was completed without any early complication. The patient was discharged after 72 hours in the intensive care unit. Pathologic analysis identified hyalinized chorion villi and necrotic decidua (Fig. 2), which were interpreted as a remnant of an ectopic pregnancy. The patient’s β-human chorionic gonadotropic (β-hCG) levels returned to normal within 6 weeks. Because of the rarity of heterotopic pregnancy, early diagnosis can be challenging. The symptoms of an intrauterine pregnancy override the symptoms of ectopic pregnancy, and serial samples of serum β-HCG are not helpful. In the absence of overt blood loss or a shock, the only symptom is abdominal or adnexal pain, which is not unusual in a normal intrauterine pregnancy. Once an intrauterine pregnancy is diagnosed, clinicians usually tend to discount the possibility of a heterotopic pregnancy. In the present case, the patient was diagnosed after a cesarean delivery. During pregnancy, she had had a blunt pain in her right upper quadrant several times, which was attributed to usual pregnancy complaints. The only notable risk factor was the previous ectopic pregnancy. The cystic mass was not noticed during cesarean probably because of its uncommon location. The standard treatment for heterotopic pregnancy is either laparoscopy or laparotomy. A local injection of potassium chloride can be administered if the salpinx is intact and the patient wishes to preserve her future fertility [4]. Methotrexate cannot be used because of the intrauterine pregnancy. In the present case, the extrauterine pregnancy was under the liver, which could have been diagnosed and treated during pregnancy or cesarean delivery. A previous review [5] showed that the intrauterine pregnancy ended with a live delivery in 66% of 139 women with a heterotopic pregnancy. In the case reported here, the patient delivered a live, healthy neonate after an uncomplicated intrauterine pregnancy. Fortunately, the patient
http://dx.doi.org/10.1016/j.ijgo.2015.02.025 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Altıntaş E, et al, Heterotopic pregnancy identified in the postpartum period, Int J Gynecol Obstet (2015), http:// dx.doi.org/10.1016/j.ijgo.2015.02.025
2
E. Altıntaş et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Fig. 1. Computed tomography images. (a) Hypodense mass (65 × 65 × 40 mm) with clear boundaries adjacent to cecum (white arrows). (b) Hypodense mass (white arrow) and postpartum uterus (red arrow).
Fig. 2. Macroscopic view of cyst wall (a), and light microscopy (b) showing chorionic villi and decidual changes (×200).
had not experienced serious complications until after delivery. However, heterotopic pregnancy has a high rate of mortality; even with substantial advances in therapy, the mortality is 0.50 maternal deaths per 100 000 live births [6]. In conclusion, all patients with acute abdominal pain in the postpartum period should undergo careful examinations of the pelvic region and the abdomen. Chorioamnionitis, dehiscence of cesarean scar, urolithiasis, or pyelonephritis should be suspected, but the possibility of heterotopic pregnancy should not be discounted.
Conflict of interest The authors have no conflicts of interest.
References [1] Reece EA, Petrie RH, Sirmans MF, Finster M, Todd WD. Combined intrauterine and extrauterine gestations: a review. Am J Obstet Gynecol 1983;146(3):323–30. [2] 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):91–3. [3] 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 Gynecol Reprod Biol 2003;106(1):79–82. [4] Guirgis RR. Simultaneous intrauterine and ectopic pregnancies following in-vitro fertilization and gamete intra-fallopian transfer. A review of nine cases. Hum Reprod 1990;5(4):484–6. [5] 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. [6] Creanga AA, Shapiro-Mendoza CK, Bish CL, Zane S, Berg CJ, Callaghan WM. Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstet Gynecol 2011; 117(4):837–43.
Please cite this article as: Altıntaş E, et al, Heterotopic pregnancy identified in the postpartum period, Int J Gynecol Obstet (2015), http:// dx.doi.org/10.1016/j.ijgo.2015.02.025
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Heterotopic pregnancy identified in the postpartum period Ertunc Altıntaş a, Beril Yuksel b,⁎, Sermin Tok c, Himmet Hatipoglu b, Figen Aslan d a
Department of General Surgery, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey Department of Obstetrics and Gynecology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey c Department of Radiology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey d Department of Pathology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, Kutahya, Turkey b
a r t i c l e
i n f o
Article history: Received 8 January 2015 Received in revised form 2 February 2015 Accepted 2 April 2015 Keywords: Acute abdominal pain Ectopic pregnancy Heterotopic pregnancy Postpartum period
Women with a heterotopic pregnancy have an ectopic pregnancy and an intrauterine pregnancy simultaneously. One in 30 000 pregnancies conceived spontaneously are heterotopic [1,2]. Heterotopic pregnancies are usually located in the uterine tubes and are diagnosed between 5 and 8 weeks of pregnancy [3]. Only 10% of heterotopic pregnancies are diagnosed after 11 weeks [3]. The aim of the present report is to describe a case of heterotopic pregnancy diagnosed after a cesarean delivery at term. Informed consent was obtained from the patient for publication of the present report. In March 2014, a woman aged 36 years presented to the Evliya Celebi Research and Education Hospital, Kutahya, Turkey, with acute abdominal pain. She had had a cesarean delivery 3 days previously and had been discharged from hospital the day before presentation. She had had one previous ectopic pregnancy. The patient reported nausea and blunt abdominal pain on the right side since her discharge. Fever, diarrhea, and dysuria were not reported. She had a body temperature of 37 °C, a blood pressure of 110/70 mm Hg, a pulse of 80 beats per minute, and a respiratory rate of 18 breaths per minute. Her lungs were clear. Rebound tenderness and distention of the abdomen were reported, along with decreased bowel sounds, suggesting paralytic ileus. The initial laboratory tests revealed an elevated white blood cell
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Dumlupinar University Faculty of Medicine, Evliya Celebi Research and Education Hospital, 43600, Kutahya, Turkey. Tel.: +90 530 885 26 52. E-mail address: [email protected] (B. Yuksel).
count (15 000) and an increased concentration of C-reactive protein (190.1 nmol/L), although these values are not unusual after a cesarean. Other laboratory tests, including urine analysis, were normal. Computed tomography showed a hypodense mass with clear boundaries adjacent to the cecum (Fig. 1). The mass was deemed to be an abscess or a gossypiboma. In view of the imaging findings and physical examinations, a diagnostic laparotomy was performed. During this procedure, the cystic mass was located in the right paracolic region, originating from the right lobe of the liver and extending to the right pelvic area. Adhesions with the liver, peritoneum, and right colon were noted. The mass was dissected and excised. The surgery was completed without any early complication. The patient was discharged after 72 hours in the intensive care unit. Pathologic analysis identified hyalinized chorion villi and necrotic decidua (Fig. 2), which were interpreted as a remnant of an ectopic pregnancy. The patient’s β-human chorionic gonadotropic (β-hCG) levels returned to normal within 6 weeks. Because of the rarity of heterotopic pregnancy, early diagnosis can be challenging. The symptoms of an intrauterine pregnancy override the symptoms of ectopic pregnancy, and serial samples of serum β-HCG are not helpful. In the absence of overt blood loss or a shock, the only symptom is abdominal or adnexal pain, which is not unusual in a normal intrauterine pregnancy. Once an intrauterine pregnancy is diagnosed, clinicians usually tend to discount the possibility of a heterotopic pregnancy. In the present case, the patient was diagnosed after a cesarean delivery. During pregnancy, she had had a blunt pain in her right upper quadrant several times, which was attributed to usual pregnancy complaints. The only notable risk factor was the previous ectopic pregnancy. The cystic mass was not noticed during cesarean probably because of its uncommon location. The standard treatment for heterotopic pregnancy is either laparoscopy or laparotomy. A local injection of potassium chloride can be administered if the salpinx is intact and the patient wishes to preserve her future fertility [4]. Methotrexate cannot be used because of the intrauterine pregnancy. In the present case, the extrauterine pregnancy was under the liver, which could have been diagnosed and treated during pregnancy or cesarean delivery. A previous review [5] showed that the intrauterine pregnancy ended with a live delivery in 66% of 139 women with a heterotopic pregnancy. In the case reported here, the patient delivered a live, healthy neonate after an uncomplicated intrauterine pregnancy. Fortunately, the patient
http://dx.doi.org/10.1016/j.ijgo.2015.02.025 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Altıntaş E, et al, Heterotopic pregnancy identified in the postpartum period, Int J Gynecol Obstet (2015), http:// dx.doi.org/10.1016/j.ijgo.2015.02.025
2
E. Altıntaş et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Fig. 1. Computed tomography images. (a) Hypodense mass (65 × 65 × 40 mm) with clear boundaries adjacent to cecum (white arrows). (b) Hypodense mass (white arrow) and postpartum uterus (red arrow).
Fig. 2. Macroscopic view of cyst wall (a), and light microscopy (b) showing chorionic villi and decidual changes (×200).
had not experienced serious complications until after delivery. However, heterotopic pregnancy has a high rate of mortality; even with substantial advances in therapy, the mortality is 0.50 maternal deaths per 100 000 live births [6]. In conclusion, all patients with acute abdominal pain in the postpartum period should undergo careful examinations of the pelvic region and the abdomen. Chorioamnionitis, dehiscence of cesarean scar, urolithiasis, or pyelonephritis should be suspected, but the possibility of heterotopic pregnancy should not be discounted.
Conflict of interest The authors have no conflicts of interest.
References [1] Reece EA, Petrie RH, Sirmans MF, Finster M, Todd WD. Combined intrauterine and extrauterine gestations: a review. Am J Obstet Gynecol 1983;146(3):323–30. [2] 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):91–3. [3] 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 Gynecol Reprod Biol 2003;106(1):79–82. [4] Guirgis RR. Simultaneous intrauterine and ectopic pregnancies following in-vitro fertilization and gamete intra-fallopian transfer. A review of nine cases. Hum Reprod 1990;5(4):484–6. [5] 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. [6] Creanga AA, Shapiro-Mendoza CK, Bish CL, Zane S, Berg CJ, Callaghan WM. Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstet Gynecol 2011; 117(4):837–43.
Please cite this article as: Altıntaş E, et al, Heterotopic pregnancy identified in the postpartum period, Int J Gynecol Obstet (2015), http:// dx.doi.org/10.1016/j.ijgo.2015.02.025
