Heterotopic pregnancy
Heterotopic pregnancy | |
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Ultrasound showing a heterotopic pregnancy (intrauterine + extrauterine pregnancies) with signs that the extrauterine (ectopic) pregnancy has ruptured.[1] | |
Specialty | Obstetrics |
A heterotopic pregnancy is a
It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or coincident pregnancy.The most common site of the extrauterine pregnancy is the fallopian tube. However, other sites of implantation include the cervix, ovary, and abdomen.[3]
Although heterotopic pregnancies were once thought to be a rare phenomenon, the
Cause
In a heterotopic pregnancy there is one fertilized ovum which implants normally in the uterus, and one fertilized ovum which implants abnormally, outside of the uterus.
Pathogenesis
In the general population, the major risk factors for heterotopic pregnancy are the same as those for ectopic pregnancy:[4]
- Previous history of ectopic pregnancy
- Tubal surgery
- Pelvic inflammatory disease
- Use of an intrauterine device
- In utero diethylstilbestrol exposure
- Smoking
Women participating in an assisted reproductive program have an increased risk of heterotopic pregnancy for several reasons including:
- Higher incidence of ovulation due to treatment
- Multiple embryo transfers
- Technical factors in embryo transfer which may increase the risk for ectopic and heterotopic pregnancy
- Higher incidence of tubal malformation and/or tubal damage in this group
- Higher levels of estradiol and progesterone due to hormonal treatment
Diagnosis
Signs and symptoms
Heterotopic pregnancies present with unspecific clinical symptoms. This means the symptoms of a heterotopic pregnancy can be the same symptoms found in several other medical conditions. The most common clinical symptoms are
Differential diagnosis
The signs and symptoms of a heterotopic pregnancy can be found in many other gynecological and non-gynecological conditions, including:
- Ovarian torsion
- Ovarian cyst
- Threatened abortion
- Urinary tract infection
- Kidney stones
- Constipation
- Diverticulitis
- Pelvic inflammatory disease
- Bowel obstruction
- Inflammatory bowel disease
Ultrasound
The gold standard for diagnosing a heterotopic pregnancy is the
Management
The goal of treatment is to preserve the viable intrauterine pregnancy and to remove the nonviable ectopic pregnancy.
The standard surgical approach for removal of the nonviable ectopic pregnancy is by
In the case of an unruptured ectopic pregnancy, local feticidal injection can be used to remove the ectopic pregnancy. For this method, ultrasound is used to guide a needle to the ectopic pregnancy and substances such as potassium chloride and hyperosmolar glucose are injected directly into the gestational sac.[3] The use of this method can be limited due the location of the ectopic pregnancy and the experience of the physician with this technique.
Treatment of heterotopic pregnancy will depend on the specific location of the ectopic pregnancy, as well as the pregnant person's clinical presentation and stability.[6]
Prognosis
Extrauterine pregnancies are non-viable and can be fatal to the mother if left untreated.[6] However, successfully continuing the intrauterine pregnancy following removal of the extrauterine is possible and has a success rate of about 50 to 66%.[7][8]
Epidemiology
The
In natural conceptions, the incidence of heterotopic pregnancy has been estimated to be 1 in 30,000 pregnancies.[10] However, due to the increasing use of assisted reproduction technology, the overall incidence is 1 in 3900 pregnancies.[11]
References
- ^ a b "UOTW #9 - Ultrasound of the Week". Ultrasound of the Week. 15 July 2014. Retrieved 27 May 2017.
- ^ Harrington JA, Lyons EA. "Heterotopic pregnancy". Archived from the original on 2006-09-27. Retrieved 2008-08-19.
- ^ S2CID 239424871.
- ^ PMID 33148586.
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- ^ PMID 24101604.
- ^ Molinaro TA, Barnhart TA (24 August 2021). Levine L, Schreiber CA, Berghella V, Chakrabarti A (eds.). "Cesarean scar pregnancy, abdominal pregnancy, and heterotopic pregnancy". UpToDate. Retrieved 2021-11-11.