Lessons learned from an early heterotopic pregnancy case

The patient, a 30-year-old gravida 1, para 0, presented to the clinic with a 3-day history of intermittent but increasing abdominal pain. She recently underwent in vitro fertilization (IVF) and embryo transfer (ET) and currently has a positive serum pregnancy test with an estimated gestational age of 5 weeks and 4 days. Three days prior to presentation (ie, at 5 weeks and 1 day gestation), she experienced 2 episodes of sudden lower midline abdominal pain that lasted 30 minutes, which resolved spontaneously.

A review of her chart at the clinic reveals that during controlled ovarian stimulation, her peak serum estradiol level was 4,755 pg/mL, and 43 oocytes were collected at retrieval. Two blastocysts were transferred on the fifth day after oocyte retrieval. A positive human chorionic gonadotropin (hCG) level of 273 mIU/mL was detected 10 days after embryo transfer, which rose appropriately in 48 hours to 566 mIU/mL.

On the day of presentation, her physical exam reveals a soft but mildly distended abdomen. A pelvic ultrasound shows enlarged ovaries, 4.8 cm and 4.2 cm, containing multiple complex follicles; a 10 cm by 9 cm by 9 cm hemorrhagic mass with mixed echogenicity extending midline to the flanks and adjacent to the enlarged left ovary; minimal free fluid noted; adequate blood flow to both ovaries; single intrauterine 0.7 cm gestational sac; present yolk sac; no fetal pole; and no cornual pregnancy.

When she returned the following day, her clinical condition had worsened. Although her vital signs were normal, her abdomen was moderately distended and tender to deep palpation. A repeat hematocrit demonstrated a 3.7% drop (30.7% to 27%) in 24 hours. Repeat ultrasound showed no interval change. Her worsening clinical status was concerning for active intra-abdominal bleeding; therefore, she was admitted to the hospital for exploratory surgery.

During surgical exploration, a ruptured left isthmic-ampullary ectopic pregnancy was discovered, and a salpingectomy was performed. Pathology confirmed chorionic villi. The patient recovered uneventfully and delivered a term infant without complication.