A 35 years primigravida married for 18 years was on treatment. She was a known case of hypothyroidism and was taking 12.5micro grams of thyroxin supplementation. There was no history of surgical intervention in the past. She had regular cycles in the past and her LMP was 7 weeks before the date of presentation. She was undergoing IVF treatment at Mamata Fertility Hospital and had Embryos transferred 4 weeks before the presentation.
She was referred from the same centre with USG report of Single intrauterine gestation with cardiac activity. They also reported an organized mass of 6.7×7.6×6.7mm adjacent to the uterus? sac with decidual reaction with minimal vascularity(Figure 1 USG). She was 7 weeks by gestation on USG at presentation. She was reporting lower abdominal discomfort and mild vaginal spotting. A provisional diagnosis of Heterotropic pregnancy was made and laparoscopy was planned.
On laparoscopy, she had a left corneal pregnancy. The challenge in corneal pregnancy is increased bleeding due to high vascularity if it ruptures spontaneously. A high index of suspicion is needed to diagnose this condition before internal haemorrhage happens. A uterus with an additional intrauterine pregnancy along with a corneal pregnancy is likely to bleed more as the corneal area of the uterus is also more vascular. We, however, planned a minimal access laparoscopic surgery. After confirming the diagnosis (Figure -2), we
injected 10 cc of diluted vasopressin (0.2units/ ml) at the left cornua. The dissection involved left salpingectomy with excision of the left corneal (Figure-3). Although the bleeding was well controlled at the time of surgery, we reinforced the left corneal area with 1/0 Vicrylsutures by laparoscopic instruments, as this is also a weak area of the uterus. This uterus was already having an intrauterine pregnancy and the uterus was expected to enlarge in the subsequent months hence the reinforcement made sense. At the time of this report, this lady is 12 weeks pregnant and her intrauterine pregnancy is doing well.
DISCUSSION Although the prevalence of heterotopic pregnancy is increasing it still remains an unusual diagnosis. The rise is mostly seen due to increased fertility treatment and the use of assisted reproductive techniques. A high clinical index of suspicion is required to diagnose heterotropic pregnancy. Presence of a live intra utrerine pregnancy on the transvaginal scan can give false reassurance. This condition is difficult to monitor with serial Beta HCG as the rise can be falsely interpreted due to associated intrauterine pregnancy. However, the presence of an intrauterine gestation does not rule out a co-existing ectopic gestation. At times a haemorrhagic corpus luteum may confuse and delay the diagnosis of heterotrophic pregnancy. Surgical treatment is the preferred treatment with the laparoscopic approach being the treatment of choice.
Dr. Rooma Sinha,
MD, Hon Professor AHERF, Senior Consultant Gynecologist, Laparoscopic & Robotic Surgeon
Apollo Health City, Jubilee Hills, Hyderabad
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