Gravidez heterotópica espontânea: implicações de um diagnóstico tardio / Spontaneous heterotopic pregnancy: implications of a late diagnosis

A gestação heterotópica é uma entidade rara, principalmente se resultante de concepção natural. O diagnóstico é ultrassonográfico, porém a gestação intrauterina concomitante contribui para a dificuldade propedêutica. Neste relato de caso, a detecção foi tardia, a ultrassonografia não identificou a gestação heterotópica e apenas durante a avaliação intraoperatória, por meio de uma cirurgia de emergência devido a choque hemorrágico, houve o reconhecimento. A suspeita de uma gestação heterotópica deve ser sempre aventada quando sinais clínicos típicos (sangramento, dor abdominal) estão presentes, mesmo na ausência de fatores de risco ou imagens anômalas na ecografia. Assim, uma intervenção precoce menos invasiva pode ser realizada, reduzindo a morbimortalidade materna e do feto intrauterino. Este relato de caso destaca uma situação incomum dentro dessa patologia rara: diagnóstico tardio, apenas no segundo trimestre de gestação, sem evidência prévia ultrassonográfica, certificada apenas durante o intraoperatório. O manejo cirúrgico preciso permitiu a manutenção da gravidez intrauterina.(AU)

Heterotopic pregnancy is a rare entity, especially if it is resulted from natural conception. The diagnosis is ultrasonographic, but the concomitant intrauterine pregnancy contributes to the propaedeutic difficulty. In this case report, the detection was late, the ultrasonography did not identify heterotopic pregnancy and, only during intraoperative evaluation through emergency surgery, exploratory laparotomy, there was recognition. The suspicion of a heterotopic pregnancy should always be raised when typical clinical signs (bleeding, abdominal pain) are present, even in absentia of risk factors or anomalous images on ultrasound. Thus, a less invasive early intervention can be performed, reducing maternal and intrauterine fetus morbimortality. This case report highlights an unusual situation within this rare pathology: late diagnosis, only in the second trimester of pregnancy, without previous ultrasound evidence, certified only during the intraoperative period. Precise surgical management allowed the maintenance of intrauterine pregnancy.(AU)

Term delivery of a heterotopic pregnancy coexisting with ruptured tubal ectopic pregnancy: A case report

Pregnancies that occur in two different implantation sites simultaneously is described as Heterotopic pregnancy (HP). In the current study, a case of term delivery of a heterotopic pregnancy coexisting with ruptured tubal ectopic pregnancy, diagnosed by ultrasound (US) and clinical examination findings, which was managed successfully. A 25 year old Nigerian female, gravida 4, para 2 (2 term gestation, 1 spontaneous abortion) presented at the Emergency room with acute abdominal pain associated with vomiting. She had 8 weeks amenorrhea and a positive pregnancy test three weeks prior to presentation. Transvaginal ultrasound scan revealed a sixweeks viable intrauterine gestation. A diagnosis of possible ectopic pregnancy was made. Further trans-abdominal ultrasonography imaging revealed viable intrauterine pregnancy with evidence of an echogenic mass measuring 6.5 x 7.5cm in the abdominal cavity with significant fluid collection, and both ovaries were visualized and separate from the mass. An emergency exploratory laparotomy with right salpingectomy was performed with minimal handling of the uterus and other pelvic structures. At 37 weeks and 5 days gestation, she had an elective C/S for a transverse lying fetus and delivered a live normal birth weight baby girl with a good Apgar score. (Afr J Reprod Health 2022; 26[4]: 110-113).

Embarazo heterotópico espontáneo con resultado perinatal favorable, reporte de un caso y revisión de la literatura / Spontaneous Heterotopic Pregnancy with a Favorable Perinatal Outcome, Case Report, and Literature Review / Gestação heterotópica espontânea com resultado perinatal favorável: relato de caso e revisão da literatura

Resumen: el embarazo heterotópico (EH) es una gestación múltiple en la que un embrión se implanta dentro de la cavidad uterina, y otro en cualquier otra parte como un embarazo ectópico (EE). Espontáneo, tiene una incidencia de uno en 30.000 embarazos, y con técnicas de reproducción asistida (TRA) hasta uno en cien. Su diagnóstico temprano permite reducir la morbimortalidad y mejorar el pronóstico para el embarazo intrauterino. El objetivo del artículo es realizar una revisión de la literatura sobre EH y presentar un caso clínico. Se realizó una búsqueda en bases de datos Pubmed y Medline, utilizando combinaciones con operadores booleanos de los términos MESH: heterotopic pregnancy, ectopic pregnancy therapy risk factors y prognosis. Los límites de la búsqueda fueron: artículos en texto completo, idiomas español e inglés, publicados en los últimos diez años. Se obtuvieron 275 títulos; luego de eliminar los duplicados y la evaluación del resumen, se utilizaron veintisiete referencias. Se presenta un caso de una paciente gesta 2, antecedente de EE roto, con EH espontáneo y ruptura de gestación tubárica; se describe su manejo y resultado perinatal. El EH puede tener implantación tubárica (más frecuente) o en cualquier otra localización. El diagnóstico debe estar centrado en los factores de riesgo y los criterios de ultrasonido. El manejo puede ser expectante, médico o quirúrgico, teniendo con el primero el peor pronóstico materno, con el segundo, menores tasas de pérdida gestacional y mejores resultados maternos, y con el último mayores tasas de aborto. El diagnóstico del EH se realiza por ultrasonido transvaginal; de acuerdo con cada caso se orienta el tratamiento. El abordaje quirúrgico es la primera línea en la presentación aguda. El manejo expectante o la aspiración guiada por ultrasonido son opciones razonables en la paciente estable. Son necesarias más cohortes de pacientes para evaluar los resultados del manejo en nuestro medio.

Summary: heterotopic pregnancy (HP) involves multiple gestations in which one embryo is implanted within the uterine cavity and another elsewhere, such as an ectopic pregnancy (EP). A spontaneous pregnancy has an incidence of one in 30.000 pregnancies, and with assisted reproduction techniques (ART) up to one in a hundred. Its early diagnosis allowsto reduce morbidity and mortality and improve the prognosis for intrauterine pregnancy. The article aims to perform a review of the literature on HP and present a clinical case. A search was conducted on Pubmed and Medline databases, using combinations with Boolean operators of the terms MESH: heterotopic pregnancy, ectopic pregnancy, therapy risk factors and prognosis. The search limits were: full-text articles, Spanish and English languages, published in the last ten years. 275 titles were obtained; after eliminating duplicates and abstract evaluation, 27 references were used. We present a case of a pregnant patient 2, records of broken EP, with spontaneous HP and rupture of tubal gestation; their management and the perinatal results are described. The HP may have tubal implantation (more frequent) or in any other location. The diagnosis should focus on risk factors and ultrasound criteria; the management can be expectant, medical, or surgical, having with the first the worst maternal prognosis, with the second lower rates of gestational loss and better maternal outcomes, and with the latter higher abortion rates. The diagnosis of HP is performed by transvaginal ultrasound; according to each case, the treatment is oriented. The surgical approach is the first line in the acute presentation. Expectant management or ultrasound-guided aspiration are reasonable options in the stable patient. More cohorts of patients are needed to evaluate management outcomes in our environment.

Resumo: a gestação heterotópica (GH) é urna gravidez múltipla na qual um embrião é implantado dentro da cavidade uterina, e outro, em qualquer outro lugar como uma gestação ectópica (GE). Espontânea ocorre em urna de 30.000 gestações, e com técnicas de reprodução assistida, até urna em cem. Seu diagnóstico precoce permite reduzir a morbimortalidade e melhorar o prognóstico para a gestação intrauterina. O objetivo deste artigo é realizar uma revisão da literatura sobre GH e apresentar um caso clínico. Foi realizada urna busca em bases de dados PubMed e Medline, a partir de combinações com operadores booleanos dos termos MESH: heterotopic pregnancy ectopic pregnancy therapy risk factors e prognosis. Os limites da busca foram: artigos em texto completo, em espanhol e inglês, publicados nos últimos dez anos. Foram obtidos 275 títulos; após eliminar os duplicados e a avaliação do resumo, foram utilizadas 27 referencias. É apresentado um caso de urna paciente gesta 2, antecedente de GE rota, com GH espontánea e ruptura da gravidez tubária ectópica; são descritos seu tratamento e resultado perinatal. O GH pode ter implantação tubária (mais frequente) ou em qualquer outra localização. O diagnóstico deve estar centralizado nos fatores de risco e nos critérios de ultrassom. A gravidez pode ser expectante, médica ou cirúrgica, tendo com o primeiro o pior prognóstico materno, com o segundo, menores taxas de perda gestacional e melhores resultados maternos, e com o último maiores taxas de aborto. O diagnóstico do GH é realizado por ultrassom transvaginal; de acordo com cada caso, é orientado o tratamento. A abordagem cirúrgica é a primeira linha na apresentação aguda. O tratamento expectante ou a aspiração guiada por ultrassom são opções razoáveis na paciente estável. São necessárias mais coortes de pacientes para avaliar os resultados do tratamento em nosso contexto.

Gestação heterotópica espontânea: relato de caso com diagnóstico e manejo oportunos / Spontaneous heterotopic pregnancy: a case report with appropriate diagnosis and management

Introdução: A gravidez heterotópica é um fenômeno obstétrico muito raro em concepções espontâneas no qual gestações tópica e ectópica coexistem. O diagnóstico é difícil, mas, se realizado precocemente, o prognóstico é favorável. Descrição do caso: Paciente do sexo feminino, de 35 anos de idade, admitida com quadro de dor abdominal e pequeno sangramento vaginal. Diagnosticada precocemente e tratada cirurgicamente por gravidez heterotópica naturalmente concebida. Como resultado, a gravidez tópica seguiu sem intercorrências. Conclusão: Esse caso enfatiza a necessidade de considerar esse diagnóstico diferencial e analisar clínica e ecograficamente as características globais da pelve, mesmo na ausência de fatores de risco em gestações tópicas.(AU)

Introduction: Heterotopic pregnancy (HP) is a rare obstetric phenomenon in spontaneous conceptions in which intrauterine and ectopic pregnancies coexist. The diagnosis is difficult, but, if performed early, the prognosis is favorable. Case description: A 35-year-old woman was admitted with abdominal pain and light vaginal bleeding. She was early diagnosed and surgically treated for a naturally conceived heterotopic pregnancy. As a result, the intrauterine pregnancy went on healthily. Conclusion: This case emphasizes the need to regard HP as a differential diagnosis and analyze the global pelvis characteristics both clinically and in ultrasound scans, even in the absence of risk factors when dealing with intrauterine pregnancies.(AU)

Cervical heterotopic pregnancy: A case report / 中南大学学报(医学版)

Heterotopic pregnancies are rare and difficult to be diagnosed early. A patient with combined intrauterine pregnancy and cervical pregnancy was admitted in Qingdao Municipal Hospital in 2019. The patient complained of abnormal vaginal bleeding after menopause and was misdiagnosed as simple intrauterine pregnancy. She underwent artificial abortion and suffered intraoperative hemorrhage. To stop bleeding, she received the treatment of uterine artery embolization immediately. Afterwards, cervical residual pregnancy tissues started necrosis, blood β-human chorionic gonadotropin level and the cervix appearance gradually returned to normal. This report suggests that cervical heterotopic pregnancy inclines to be mis diagnosed. Correct diagnosis should be made as soon as possible. Selective uterine artery embolization is an effective measure to prevent and treat massive bleeding.

Embarazo heterotópico: reporte de un caso / Heterotopic pregnancy: a case report

Se presenta el caso clínico de una paciente de sexo femenino de 36 años de edad, natural de Cochabamba, con embarazo ectópico tubárico en la trompa derecha, asociado a un embarazo intrauterino de 6.4 semanas de gestación por FUM, sin antecedentes patológicos personales ni familiares de relevancia clínica; fue tratada quirúrgicamente en el Hospital Obrero Nro 2 CNS, optándose por la laparotomía con salpinguectomía; se realizó prevención de aborto del saco intrauterino con resultados satisfactorios.

The case of a female patient 36 years old, born in Cochabamba, with tubal ectopic pregnancy in the fallopian right, associated with an intrauterine pregnancy of 6.4 weeks LMP, with no personal or family history of disease clinical relevance is presented; He was treated surgically in the CNS Hospital Obrero No. 2, whichever laparotomy with salpingectomy and prevention of intrauterine sac abortion was performed with satisfactory results.

A rare case of triplet heterotopic pregnancy with a live intrauterine and bilateral tubal ectopic

Heterotopic pregnancy (HP) is a condition characterized by the coexistence of an ectopic pregnancy (EP) with a viable intrauterine pregnancy (IUP). The occurrence of a triplet heterotopic pregnancy is an exceptionally rare medical condition. Hence, timely diagnosis and management are challenging, but essential to prevent mortality. Authors report the case of a young woman who presented with a heterotopic triplet pregnancy, after in-vitro fertilization (IVF), at 12 weeks of gestation. She had been misdiagnosed as a case of severe ovarian hyperstimulation syndrome but had a ruptured tubal ectopic on the right side and an unruptured ectopic on the left side. Both the ectopics were managed by performing an emergency laparotomy with bilateral salpingectomy. The live intrauterine pregnancy was continued till term with the delivery of a healthy baby. High clinical suspicion and timely treatment can preserve the intrauterine gestation thus, ensuring a successful outcome.

Embarazo heterotópico espontáneo: Presentación de dos casos / Spontaneous heterotopic pregnancy: Report of two cases

Heterotopic pregnancy is the simultaneous development of an intrauterine and an ectopic pregnancy. This complication is increasing due to infertility treatment, especially assisted reproduction techniques. There are two types: induced (associated with in vitro fertilization techniques, rate 1:1 000 to 1: 1 500 pregnancies) or spontaneous (1:20 000 to 1:80 000 pregnancies). Causal factors for spontaneous heterotopic pregnancies include pelvic inflammatory disease, use of intrauterine device or hormonal devices, previous pelvic surgery, and history of ectopic pregnancy. We present two cases of spontaneous heterotopic pregnancies.

El embarazo heterotópico es el desarrollo simultáneo de un embarazo intrauterino y de otro extrauterino. Es una complicación en aumento en relación al tratamiento de la infertilidad, en especial con técnicas de reproducción asistida. Puede presentarse de dos maneras: inducido (relacionado con técnicas de fertilización in vitro, incidencia de 1:1 000 hasta 1:1 500 embarazos) o espontánea (frecuencia 1:20 000 hasta 1:80 000 embarazos). Sus factores causales son la enfermedad pélvica inflamatoria, uso de dispositivo intrauterino o dispositivos hormonales, cirugía pélvica previa o embarazo ectópico previo. Presentamos dos casos de embarazos heterotópicos espontáneos.

Embarazo heterotópico espontáneo. Presentación de un caso / Spontaneous heterotopic pregnancy. Presentation of a case / Gravidez heterotópica espontânea. Apresentação de um caso

RESUMEN Introducción: el embarazo heterotópico es aquel en el que coexisten de forma simultanea un embarazo intrauterino y uno extrauterino. Puede presentarse de forma inducida relacionado con las técnicas de Reproducción Asistida o espontánea. Sus factores causales son: enfermedad pélvica inflamatoria, uso de dispositivos intrauterinos y anticonceptivos hormonales, cirugía pélvica previa y embarazo ectópico anterior. Presentación de caso: se diagnosticó un caso de embarazo heterotópico espontáneo a una paciente de 25 años de edad y 9 semanas de gestación. Se realizo laparotomía de urgencia con salpingectomia derecha y la gestación intrauterina evoluciono favorablemente hasta el término sin complicaciones. Discusión: el caso que aquí se reporta es el de un embarazo heterotópico espontáneo, excepcional en comparación con los que se originan en pacientes que han recibido técnicas de reproducción asistida. La presentación clínica es variable, su manejo depende del momento en que se realiza el diagnostico (antes o después de que presente complicaciones), de la gestación comprometida (intrauterina o extrauterina) y de la viabilidad del producto intrauterino. Conclusiones: el embarazo heterotópico es un hecho insólito que ha ido en incremento en los últimos tiempos y continua siendo en la actualidad un reto para los Ginecobstetras, debido a las diversas manifestaciones clínicas y a la existencia del embarazo intrauterino que continua la producción de fracción Beta de la gonadotropina corionica humana.

ABSTRACT Introduction: heterotopic pregnancy is one in which an intrauterine and an extrauterine pregnancy coexist simultaneously. It can be presented in an induced way related to assisted or spontaneous reproduction techniques. Its causative factors are: pelvic inflammatory disease, use of intrauterine devices and hormonal contraceptives, previous pelvic surgery and previous ectopic pregnancy. Case presentation: a case of spontaneous heterotopic pregnancy was diagnosed in a patient of 25 years of age and 9 weeks of gestation. An emergency laparotomy was performed with right salpingectomy and the intrauterine gestation evolved favorably until the end without complications. Discussion: the case reported here is that of a spontaneous heterotopic pregnancy, exceptional compared to those that originate in patients who have received assisted reproduction techniques. The clinical presentation is variable, its management depends on the moment in which the diagnosis is made (before or after it presents complications), of the committed gestation (intrauterine or extrauterine) and of the viability of the intrauterine product. Conclusions: the heterotopic pregnancy is an unusual fact that has been increasing in recent times and continues to be a challenge for gynecologists today, due to the various clinical manifestations and the existence of intrauterine pregnancy that continues the production of Beta fraction of the human chorionic gonadotropin.

RESUMO Introdução: a gestação heterotópica é aquela em que a gravidez intrauterina e a extrauterina coexistem simultaneamente. Pode ser apresentado de forma induzida relacionada a técnicas de reprodução assistida ou espontânea. Seus fatores causais são: doença inflamatória pélvica, uso de dispositivos intra-uterinos e contraceptivos hormonais, cirurgia pélvica prévia e gravidez ectópica prévia. Apresentação do caso: um caso de gravidez heterotópica espontânea foi diagnosticado em um paciente de 25 anos de idade e 9 semanas de gestação. Uma laparotomia de emergência foi realizada com salpingectomia direita e a gestação intra-uterina evoluiu favoravelmente até o final sem complicações. Discussão: o caso relatado é o da gravidez heterotópica espontânea, excepcional em comparação com aqueles originados em pacientes que receberam técnicas de reprodução assistida. A apresentação clínica é variável, a sua gestão depende de quando o diagnóstico é feito (antes ou depois deste complicações) de gravidez comprometidos (intra-uterina ou extra-uterina) e produto de viabilidade intra-uterina. Conclusões: a gravidez heterotópico é um evento incomum que tem vindo a aumentar nos últimos anos e continua a ser hoje um desafio para ginecologistas devido às várias manifestações clínicas e a existência de intra-uterino gravidez continuou fração produção Beta gonadotrofina coriônica humana.

Spontaneous heterotopic triplet pregnancy with a two viable intrauterine embryos and an ectopic one with right tubal rupture / Gravidez heterópica tripla espontânea com dois embriões intrauterinos viáveis e um ectópico com ruptura da tuba uterina direita

Abstract Heterotopic pregnancy (HP) is defined as the simultaneous development of an intra- and an extra uterine gestation. The occurrence of a spontaneous triplet HP is an exceptionally rare medical condition. We report the case of a young woman with spontaneous heterotopic triplets at 8weeks of gestation, with amisdiagnosis of topic twins and acute appendicitis. The ectopic tubal pregnancy was ruptured and a salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed uneventfully. The two healthy babies were delivery by cesarean section at 36 ± 2 weeks of gestation. Heterotopic triplets with ruptured tubal ectopic pregnancy represent a special diagnostic and therapeutic challenge for the obstetrician. A high rate of clinical suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Resumo A gravidez heterotópica é definida como o desenvolvimento simultâneo de uma gestação intra- e extra-uterina. A ocorrência de gravidez tripla heterotópica espontânea é uma condição médica excepcionalmente rara. Relatamos o caso de uma jovem com gravidez tripla espontânea, às 8 semanas de gestação, com um diagnóstico errôneo de gêmeos tópicos e apendicite aguda. A gravidez tubária ectópica estava rota e uma salpingectomia foi realizada por laparotomia. A gravidez intrauterina progrediu sem intercorrências. Os bebês nasceramsaudáveis por cesariana realizada às 36 semanas de gestação.Agravidez de heterotópicos comectopia e rotura tubária é umdesafio diagnóstico e terapêutico.Umalto índice de suspeita e tratamento oportuno por laparotomia ou laparoscopia podem preservar a gestação intrauterina com um resultado bem sucedido da gravidez tópica.

Embarazo heterotópico / Heterotopic Pregnancy

El embarazo heterotópico es aquella entidad en la que coexisten gestación intra- extrauterina. La incidencia es baja en embarazos espontáneos, que ha aumentado con técnicas de reproducción asistida. Su diagnóstico precisa un elevado índice de sospecha y tener en consideración los factores de riesgo. Se describen las características de un caso ocurrido en el Hospital Docente Ginecobstétrico de Guanabacoa en La Habana. Cuba. Se presenta una paciente de 26 años de edad con amenorrea de 9 semanas, que acude por dolor intenso a Cuerpo de Guardia con diagnóstico ultrasonográfico de hemoperitoneo. Se sometió a laparotomía exploratoria donde se constató un útero que impresionó grávido y estallamiento del cuerno derecho del útero. No fue posible realizar hemostasia, por lo que se realizó histerectomía total abdominal sin anexectomía. El diagnóstico anátomopatológico fue embarazo heterotópico(AU)

Heterotopic pregnancy is that entity in which intra- and extra-uterine gestation coexist. The incidence is low in spontaneous pregnancies; however, it has increased with assisted reproduction techniques. Its diagnosis requires high index of suspicion and the consideration of risk factors. We describe the characteristics of a case of a 26-year-old patient with 9 weeks amenorrhea who came to the Obstetric Teaching Hospital in Guanabacoa, Havana, Cuba. This patient presented with intense pain and ultrasonography diagnosis of hemoperitoneum. She underwent exploratory laparotomy where the gravid uterus and bursting of the right horn of the uterus were confirmed. It was not possible to perform hemostasis, so total abdominal hysterectomy was performed without adnexectomy. The anatomopathological diagnosis was heterotopic pregnancy(AU)

Management of cervical heterotopic pregnancy with inevitable miscarriage

The objective is to report a case of successful treatment of heterotopic cervical pregnancy resulting from IVF–ICSI conception. Case report from Amrita Institute of Medical sciences: a tertiary care referral hospital. A 47-year-old Primigravida, diagnosed with heterotopic cervical pregnancy at 6 weeks of gestation, presented with significant first trimester vaginal bleeding. Under IV sedation, Transvaginal ligation of descending cervical branches of the uterine arteries arrested the bleeding. The cervical pregnancy was successfully aborted with minimal bleeding and the intrauterine pregnancy was successfully maintained till 32 weeks, after which she required emergency preterm LSCS in view of Severe preeclampsia superimposed on chronic hypertension a non-reassuring non-stress test (NST). The intervention applied maybe used in treatment of heterotopic cervical pregnancy in a low resource setting to control the bleeding.

Embarazo heterotópico con las nuevas técnicas de reproducción asistida. Reporte de un caso / Heterotopic pregnancy with the new techniques of assisted reproduction. Case report

Resumen Mujer infértil, de 39 años, con diagnóstico de disminución de la reserva ovárica. Tenía 4 intentos previos de fertilización in vitro, sin éxito. Se le realizó fertilización in vitro con donación de óvulos. Fueron transferidos 2 embriones, y la paciente resultó embarazada. Dos semanas después se efectuó un ultrasonido vaginal y se encontró un saco gestacional intrauterino, con embrión y actividad cardiaca. El embarazo evolucionó bien hasta 3 semanas después de la prueba de embarazo, cuando presentó dolor en la fosa iliaca izquierda. Al revisarla se encontró resistencia muscular y rebote en la zona referida. Se efectuó un ultrasonido vaginal y se encontró un feto intrauterino con actividad cardiaca y embarazo ectópico tubario izquierdo. A la paciente se le practicó una laparotomía con incisión Pfannenstiel y se le realizó una salpingectomía izquierda. Después de la cirugía, fue tratada con inhibidores de las contracciones uterinas. El embarazo evolucionó satisfactoriamente hasta la semana 35, cuando presentó ruptura prematura de membranas. Se le realizó una cesárea y se obtuvo un producto masculino que pesó 2,500 g. El recién nacido desarrolló síndrome de dificultad respiratoria leve e hipertensión de la arteria pulmonar, que fueron tratados con agente surfactante y sildenafil; se le egresó en buenas condiciones.

Abstract We present the case of a 39-year-old infertile woman with the diagnosis of diminished ovarian reserve and a history of four previous attempts of in vitro fertilization, which were unsuccessful. She was treated by means of in vitro fertilization with oocyte donation, two embryos being transferred. Two weeks after embryo transfer, the pregnancy test was positive. Two weeks later a vaginal ultrasound was performed, finding an intrauterine gestational sac, within which an embryo with cardiac beat was detected. The pregnancy had a normal evolution until three weeks after the pregnancy test when the patient presented with left-sided lower abdominal pain. On examination, guarding and rebound signs in the left iliac fossa were positive. A vaginal ultrasound was performed, encountering both an intrauterine fetus with cardiac beat and a left tubal ectopic pregnancy. The patient was treated by means of Pfannenstiel incision laparotomy with a left salpingectomy. After surgery, the patient was treated with uterine contractility inhibitors. The pregnancy progressed without complications until the thirty-fifth week, when the patient presented premature rupture of membranes. A cesarean section was performed obtaining a live male, weighing 2500g. The newborn developed mild respiratory distress and pulmonary artery hypertension, for which a surfactant agent and sildenafil were administered. He was deemed healthy and egressed.

Gestação heterotópica: diagnóstico ultrassonográfico com gravidez ectópica não rota em serviço de emergência - Relato de caso / Heterotopic pregnancy: ultrasonographic diagnosis with non - route ectopic pregnancy in emergency service - Case report

A gravidez heterotópica é uma entidade rara, caracterizada por uma gravidez tópica associada a uma gravidez ectópica, sobretudo quando ocorre de forma espontânea. Os fatores de risco são semelhantes aos vistos em ectópicas, sendo a maior incidência nas mulheres que se submetem a técnicas de reprodução assistida. O diagnostico é feito com ß-HCG positivo e exame ultrassonográfico, geralmente após quadro de abdome agudo hemorrágico decorrente do rompimento da prenhez ectópica, com o tratamento divergindo em relação ao quadro e da idade gestacional da paciente. (AU)

The heterotopic pregnancy is a rare disease characterized by a topical pregnancy associated with an ectopic pregnancy, especially when it occurs spontaneously. Risk factors are similar to those seen in ectopic pregnancy, with the highest incidence in women undergoing assisted reproduction techniques . Diagnosis is made with a positive ß -HCG and ultrasound examination, usually after hemorrhagic acute abdomen due to the rupture of the ectopic pregnancy, with treatment differing in relation to the frame and the gestational age of the patient. (AU)

Embarazo heterotópico espontáneo con ruptura tubárica y choque hipovolémico. Reporte de un caso y revisión de la bibliografía / Spontaneous heterotopic pregnancy with tubular breakage and hypovolemic Shok. A case report and literature review

Resumen ANTECEDENTES: Puesto que el embarazo heterotópico es poco común, representa un reto diagnóstico clínico y ecográfico que requiere un alto índice de sospecha. El enfoque terapéutico y la vía quirúrgica a elegir dependen de las condiciones clínicas y hemodinámicas de la paciente. Cuando las intervenciones son oportunas el embarazo intrauterino puede continuar y llegar a término. CASO CLÍNICO: Paciente con embarazo intrauterino de 11.1 semanas que ingresó al servicio de Urgencias debido a sangrado vaginal, con signos clínicos de choque. La ecografía pélvica reportó, además del embarazo intrauterino, una imagen sugerente de embarazo heterotópico tubárico derecho y abundante cantidad de líquido libre. Se reanimó con hemocomponentes, laparotomía de urgencia, drenado de hemoperitoneo masivo. Requirió salpingectomía y resección del epiplón afectado, con buena evolución del embarazo intrauterino hasta el término CONCLUSIONES: El tratamiento de elección del embarazo ectópico sigue siendo quirúrgico. La vía de acceso depende de las condiciones hemodinámicas de la pa-ciente. La laparoscopia es el patrón de referencia del tratamiento y la laparotomía es la opción cuando la laparoscopia no es posible por razones técnicas, logísticas, o por inestabilidad hemodinámica derivada de la ruptura tubárica.

Abstract BACKGROUND: The heterotopic pregnancy is considered a rare condition that rep-resents a diagnostic challenge both clinical and ultrasound requiring a high index of suspicion, the therapeutic approach and the surgical route will depend on the clinical and hemodynamic conditions of the patient, being able to achieve a successful conti-nuity of intrauterine gestation when timely interventions are made. CLINICAL CASE: Patient with a known diagnosis of intrauterine gestation of 11.1 weeks who was admitted to the emergency room due to vaginal bleeding, with clini-cal signs of shock and pelvic ultrasound that reports a suggestive image of right tubal heterotopic pregnancy and abundant free liquid. Resuscitation is performed with blood components and surgical management with emergency laparotomy, draining massive hemoperitoneum, requires salpingectomy and resection of omentum compromised, with good evolution and progression of intrauterine gestation to term CONCLUSIONS: The treatment of choice for ectopic pregnancy remains surgical. The route of admission depends on the hemodynamic conditions of the patient. Laparoscopy is the reference standard of treatment and laparotomy is the option when laparoscopy is not possible due to technical, logistical or hemodynamic instability derived from tubal rupture.

Embarazo heterotópico espontáneo. Reporte de un caso y revisión de la bibliografía / Spontaneous heterotopic pregnancy. Case report and literature review

Resumen ANTECEDENTES: el embarazo heterotópico es la coexistencia de una gestación intrauterina y otra extrauterina. Puesto que es una posibilidad excepcional asociada con gran morbilidad y mortalidad materna, su diagnóstico y atención oportuna son decisivos. La fracción β de la hormona gonadotropina coriónica humana y el ultrasonido endovaginal son las opciones de mayor utilidad para el diagnóstico y el acceso quirúrgico laparoscópico es el de elección porque ofrece ventajas en relación con la técnica abierta. CASO CLÍNICO: paciente con embarazo heterotópico logrado espontáneamente, de 7.4 semanas de gestación. Embarazo ectópico izquierdo roto y el intrauterino con vitalidad corroborada. Ingresó al servicio de Urgencias por amenorrea y dolor abdominal. El embarazo ectópico roto se corroboró mediante salpingectomía laparoscópica, con hemoperitoneo de 800 cc. Gracias al adecuado control prenatal se logró un embarazo que finalizó por vía abdominal, con trabajo de parto en fase latente y feto en presentación pélvica. El recién nacido fue de sexo femenino, de 34 semanas de gestación. CONCLUSIONES: la atención multidisciplinaria, la identificación de los factores de riesgo, la sospecha clínica y el apoyo de estudios de gabinete permitieron el diagnóstico y la intervención quirúrgica de mínima invasión de forma oportuna, con resultados favorables transquirúrgicos y el nacimiento viable, a las 34 semanas, del embrión coexistente.

Abstract BACKGROUND: The heterotopic pregnancy is the coexistence is an intrauterine and extrauterine gestation, although the frecuency of presentation is rare, it is associated with a high maternal morbidity and mortality, reason why a diagnosis and timely management are the cornerstone of these cases. The β fraction of the human chorionic gonadotropin hormone and the endovaginal ultrasound are the most useful tools in the diagnosis and the laparoscopic surgical approach has been proposed as the best choice since it offers advantages over an open technique approach. CLINICAL CASE: The case of a spontaneous heterotopic pregnancy of 7.4 weeks of gestation was reported, with a ruptured left ectopic pregnancy and an intrauterine pregnancy with corroborated vitality, emergency admission for amenorrhea and abdominal pain, corroborating a ruptured ectopic pregnancy with hemoperitoneum by means of laparoscopic salpingectomy, obtaining hemoperitoneum of 800 cc, later with an adequate prenatal control, the pregnancy was resolved abdominal route by indication of labor in latent phase and fetus in pelvic presentation, a female newborn of 34 weeks of gestation was obtained. CONCLUSION: The multidisciplinary care, the identification of risk factors, clinical suspicion and the support of cabinet studies allowed the diagnosis and surgical approach of minimal invasion in a timely manner, with favorable transsurgical results and a viable pregnancy of 34 weeks of coexisting embryo.

Gestación heterotópica: dos casos con gestación intrauterina viable a término / Heterotopic pregnancy: two cases with viable intrauterine pregnancy at term

Se presentan dos casos de gestación heterotópica, el primero de ellos espontáneo y el segundo tras técnicas de fecundación in vitro. En ambos la gestación intrauterina evolucionó de forma favorable, con control gestacional normal y llegando a término, con el nacimiento de recién nacidos sanos. La gestación heterotópica se define como la presencia simultánea de gestación en dos lugares de implantación distintos, lo más frecuente una gestación intrauterina acompañada de otra ectópica. Se trata de una situación poco frecuente, con una incidencia de 1/8000 embarazos espontáneos según la bibliografía más reciente.

We report two cases of heterotopic pregnancy, the first one spontaneous and the second one after in vitro fertilization techniques. In both, the intrauterine gestation evolved favorably, normal pregnancy control and coming to terms with the birth of healthy newborns. Heterotopic pregnancy is defined as the simultaneous presence of gestation at two different locations, most often in utero accompanied by another ectopic pregnancy. This is a rare situation, with an incidence of spontaneous pregnancies 1/8000 according to the most recent literature.

Tratamiento exitoso de un embarazo heterotópico cervical luego de un procedimiento de fecundación in vitro / Successful treatment of a cervical heterotopic pregnancy following an in vitro fertilization procedure

Mujer nulípara infértil de 37 años presentó un embarazo heterotópico cervical luego de tratamiento por fecundación in vitro. Una intervención temprana durante la 6ta semana de gestación logró remover el saco cervical mediante un aspirador manual. Para prevenir una posible hemorragia, se realizó la ligadura de las ramas cérvico-uterinas y se colocó un cerclaje cervical, antes de la aspiración. Se logró extraer el embarazo cervical con mínima hemorragia. El embarazo intrauterino progresó sin complicaciones, resultando en el parto de un varón de 2740 g, a las 35.4 semanas.

A 37-year-old nulligravida infertile female had a cervical heterotopic pregnancy following an in vitro fertilization procedure. Early intervention on the 6th week of gestation with a manual vacuum aspirator reached to remove the cervical pregnancy. Ligation of the descending cervical branches of the uterine arteries and a cervical cerclage, were placed before the aspiration, for prevention of possible hemorrhage. Successful removal of the cervical pregnancy was achieved with only mild bleeding. An intrauterine pregnancy progressed to viability without complications, resulting in a vaginal delivery of a preterm live-birth at 35.4 weeks, of a male that weighted 2740 g.

Heterotopic pregnancy after a single embryo transfer

Heterotopic pregnancy is a rare and life-threatening condition which is defined as coexistent intrauterine and ectopic gestation. The risk of ectopic and heterotopic pregnancy is increasing due to the increased risk of multiple pregnancies with the aid of assisted reproductive technologies. However, it hardly happens in the setting of single embryo transfer, since single embryo transfer significantly reduces the incidence of multiple pregnancies. Surprisingly, we experienced a case of heterotopic pregnancy after a single embryo transfer caused by coincidental natural pregnancy during assisted reproductive technologies. An infertile woman who underwent, during her natural cycle, transfer of a single embryo that had been cryopreserved for 3 years was found to be heterotopically pregnant. After an early and successful management with laparoscopic right salpingectomy, she finally reached at full-term vaginal delivery.

Embarazo heterotópico cervical: reporte de un caso

El embarazo heterotópico, de presentación muy rara, generalmente es de localización tubárica, siendo los cervicales de presentación excepcional, todo un reto para el médico ginecoobstetra. Se describe el caso de una paciente nulípara de 45 años que presentó embarazo heterotópico cervical. Contaba con el antecedente de haber sido sometida a técnicas de reproducción asistida. Clínicamente solo había sangrado vaginal escaso. El diagnóstico ecográfico fue alrededor de las 9 semanas de gestación, que mostró doble saco gestacional, uno de ellos localizado en el endocérvix, y con ambos fetos vivos. Se planteó las alternativas terapéuticas curetaje y colocación de balón intracervical, embrio-reducción con cloruro de potasio e histerectomía; la gestante optó por histerectomía electiva. Anatomía Patológica confirmó el diagnóstico.

Heterotopic pregnancy is of very rare presentation, usually with tubal location and exceptionally cervical, constituting a challenge for the obstetricia n and gynecologist. A nulliparous 45 year-old patient presented a heterotopic cervical pregnancy. She had been subjerted to assisted reproductive techniques. Clinically, there was only scarce vaginal bleeding. Ultrasound at 9 weeks of gestation showed double gestational sac, one located in the endocervix, and both fetuses alive. Treatment options were curettage and placement of intra-cervical balloon, embryo-reduction with potassium chloride, and hysterectomy; the patient decided a single elective hysterectomy. Pathology confirmed the diagnosis.