G3P2+0 patient with a gestational age of 7 weeks (by dates), complaining of a 1-day history of bleeding and abdominal pain. The patient had a loss of consciousness while attempting to empty her bladder, preventing a transvaginal ultrasound.
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Intrauterine gestational sac with a normal heart rate.
The left ovary is not visualized. The left adnexa is unremarkable.
A 5 cm heterogeneous lesion with minimal vascularity at the right adnexa.
Free abdominopelvic fluid reaching the peri-hepatic space.
The clinical presentation, heterogeneous right adnexal lesion and moderate ascites are highly suggestive of an ectopic pregnancy. The presence of an intrauterine pregnancy along with an ectopic pregnancy represents a heterotopic pregnancy.
The patient was taken to the OR immediately where they found hemoperitoneum, a ruptured right tubal ectopic pregnancy and a viable intrauterine fetus. Suction and irrigation were done, the right ectopic pregnancy was removed and a sample was sent to pathology.
Histopathology confirms the radiological and surgical findings as there were blood clots, decidualized tissue and chorionic villi within the wall of the fallopian tube.
Heterotopic pregnancy is a relatively rare entity occurring in about 1 in 30,000 pregnancies. The presence of an intrauterine pregnancy, as well as signs of ectopic pregnancy, is highly suggestive of the diagnosis. The most common location for the ectopic fetus is at the Fallopian tube. Patients usually present with abdominal pain and bleeding. There is an increased incidence among patients who undergo induced ovulation. Early diagnosis is crucial for successful treatment. With the presence of a viable fetus, the use of Methotrexate becomes less favorable. Laparoscopic surgery is usually the next step in management.
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