A 41-year-old woman, without any relevant risk factors, primigravida nulliparous with a spontaneous pregnancy, consulted the emergency department for brownish vaginal discharges and a mention of delayed menstruation.
The clinical examination found a stable hemodynamic state with lower abdominal pain. On speculum examination, the cervix was purplish without the stigma of bleeding.
A transvaginal ultrasound was performed and revealed a 6 mm intrauterine gestational sac (IUGS), a normal right ovary, and a left ovary containing a cystic image of 5 cm × 5 cm suggesting a corpus luteum and a ring-like structure of 2.5 cm suggesting an ectopic pregnancy [Figure 1]. A heterotopic pregnancy was suspected. Gestational sac size and kinetics of serum human chorionic gonadotropin levels were monitored periodically to determine pregnancy status.
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Figure 1: Transvaginal ultrasound findings
On ultrasound checks, the ring-like structure persisted, the IUGS grew, and the human chorionic gonadotropin (HCG) titer were in favor of an evolving pregnancy. The HCG level rised from 14491 IU/ml to 19237 over a period of 24 hours. As early diagnosis and treatment of heterotopic pregnancy is crucial,[1] laparoscopy was indicated to clarify the diagnosis. Surgery and medication are the primary management modalities for PH, but the decision remains debatable based on the desire to preserve intrauterine pregnancy.[1] Intraoperatively, we found a gravid uterus, serous effusion, and a solid mass over the left ovary suggesting a 3 cm ovarian fibrothecoma that was just biopsied for anatomopathological examination [Figure 2]. Histology confirmed the diagnosis of ovarian fibrothecoma. The diagnosis of heterotopic pregnancy was eliminated and the intrauterine pregnancy continued to progress. The ultrasound check 1 week later revealed a 6-week pregnancy [Figure 3]. She had her first-trimester ultrasound at 13 weeks of gestation which was without anomalies. Unfortunately, the patient had an abortion at 25 weeks gestation.
Figure 2: Laparoscopic intraoperative view
Figure 3: Ultrasound control after laparoscopy
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
REFERENCE
1. Liu C, Jiang H, Ni F, Liu Y, Zhang W, Feng C. The management of heterotopic pregnancy with transvaginal ultrasound-guided local injection of absolute ethanol. Gynecol Minim Invasive Ther 2019;8:149–54.
