Heterotopic tubal pregnancy with live twin birth complicating ovulation induction assisted cycle

doi:10.4236/ojog.2012.23068

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Open Journal of Obstetrics and Gynecology, 2012, 2, 325-327 OJOG

http://dx.doi.org/10.4236/ojog.2012.23068 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

Heterotopic tubal pregnancy with live twin birth

complicating ovulation induction assisted cycle

Adebiyi Gbadebo Adesiyun1*, Benson Ayodele-Cole2

1Department of Obstetrics & Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

2Echo-Scan Services, Kaduna, Nigeria

Email: *[email protected]

Received 10 April 2012; revised 14 May 2012; accepted 31 May 2012

ABSTRACT

Het erotopic pregnancy is an uncommon clinica l ent ity

in Nigeria even though some of the risk factors are

highly prevalent in the population. We report a case

of heterotopic pregnancy following ovulation induc-

tion with clomiphene citrate. A favourable outcome

resulting in live twin birth was recorded despite the

presence of poor clinical features that affects preg-

nancy and foetal outcome.

Keywords: Heterotopic Pregnancy; Ovulation Induction;

Clomiphene Citrate; Laparotomy; Twin Birth

1. INTRODUCTION

Heterotopic pregnancy is said to occur when there is

simultaneous coexistence of two or more intrauterine and

extra uterine implantation sites. Heterotopic pregnancy

could follow an assisted conception cycle or a natural

conception cycle. Interestingly, there has been an in-

crease in the incidence of assisted conception related

heterotopic pregnancy since the introduction of assisted

conception technology into the treatment array of infer-

tile couples [1]. Heterotopic pregnancy is an uncommon

clinical condition in Nigeria probably due to under-

reporting or missed diagnosis, because the risk factors

like pelvic inflammatory disease, ectopic pregnancy and

multiple pregnancy are highly prevalent in the population

[2]. We report a case of heterotopic tubal pregnancy

following ovulation induction with clomiphene citrate,

resulting in twin live birth.

2. CASE REPORT

A 36-year old Nigerian woman presented with a year

history of infertility. She was para 1 + 1. Her last child

birth was 23 months prior to presentation; she had a

vaginal delivery of a live female baby and the placenta

was manually removed under anaesthesia. She had stop-

ped breastfeeding 11 months earlier. Evaluation revealed

a normal pelvic ultrasound scan, serum prolactin of 26.2

ng/ml, normal semen analysis and the hysterosalpingo-

graphy showed a normal size uterine cavity, left cornual

tubal occlusion and right fimbrial end tubal occlusion.

She was commenced on treatment with cabergoline and

had therapeutic hydrotubation. After a month treatment

w ith cabergoline, a r epeat serum prolac tin was 12.3 ng /ml .

She subsequently had ovulation induction with clomi-

phene citrate, followed with follicular tracking and timed

intercourse after human chorionic gonadotrophin inject-

tion was given whenever the lead fo llicle was at least 18

mm. She conceived at the fourth assisted conception

treatment course with the last menstrual period being on

the 13th of December, 2010. Pregnancy was confirmed

with a positive serum human chorionic gonadotrophin

hormone and an ultrasound scan that showed two viable

intrauterine fetuses at gestational age of 6 weeks and 4

days.

She suddenly felt a sharp lower abdominal pain when

the pregnancy was 7 weeks, the pain progressed and ne-

cessitated her to present in the hospital the next day. As-

sessment revealed severe pallor, signs of hypovolemia

and features of intra abdominal fluid collection. A diag-

nosis of rup tured ectopic pregnancy was made. An urgent

sonography revealed twin viable intrauterine fetuses and

ruptured adnexial ectopic pregnancy, thus confirming the

diagnosis of heterotopic pregnancy. She was resuscitated

and had an urgent laparotomy. Intra operative findings

were haemoperitoneum of 2 litres and a ruptured right

ampullary tubal ectopic pregnancy; she had right sal-

pingectomy. In all she had 4 units of whole blood trans-

fused and post operative treatment include antibiotics,

analgesia and progesterone injection. Post-operative

period was uneventful. Sonography done on 7th day post

surgery showed viable intrauterine twin fetuses.

Thereafter pregnancy remained uneventful until 36

weeks when she had spontaneous rupture of fetal mem-

branes. She had emergency caesarean section because

*Corresponding a uthor.

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A. G. Adesiyun, B. Ayodele-Cole / Open Journal of Obstetrics and Gynecology 2 (2012) 325-327

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the fetuses were lying transversely. She was delivered of

2 male fetuses that weighed 2.5 kg and 2.05 kg with

good apgar scores. She had primary postpartum haemor-

rhage due to uterine atony and lost about 2.2 litres of

blood despite rectal insertion of misoprostol, manual

uterine compression .and oxytocin drip. She had a total

of 5 units of blood transfusion intra and post operatively.

On the 8th post surgery day she was discharged home

following good recuperation and satisfactory general

condition.

3. DISCUSSION

Heterotopic pregnancy which was first described at an

autopsy study [3] was hitherto a rarity before the intro-

duction and widespread use of ART. In natural concep-

tion cycles low frequency ranging from 1 in 10,000 to 1

in 50,000 was reported and high rates of heterotopic

pregnancy from 1 in 100 to 1 in 500 was reported in ART

treatment cycles [4-6]. The later is attributable to super

ovulation induction, multiple embryo transfer with re-

sultant increase in multiple pregnancy and ectopic preg-

nancy. In this report the intrauterine pregnancy was a

twin. This is in conformity with authors that reported an

increase in and not in uterine twin gestation. In ART-

related heterotopic pregnancy and an exclusive singleton

intrauterine gestations in natural cycle related heterotopic

pregnancy [4]. In this case report, heterotopic diagnosis

was made at about seven weeks of gestation. This is

within the 5th to 8th week gestation reported to be the

commonest diagnostic period interval for heterotopic

pregnancies [4,7]. Furthermore, the type of cycle, be it

assisted or natural cycle did not affect the gestational age

at diagnosis [4]. The ectopic gestation in this report was

tubal, similar to finding in other series [4,7,8]. Though,

the ectopic gestation was in the right tube in this patient,

there is no predilection for right or left tube in hetero-

topic pregnancy [4,8]. In the evaluation of this patient

before index conception, she had hysterosalpingographic

tubal occlusion and therapeutic hydrotubation as earlier

described by these authors [9]. Studies have highlighted

the importance of previous pelvic pathology as a risk

factor for heterotopic pregnancy, especially in the cohort

that had heterotopic pregnancy following assisted con-

ception [4].

The clinical presentation in this case report includes

hypovolemic shock, tubal rupture and haemoperitoneum.

Being a case of heterotopic pregnancy fo llowing assisted

conception this finding are in contrast to that of a series

that reported on outcome of heterotopic pregnancies and

found a significantly lower rate of low systolic blood

pressure, tubal rupture and haemoperitoneum in the as-

sisted conception group compared to spontaneous con-

ception group [4]. A high miscarriage rate have been

reported in multiple pregnancy and pregnancy compli-

cated by heterotopic implantation with higher rate of

miscarriage documented in heterotopic pregnancy com-

plicating assisted conception than spontaneous concep-

tion [4,10-12]. The aggregate of these predisposing fac-

tors did not result in miscarriage in the case presented.

Mu ltiple pregnancy and Heterotopic pregnancy are kn own

to individually predispose to preterm births [4,7,13]. This

patient was delivered of 2 male babies by caesarean

section at 36 weeks due to preterm spontaneous rupture

of fetal membranes. In heterotopic pregnancy, survival

rate of the intrauterine gestation range from 35% to

66.2% [7,14,15]. This rates are influenced by variables

that hovers round ear ly diagnosis and treatment viz- a-viz

treatment before tubal rupture and development of hae-

moperitoneum and hypovolemic shock that may result in

hypoxic challenge to the intrauterine fetus [4]. A high

survival rate translate to improve live birth rate. The poor

clinical condition in this case as exhibited by tubal

rupture, haemoperitoneum and shock did not affect the

survival of the two fetuses which is in accord with

another study that did not demonstrate a relationship

between intra uterine fetal mortality and presence of

haemoperitoneum [7]. Though with figure that was not

statistically significant, live birth rate was reported to be

two-fold higher in the subgroup that had heterotopic

pregnancy following assisted conception compared to

spontaneous conception [4]. Although, studies have not

demonstrated a link between heterotopic pregnancy and

fetal congenital anomalies, one of the twin in this report

had an upper respiratory tr act obstructive pathology with

no definitive diagnosis up till th e time of this report [4,7].

In conclusion, this report recorded a favourable fetal

outcome.

REFERENCES

[1] Lemus, J.F. (2000) Ectopic pregnancy: An update. Cur-

rent Opinion i n O b s t et r i c s and G y n e co l o gy, 12, 369-375.

doi:10.1097/00001703-200010000-00005

[2] Eigbefoh, J.O., Mabayoje, P.S. and Aliyu, J.A.Y. (2008)

Heterotopic pregnancy: A report of two cases. Nigerian

Journal of Clinical Practice, 11 , 85-87.

[3] Bright, D.A. and Gaupp, F.B. (1990) Hetertopic preg-

nancy: A reevaluation. The Journal of the American

Board of Family Medicine, 3, 125-128.

[4] Han, S.H., Jee, B.C., Suh, C.S., Kim, S.H., Choi, Y.M.,

Kim, J.G. and Moon, S.Y. (2007) Clinical outcomes of

tubal heterotopic pregnancy, assisted vs spontaneous

conceptions. Gynecologic and Obstetric Investigation, 64,

49-54.

[5] Dor, J., Seidman, D.S., Levran, D., Ben-Rafael, Z., Ben

Shlomo, I. and Mashiach, S. (1991) The incidence of

combined intrauterine and extrauterine pregnancy after in

vitro fertilization and embryo transfer. Fertility and

A. G. Adesiyun, B. Ayodele-Cole / Open Journal of Obstetrics and Gynecology 2 (2012) 325-327

327

Sterility, 55, 833-834.

[6] Marcus, S.F., Macnamee, M. and Brinsden, P. (1995)

Heterotopic pregnancies after in-vitro fertilization and

embryo transfer. Human Reproduction, 10, 1232-1236.

doi,10.1093/humrep/10.1.199

[7] Tal, J., Haddad, S., Gordon, N. and Timor-Tritsch, I.

(1996) Heterotopic pregnancy after ovulation induction

and assisted reproductive technology, a literature review

from 1971 to 1993. Fertility and Sterility, 66, 1-12.

[8] Reeece, E.A., Petrie, R.H., Sirmans, M.F., Finster, M. and

Todd, W.D. (1983) Combined intrauterine and extrau-

terine gestations, a review. American Journal of Obste-

trics & Gynecology, 146, 323-330.

[9] Adesiyun, A.G., Cole, G. and Ogwuche, P. (2009) Hy-

drotubation in the management of female infertility, out-

come in low resource setting. East African Medical Jour-

nal, 86, 31-36. doi,10.4314/eamj.v86i1.46925

[10] Seoud, M.A. (1992) Outcome of twin, triplet and quadru-

plet in in-vitro fertilization pregnancies, the Norfolk ex-

perience. Fertility and Sterility, 57, 825-834.

[11] Mcdonald, S., Murphy, K., Beyene, J. and Ohlsson, A.

(2005) Perinatal outcomes of in vitro fertilization twins, a

systematic review and meta-analyses. American Journal

of Obstetrics & Gynecology, 193, 141-152.

doi,10.1016/j.ajog.2004.11.064

[12] Goleman, G.A., Fisch, B., Ovadia, J. and Tadir, Y. (1992)

Heterotopic pregnancies after assisted reproductive tech-

nologies. Obstetrical & Gynecological Survey, 47, 217-

221. doi,10.1097/00006254-199204000-00001

[13] Talo, C.P. (1995) Maternal and neonatal morbidity asso-

ciated with in vitro fertilization. The Journal of Pediatrics,

5, 794-800. doi,10.1016/S0022-3476(95)70175-3

[14] Smith, D.J.H. and Siddique, F.H. (1970) A case of heter-

otopic pregnancy. American Journal of Obstetrics & Gy-

necology, 108, 1289-1290.

[15] Rojansky, N. and Schenker, J.G. (1996) Heterotopic

pregnancy and assisted reproduction—An update. Jour-

nal of Assisted Reproduction and Genetics, 13, 594-601.

doi:10.1007/BF02066615