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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 6, Num. 3, 2002, pp. 117-119
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African Journal of Reproductive Health, Vol. 6, No. 3, December, 2002 pp.
117119
Heterotopic Pregnancy with Live
Twins
Eseohe A Aneziokoro1
1Department of Obstetrics
and Gynaecology, Ebonyi State University Teaching Hospital, PMB 077, Abakaliki,
Ebonyi State, Nigeria.
Code Number: rh02043
ABSTRACT
A 24-year-old primigravida
presented with subacute ectopic pregnancy and had salpingectomy for a ruptured
tubal pregnancy involving the ampullary portion of the left fallopian tube.
Post-operative follow-up revealed continuing symptoms of pregnancy and increasing
uterine size. A diagnosis of multiple pregnancy was confirmed by abdominal
ultrasonography. The patient was managed to term and had normal delivery of
twins. (Afr J Reprod Health 2002; 6[3]: 117119)
RÉSUMÉ
Grossesse hétérope aux
jumeaux vivants. Une primigeste âgée de 24 ans a présenté une grossesse
ectopique sous-aigu et elle a eu une salpingectiomie pour une rupture de
grossesse tubaire concernant la portion ampullaire de la trompe utérine gauche.
Les suites opératoires ont révélé des symptômes ininterrompus de la grossesse
et l'accroissement de l'utérine. L'ultrasonographie abdominale a confirmé le
diagnostic d'une grossesse multiple. La patiente a suivi du traitement jusqu'à terme
et elle a eu un accouchement normal des jumeaux. (Rev Afr Santé Reprod 2002;
6[3]: 117119)
KEY WORDS: Heterotopic
pregnancy, ectopic pregnancy, salpingectomy, twins
INTRODUCTION
Naturally occurring heterotopic pregnancy, first decribed by Duverney in 1708
at autopsy but now more commonly diagnosed in life, is rare.1 With
the rising incidence of ectopic pregnancies due to increasing risk factors
and the rising incidence of multiple pregnancies due to expansion in assisted
reproductive technologies in infertile couples, the chances of heterotopic
pregnancies are increasing in many centres.
CASE REPORT
A 24-year-old primigravida was admitted on January 4, 1998, presenting with
a history of two episodes of vaginal spotting following eight weeks amenorrhea.
Her LMP was November 5, 1997. The first episode of spotting was on December
29, 1997, and it lasted for one day. The second episode started on January
3, 1998, and was continuing. She also complained of weakness and lower abdominal
pain. She gave a past history of appendectomy in 1991. On examination, she
was pale with a rapid pulse and had abdominal tenderness. A diagnosis of subacute
ectopic pregnancy was made and the patient was prepared for surgery.
On January 5, 1998, laparotomy
revealed a ruptured tubal pregnancy involving the ampullary portion of the
left fallopian tube, massive hemoperitoneum and a bulky uterus about 10 weeks
with a tiny fibroid posteriorly. The right fallopian tube and both ovaries
were normal. Left salpingectomy was performed. Blood loss was 1250 ml. The
patient made an uneventful recovery and was discharged home on the 7th post-operative
day.
- The histology report
showed retained products of conception.
The patient was readmitted on February 5, 1998, with a history of nausea,
vomiting, abdominal discomfort, fever and weakness. She gave a history of laparotomy
one month earlier and her LMP as November 5, 1997. On examination, she was
afebrile but slightly pale. Temperature 37oC, pulse 90, respiration
30, blood pressure 110/60mmHg. Abdominal examination showed a fundal height
of 16 weeks (gestational age 13 weeks). Abdominal ultrasonography revealed
intrauterine gestation twins. Her EDD calculation was August 12, 1998.
- Laboratory
results: Haemoglobin 9.8 g/dl. Urine: Glucose nil, protein +, blood +, pus
cells +.
The patient was managed at the antenatal clinic and admitted when she went
into established labour on August 2, 1998, at 7.30 a.m. Early labour was said
to have started the previous night at about 8 p.m. On admission, her temperature
was 36.6OC, pulse 80, respiration 24, blood pressure 110/60mmHg,
fetal heart rates 140 and 148. Fundal height: term. Presentations: 1st baby
cephalic, engaged; 2nd baby breech, membrane intact. No vaginal bleeding. Vaginal
examination: cervix 90% effaced, Os 4cm dilated, station 0. Assistance given:
enema, artificial rupture of membrane (ARM), 5% dextrose intravenous drip.
First twin: female, delivered at 6.45 p.m., vacuum extraction due to poor maternal
effort, Apgar 7/1, 9/5, head circumference 34cm, length 50cm, weight 3.7kg.
Second twin: male, delivered at 6.50 p.m., breech extraction, apgar 6/1, 8/5,
head circumference 36cm, length 50cm, weight 3.8kg. Both babies developed physiological
jaundice between the second and third days. Both responded well to phototherapy
and phenobarbitone. First twin: female, total bilirubin 5.7mg/dl, conjugated
bilirubin 0.1mg/dl. Second twin: male, total bilirubin 4.6mg/dl, conjugated
bilirubin 0.08mg/dl.
Mother and babies were discharged
home on August 18, 1998. Follow-up: photograph of the twins; code-named by
parents, Testimony (the girl) and Miracle (the boy), at the age of nine months.
Their mother is now 15 weeks pregnant (April 4, 2000).
DISCUSSION
Naturally occurring heterotopic pregnancy (co-existence of intrauterine pregnancy
with ectopic pregnancy) remains rare. But in the last three decades, its incidence
has been rising in step with the increasing risk factors for ectopic pregnancy
and the increasing use of ovulation induction and new assisted reproductive
techniques in infertile couples.2
This patient falls into the category
of naturally occurring heterotopic (combined) pregnancies. Early diagnosis
was not easy. The threat to life of a ruptured tubal pregnancy drew attention
to the ectopic aspect of the condition. Persistence of symptoms of pregnancy
and abdominal ultrasonography revealed the intrauterine aspect of the condition.
The patient's management to term and safe delivery of dizygous twins (female
and male) were uneventful. A perfect outcome as in this case is not always
the rule. Approximately two thirds of intrauterine pregnancies in heterotopic
pregnancies are delivered alive while one third are aborted.
This patient had two risk factors,
which combined to produce this rare condition. She had a family history of
twin pregnancies and had had appendectomy seven years before her pregnancy.
The possibility of post-appendectomy adhesions rendered her prone to ectopic
pregnancy.
The lesson from this case is the
need for increased surveillance for the occurrence of heterotopic pregnancies
in Africa for the following reasons:
(a) The incidence of pregnancies
here remains among the highest in the world.
(b) The higher incidence of
multiple pregnancies here than in most other regions. In Nigeria, there are
45 twin pairs per 1000 births. This contrasts with 1012 pairs per 1000 births
in Caucasians and 5 pairs per 1000 births in some Far East (Asian) countries.
(c) The high incidence of
multiparity and grandmultiparity.
(d) The increase in risk factors
for ectopic pregnancy: pelvic inflammatory disease (PID), previous sexually
transmitted infections, previous abdominal surgery, previous ectopic pregnancy,
secondary infertility, intrauterine contraceptive devices (IUCDs), progestin-only
oral contraceptives, delayed marriages, and tubal surgery.
(e) The introduction of ovulation-induced
(fertility) drugs and new assisted reproductive techniques.
ACKNOWLEDGEMENTS
I wish to express my gratitude to Drs O.R. Onyebuchi, A. Ikpeamarom and I.
Dimejesi, my colleagues in the department who helped with the management of
the case; and to Professor C.A. Attah, Provost College of Health Sciences for
editorial guidance. I am also grateful to Dr C.N. Ogbu, Chief Medical Director
for sponsoring me to the 35th Annual Conference of the International College
of Surgeons in Port Harcourt where this paper was first presented on March
31, 2000.
REFERENCES
- Reece EA, Petrie RH, Sirmans
MF, Finster M and Todd WD. Combined intrauterine and extrauterine gestations:
a review. Am J Obstet Gynecol 1983; 146: 323330.
- Tat J, Haddad S, Gordon
N and Timor-Trisch I. Heterotopic pregnancy after ovulation induction and
assisted reproductive technologies: a literature review from 1971 to 1993.
Fertil Steril 1996;
66: 1-12.
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