What is a heterotopic pregnancy? 32-year-old woman's diagnosis highlights hidden risk

A 32-year-old woman who conceived through IVF was found to be carrying two pregnancies at once, one in the uterus and the other in the right fallopian tube. By the time she reached surgery, the tubal pregnancy had ruptured, and about 800 ml of blood and clots had collected in her abdomen.

What is a heterotopic pregnancy?

She was 11 weeks pregnant and was diagnosed with a heterotopic pregnancy, which is when an intrauterine pregnancy and an ectopic pregnancy occur at the same time. It is a rare condition, occurring in about 1 in 30,000 pregnancies (around 0.003%) in the general population. If the pregnancy follows assisted reproductive techniques such as IVF, the risk is higher.

The main difficulty for the doctors was to remove the ruptured ectopic pregnancy and stop the internal bleeding without disturbing the pregnancy inside the uterus.

The team carried out an emergency laparoscopic right-sided salpingectomy, removing the ruptured fallopian tube, and then cleared the blood and clots from the abdominal cavity. They found about 800 ml of blood and clots in the pelvis and abdomen. The right tube was swollen, ruptured and bleeding, with products of conception inside it.

Why it can be difficult to locate the pregnancy?

The patient also had endometriosis-related adhesions, which made the operation harder. Bands of tissue between the back of the uterus and the bowel had hidden the tube and ovary lying behind the uterus. This made it difficult to locate the tubal pregnancy and complicated the dissection. The surgeons had to take out the tube while handling the enlarged uterus as little as possible, to protect the pregnancy inside it.

Dr Renu Sehgal of the Department of Obstetrics & Gynaecology at Artemis Hospitals said, "The primary challenge in a heterotopic pregnancy is to manage the ectopic pregnancy while preserving the ongoing intrauterine pregnancy. In this case, the situation was particularly complex because the patient was already 11 weeks pregnant. At this stage, the uterus is significantly enlarged, while the tubal pregnancy is also well developed. Once the tubal pregnancy ruptures, bleeding can be torrential and immediate surgical intervention becomes necessary. The presence of endometriosis-related adhesions had also obscured the tube and ovary behind the uterus, making both identification and dissection difficult. Our focus throughout the procedure was to control the bleeding and remove the ruptured ectopic pregnancy while minimising manipulation of the uterus and protecting the ongoing pregnancy."

ALSO READ | Before 45: What every woman must know about early menopause and perimenopause

What happens if the ectopic pregnancy develops?

Doctors said that when a heterotopic pregnancy is picked up early, around 6 to 8 weeks, surgery is comparatively easier because the uterus and the ectopic pregnancy are both still small. In later cases, as the uterus grows and the ectopic pregnancy develops, the procedure becomes more technically demanding, especially if rupture has already happened.

The woman recovered without complications. She was able to move about soon after the surgery, her catheter was taken out on the first day, and she was discharged in stable condition. She was advised to come back for follow-up and ultrasound checks to monitor the pregnancy in the uterus.

Dr Nidhi said, "Heterotopic pregnancy is a rare and serious condition requiring prompt diagnosis and careful surgical management. The ruptured fallopian tube was causing major internal bleeding, but the pregnancy inside the uterus had to be preserved. The endometriosis adhesions made it even more difficult. Our priority was to control the bleeding, remove the ruptured pregnancy safely and minimize uterine manipulation to protect the ongoing pregnancy."

Heterotopic pregnancy can be hard to spot. Once a pregnancy is seen inside the uterus, it can seem as though an ectopic pregnancy has been ruled out, but a pregnancy in the uterus does not exclude one in the tube. This matters most in pregnancies that come from IVF or other assisted reproductive techniques.

How weight loss helps prevent pregnancy complications?

"Weight loss is also helpful in keeping away the chances of miscarriage and pregnancy complications like hypertension, gestational diabetes, and premature delivery. So, a healthy body weight is crucial for sustaining a pregnancy. However, it's crucial to clearly understand that weight is not the only determining factor for treatment success. Age, egg reserve in the ovaries, embryo quality, and underlying medical issues are among the major contributing factors," Dr Ila Gupta, Chief IVF Consultant, Pristyn Care Ferticity, further explains.

Doctors say the case is a reminder that severe or persistent abdominal pain, bleeding or other worrying symptoms in early pregnancy should be checked promptly, even if a pregnancy in the uterus has already been confirmed. Catching the problem early can prevent serious complications from a ruptured ectopic pregnancy and give the pregnancy in the uterus a chance to continue.

(This article is meant for informational purposes only and must not be considered a substitute for advice provided by qualified medical professionals. Always seek the advice of your doctor for any questions about medical conditions.)