Acute hemoperitoneum after tubal rupture in a patient with synchronous intrauterine and ectopic pregnancy: A rare and life-threatening condition

C. R. Scarpa, O. Julen, P. Morel, T. Berney

Objective

Heterotopic pregnancy is defined as the coexistence of normal intrauterine and ectopic pregnancies. It is a rare event in natural conception cycles, occurring in around 1: 30,000 pregnancies, but is much more frequent in the case of in-vitro fertilization pregnancy (1:500). This rare event can be fatal for both mother and fetus, and can sometimes be challenging to diagnose.

This case report illustrates the fact that, even in a setting of natural intrauterine pregnancy, urgent explorative laparoscopy should be considered in a patient with acute abdominal pain and free intra-abdominal fluid.

Methods

A report of a single case of a disease, usually with an unexpected presentation.

Results

A 32-year-old patient, with an 8-week documented intrauterine pregnancy, presented with acute abdominal pain, localized peritonitis in the right iliac fossa and without inflammatory signs or hemodynamic instability. Gynaecological examination was reported as normal. Ultrasonography revealed an intrauterine evolutive pregnancy, moderate free intra-abdominal fluid with an image in the right iliac fossa compatible with appendicitis therefore the patient was transferred to the surgical emergency room.

Since supplementary radiological exams could not be performed, it was decided, with the patient's consent, to perform an emergency exploratory laparoscopy.

During surgery, a hemoperitoneum originating from a heterotopic pregnancy with right tubal rupture was identified. Consequently, the patient underwent a rightsalpingectomy.

Conclusion

The heterotopic pregnancy occurs in very rare cases during a natural pregnancy.

The diagnostic process is difficult, but in case of acute abdominal pain with evidence of free intra-abdominal fluid on the ultrasonography study, a diagnosis of concomitant heterotopic pregnancy should be suspected. In such cases, and when the diagnosis in unclear, explorative laparoscopy may contribute to a rapid diagnosis and reduce maternal and foetal morbidity and mortality, i.e. establishing and treating the condition while preserving foetal viability.

Figure 1: Ultrasonography, showing an intrauterine 8-­week pregnancy
Figure 2: Laparoscopic view, hemoperitoneum in right flank and hypochondrium
Figure 3: Laparoscopic view, hemorragic right ampullary pregnancy
Figure 4: Laparoscopic view of Fitz-­Hugh-­Curtis adherences