Spontaneous Heterotopic Pregnancy Managed in a Low‐Resource Setting: A Case Report of a Viable Intrauterine Pregnancy Following an Open Salpingectomy

ABSTRACT

Heterotopic pregnancy, though uncommon especially after natural conception, requires early diagnosis and optimal surgical management, particularly in low‐resource settings. This case underscores successful intrauterine pregnancy preservation following a ruptured ectopic pregnancy, highlighting the importance of clinical vigilance and timely intervention.

1. Introduction

A heterotopic pregnancy (HP) is an obstetrical/gynecological pathology defined as the simultaneous occurrence of both an intrauterine and extrauterine pregnancy. With an incidence in the general population ranging from 1 in 4000 to 1 in 30,000 pregnancies, it can progress to a potentially fatal situation that needs to be diagnosed and treated right away [1, 2]. Most reports on HP occur after assisted conceptions, with few cases reported after naturally occurring conception [3]. As a rule, in the context of a positive pregnancy test, an associated ectopic pregnancy cannot be ruled out after sole ultrasonographic examination of the intrauterine cavity revealing an intrauterine pregnancy (IUP) [1]. Optimizing the outcome of HP, especially that of the viable IUP, requires early detection and prompt treatment. When detected early, the treatment is usually surgical laparoscopically so as to maximize a favorable outcome for the viable IUP. In low‐resource settings, with limited access to health services and infrastructure, patients usually present with complications (ruptured ectopic pregnancy with hypovolemic shock), and treatment usually involves more invasive approaches, which can be detrimental to the IUP, resulting in a spontaneous abortion. This is a case report describing the surgical management and positive outcome of the intrauterine component of a HP after a spontaneous conception in a low‐resource setting. This piece of work has been reported according to the Surgical CAse REport guidelines [4].

2. Case Report

2.1. History, Physical Examination, and Investigation

This is the case of a 31‐year‐old G5P2021 of African descent known to be HIV positive and a defaulter. She also had a prior use of injectable contraceptives but stopped about 2 years prior to this admission and had a chronic history of burning epigastric pain managed with antacids and diet modifications. She presented at a clinic in the place at 11 weeks 6 days of amenorrhea (calculated from the first day of the last reported menstrual period), with a crampy, non‐radiating lower abdominal pain of mild severity, associated with vaginal spotting in an afebrile context. A urine pregnancy test done was positive, and an abdominopelvic ultrasound requested showed findings suggestive of a single viable IUP with a non‐ruptured left fallopian tube ectopic pregnancy at 8 weeks 4 days' gestational age. The patient was initially treated with antispasmodics and strict bed rest on an outpatient basis. Worsening in the intensity of the pain 2 days later prompted reevaluation at the clinic and referral to our setting for better management the same day following a repeat ultrasound done. On admission, vital signs were as follows: blood pressure, 100/60 mmHg; pulse, 104 beats/min, regular and rapid; respiratory rate, 20 cpm; temperature, 37°C. There was mild pallor, tenderness at both iliac and suprapubic regions, with rebound tenderness and rigidity in the same regions on deep palpation. There was also cervical motion tenderness, multiple ringworm‐like lesions at the lower abdomen, and medial aspects of both thighs and pubic regions.

2.2. Investigation and Diagnosis

Another pelvic ultrasound done showed a single viable IUP and an extrauterine gestational sac with fetal pole on the left tube with free fluid in the Morrison's pouch (Figure 1). This was suggestive of a HP with a ruptured left fallopian tube pregnancy and a viable IUP.

FIGURE 1.

(A) Hypoechogenicity suggestive of free fluid [FF] in the Morrison's pouch. (B) Extrauterine pregnancy [EUP] with fetal pole on the left fallopian tube. (C) Viable intrauterine pregnancy [FETUS].

2.3. Treatment

Following diagnosis, counseling for an emergency laparotomy was done. Preanesthetic evaluation was done, and coagulation profile tests with values within normal ranges were conducted. The patient was optimized with crystalloids and immediately taken to the theater for an emergency open laparotomy under general anesthesia. A midline abdominal incision was made for better exposure of the operative field and to optimize minimal manipulation of the uterus, as this can stimulate uterine contractions. Also, stable blood pressure and heart rate were maintained using fluid resuscitation via crystalloids and blood products administered as needed to maintain adequate circulation, aiming to keep systolic blood pressure > 90 mmHg and heart rate < 120 bpm. Intraoperatively, a dark red hemoperitoneum, a left ruptured ampullary ectopic pregnancy adhered to the greater omentum, a soft and bulky uterus, and an inflamed appendix were observed. Left salpingectomy, appendicectomy, and evacuation of 700 cc of dark red hemoperitoneum were effected without any complications. The patient received 2 units of whole compatible blood (1 intra‐operatively and 1 in the immediate post‐operative period) and received a course of non‐gastric irritant analgesics, antibiotic therapy, progesterones, and a proton pump inhibitor in the postoperative period.

2.4. Outcome and Follow‐Up

Post‐salpingectomy counseling was done; the patient was placed on blood tonics, topical antifungals, and reinitiated on antiretroviral therapy. Fetal heart sounds of the intrauterine gestation were within normal range in the immediate postoperative period. The patient was discharged on day 6 post‐operation for a follow‐up in 6 weeks' time by the gynecologist‐obstetrician. The patient was eventually lost to follow‐up, limiting our knowledge on the IUP viability beyond discharge, which remains questionable.

3. Discussion

HP, though rare, is increasingly reported due to factors such as assisted reproductive technologies (ART), infertility treatments, and prior pelvic inflammatory diseases. ART, in particular, has heightened the risk of HP, accounting for a notable rise in its incidence, from 0.1% to 1% of pregnancies [5]. In addition to raising the risk of HP, ART also makes certain types of extrauterine pregnancies (EUPs) more complicated. Some EUPs that are uncommon or even generally thought to be impossible to occur in a natural pregnancy appear after ART [3]. Despite this, naturally occurring HP, as presented in this case, remains less commonly documented, especially in low‐resource settings.

Diagnosing HP is challenging, as up to 33% of cases have initial sonographic findings limited to a normal IUP, resulting in misdiagnosis or delays in diagnosis and treatment initiation [6]. Early diagnosis and management are critical, especially for the preservation of the IUP. While β‐hCG levels assist in detecting EUPs without a simultaneously occurring IUP, their utility when used alone in the diagnosis of HP is limited. This is because they can be influenced by the concurrent IUP, which normally causes an elevation in serum β‐hCG [3]. This makes transvaginal ultrasound (TVUS) coupled with the β‐hCG levels the mainstays of HP diagnosis [3]. This is because, in our case, an abdominopelvic ultrasonography was used, coupled with a qualitative β‐hCG measurement (pregnancy test). According to the experience of the ultrasonographer, the gestational age, and the kind of EUP, the sensitivity of TVUS for the diagnosis of EUP might range from 73% to 93%. The sensitivity of TVUS is lower, missing the diagnosis if the pelvis cannot be adequately examined and if the position of the embryo implantation is uncommon [3]. In the context of an EUP implanted in the fallopian tube, with an associated IUP as in this case, the diagnosis of an HP depends on the ease of identifying the fallopian tubes. Typically, it can be identified in 70% of the cases between 5 and 8 weeks of gestation and becomes more difficult as the gestational age rises [7]. Early diagnosis and management of HP are thus very important. Diagnosis of this case was done at 11 weeks and 6 days of amenorrhea. The concurrent sonographic visualization of an IUP, a complex adnexal mass including a yolk sac, embryo, or fetal pole, or echogenic fluid in the posterior cul‐de‐sac can all be used to diagnose heterotopic pregnancy [2]. In this case, sonography showed findings suggestive of a single viable IUP with a left fallopian tube ectopic pregnancy and hemoperitoneum.

The symptoms, which include flank discomfort, vaginal bleeding, and in severe cases, hemodynamic instability, are comparable to those of an ectopic pregnancy, which may be ruptured if the latter sign is apparent [8, 9]. It may also manifest with spotting and an adnexal mass in the presence of an enlarged gravid uterus, with or without peritoneal irritation [7]. The state of the IUP has a significant impact on how HP is managed. The least intrusive method to preserve the intrauterine pregnancy is the best HP treatment, especially if the IUP is viable [8, 10]. Laparoscopic salpingectomy is a standard approach for surgical management of tubal heterotopic pregnancies [9, 11]. In the setting of hemodynamic instability, the priority may deviate toward arresting the ongoing bleeding secondary to the ruptured EUP. In this case, an emergency open laparotomy was performed due to the patient's hemodynamic instability and limited access to minimally invasive surgical facilities. However, this approach resulted in a good outcome and prognosis for the viable intrauterine gestation, as the postoperative period saw a normal state of the IUP, resulting in the discharge on postoperative day 6. Although evidence supporting the use of progesterone in first trimester bleeding management is low, studies suggest that its administration in patients with a prior history of miscarriage and first trimester bleeding plays an important role in limiting miscarriage [1]. Its utilization in this case was to improve the outcome of the IUP.

While the immediate surgical management of the ruptured EUP in this HIV‐positive defaulter patient was successful without apparent perioperative complications, generally a patient's HIV status profoundly impacts the clinical decision‐making process, especially in situations of unknown viral load and/or CD4+ count [12]. The absence of preoperative ART eliminated potential drug interactions, especially with general anesthetic drugs but highlighted the need to optimize HIV care before surgery for compliant patients. The successful immediate outcome, despite these challenges, underscores the importance of prompt surgical intervention for life‐threatening conditions, even in complex cases. However, the subsequent loss to follow‐up emphasizes the persistent challenges in managing HIV in vulnerable populations, particularly those who default from treatment, and the need for robust support systems to ensure continuous care [13]. Additionally, the delayed diagnosis in this case may not merely be an isolated event but rather a result of broader systemic deficiencies in healthcare delivery within low‐resource environments [14]. Addressing the challenges of patient health literacy, mitigating the impact of HIV‐related stigma on healthcare‐seeking behaviors, and improving equitable access to essential quality diagnostic technologies like ultrasound are crucial steps. A proactive approach to these systemic barriers could significantly reduce the incidence of catastrophic outcomes like ruptured EUP, ensuring that complex conditions like HP are diagnosed and managed promptly, thereby improving maternal morbidity and mortality in these vulnerable populations [13, 14].

4. Conclusion

It is important to have HP as a differential diagnosis in patients presenting with lower abdominal pain, vaginal spotting, or signs of ruptured EUP in the first and second trimesters of gestation, even in the presence of a confirmed IUP. Despite the challenges in accessing timely, quality, and safe surgical, obstetric, and anesthesia care in low‐resource settings, early identification and prompt surgical management of heterotopic pregnancy can be lifesaving.

Author Contributions

Berjo Takoutsing: conceptualization, writing – original draft, writing – review and editing. Nathan Ezie Kengo: writing – original draft, writing – review and editing. Aissatou Sow: writing – original draft, writing – review validation. Derek Ofon Nyoh: writing – review and editing. Cyril Egbe Obi: writing – review and editing. Caven Ngaise Ngoe: writing – review and editing. Vera A. Fontem: supervision, validation.

Disclosure

Patient perspective: The patient was satisfied with the level of care provided to her.

Ethics Statement

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient prior to the collection of data for our study.

Conflicts of Interest

The authors declare no conflicts of interest.

Takoutsing B., Kengo N. E., Sow A., et al., “Spontaneous Heterotopic Pregnancy Managed in a Low‐Resource Setting: A Case Report of a Viable Intrauterine Pregnancy Following an Open Salpingectomy,” Clinical Case Reports 13, no. 10 (2025): e70927, 10.1002/ccr3.70927.

Data Availability Statement

All the materials used in this study are available on request.