Successful Laparoscopic Management of Heterotopic Pregnancy at 12⁺² Weeks of Gestation

To the Editor: A 30-year-old pregnant women at 12⁺² (means 12 weeks and 2 days of gestation) weeks of gestation suffered severe distending pain in the lower abdomen, dizzy, and weakness for over 5 h. The patient had no other medical history except one abortion. Bimanual examination revealed tenderness in the left adnexal region and no hemorrhage in closed cervical os. Ultrasound showed a live fetus of 12⁺² weeks in the uterus, an irregular heterogeneous hypoechoic mass in front of the uterus, and massive fluid in the pelvis [Figure 1]. Culdocentesis revealed ~5-ml blood. The laboratory test showed hemoglobin of 85 g/L, hematocrit of 26.6%, white blood cell count of 19.09 × 10⁹/L, and normal platelet and clotting. Due to unknown intraperitoneal hemorrhage, an emergency laparoscopy was arranged.

Figure 1.

(a) Transabdominal ultrasound image showing an intrauterine pregnancy (crown-rump length, 58.34 mm). (b) Transabdominal ultrasound image showing an irregular heterogeneous hypoechoic mass in front of the uterus, the limit to the left ovary obliterated. (c) Transabdominal ultrasound image showing free intraperitoneal fluid.

After anesthesia, a 10-mm trocar was inserted 2 cm below xiphoid and insufflated with carbon dioxide at 12 mmHg (1 mmHg=0.133 kPa). Another two trocars (10 and 5 mm) were placed through left lower abdominal incisions on direct view. There was approximately 2000 ml of hemoperitoneum and blood clots in the abdomen. The left fallopian tube was enlarged by 50 mm × 30 mm × 30 mm with 5-mm long rupture where was bleeding. Aspirator was used carefully to avoid irritating the corpus uteri and clean the abdomen to prevent postoperative adhesions and trophoblastic implants. A left salpingectomy was performed using bipolar electrocoagulation to prevent massive hemorrhage and ischemic necrosis. Intraoperative bleeding was <20 ml. The patient was transfused with 4 units of red blood cells and 250-ml fresh frozen plasma during the procedure. Postoperative pathological examination of the resected tissue confirmed the presence of trophoblastic tissues [Figure 2]. The patient was diagnosed as heterotopic pregnancy (HP), rupture of the left fallopian tube pregnancy with G2P0, 12⁺² weeks of intrauterine pregnancy. The patient was discharged 4 days after operation. While the decline of human chorionic gonadotropin was not detected, repeated ultrasonographic examination, weekly follow-up, and close monitoring of clinical symptoms are required. The intrauterine pregnancy continued with no further complications and resulted in the delivery of a term pregnancy a few months later.

Figure 2.

Postoperative paraffin-section image showing the villus of tubal pregnancy in the background of blood clot (Hematoxylin and eosin staining, original magnification ×400).

HP is defined as the coexistence of an intrauterine pregnancy and an extrauterine pregnancy. The incidence is less than 1 in 30,000. However, with higher incidence of pelvic inflammatory disease and proliferation of assisted reproductive technologies, the incidence has increased >20 times.[1] HP is rarely encountered, and the presence of intrauterine pregnancy often impedes the diagnosis and early intervention for the ectopic pregnancy.[2] Clinical features of HP vary from asymptomatic, severe abdominal pain to hypovolemic shock.

The safety of laparoscopic surgery during pregnancy has been well documented in literature. Previous studies showed that there are no significant differences in postoperative complications or pregnancy outcomes compared with laparotomy. Moreover, laparoscopy has less postoperative pain, reduces hospital stays, and decreases risk of wound morbidity and thromboembolic events. Furthermore, laparoscopy can be safely performed during any trimester of pregnancy when operation is indicated.[3]

In conclusion, the clinical presentations of HP vary and could occur within 5–34 weeks of gestational age. This should be well aware to avoid misdiagnosis. Laparoscopy is a safe and effective technique during pregnancy with consistently positive outcomes.

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The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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Conflicts of interest

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