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Abdominal pain in first trimester pregnancy
The Journal of Emergency Medicine, Vol. 24, No. 1, pp. 55–58, 2003 Copyright © 2003 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/03 $–see front matter
doi:10.1016/S0736-4679(02)00666-2
Case Presentations of the Harvard Emergency Medicine Residency
ABDOMINAL PAIN IN FIRST TRIMESTER PREGNANCY Todd Thomsen,
MD,*
David F. M. Brown,
MD,*†
and Eric S. Nadel,
MD†‡
*Harvard Affiliated Emergency Medicine Residency, †Department of Emergency Medicine, Massachusetts General Hospital, and ‡Department of Emergency Medicine, Brigham & Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, CLN-115, Boston, MA 02114
intrauterine pregnancy (IUP) with a fetal pole, as well as a second intrauterine gestational sac without a fetal pole. No adnexal abnormalities were noted. The patient denied any vaginal bleeding during the course of the current pregnancy. Dr. Peter Pang: Are there any other significant factors in her medical or surgical history? Dr. Thomsen: She denied any chronic medical problems and had no previous surgeries. A prenatal vitamin supplement was her only medication and she had no drug allergies. She denied the use of alcohol, tobacco and illicit substances. Upon our initial evaluation, the patient was pale, profusely diaphoretic, and in obvious distress; she preferred to lay motionless on the gurney, as any movement seemed to exacerbate her symptoms. Vital signs were as follows: temperature 37.2°C (99.0°F), heart rate 126 beats per minute, systolic blood pressure 68 mm Hg, respiratory rate 22 breaths per minute, oxygen saturation 98% on 100% oxygen via face mask. The head and neck examinations were unremarkable. The lungs were clear. Cardiac examination revealed a normal S1 and S2 without a murmur or gallop. The abdominal musculature was held tight with voluntary and involuntary guarding; there was exquisite tenderness to palpation in all four quadrants and rebound tenderness was also present. The pelvic examination revealed a closed os with no vaginal bleeding or discharge. There was bilateral adnexal ten-
Dr. Todd Thomsen: Today’s case is that of a 6-week pregnant 37-year-old woman with a chief complaint of severe abdominal pain. She was feeling well until the morning of admission, when she experienced the acute onset of severe lower abdominal and pelvic pain. She described the pain as sharp, constant and severe. Shortly after the onset of the pain, she felt lightheaded and had several near-syncopal episodes. There was no malaise, anorexia or dull abdominal pain, and she denied recent trauma, nausea, vomiting, diarrhea, dysuria, flank pain, fever or chills. Her last bowel movement was earlier that morning and was normal. She had eaten a light breakfast of toast and juice several hours before the pain had begun. Dr. Nathan Mick: While the differential diagnosis of abdominal pain is large, the first diagnosis to consider in a woman in her first trimester is ectopic pregnancy. Can you tell us more about her obstetrical history? Was she experiencing any vaginal bleeding? Dr. Thomsen: The patient was G2P1. Her first pregnancy was approximately 10 years ago and was without complications. The current pregnancy was a result of in vitro fertilization (IVF), and three embryos had been transferred into her uterus 6 weeks prior to her Emergency Department (ED) visit. The cause of her infertility was unknown, and she had no history of tubal surgery or pelvic inflammatory disease. An ultrasound performed 1 week prior to presentation showed a normal 5-week-old
Case Presentations of the Harvard Emergency Medicine Residency are coordinated by David F. M. Brown, MD, and Eric S. Nadel, MD, of Harvard University Medical School, Boston, Massachusetts
RECEIVED: 20 September 2002; ACCEPTED: 21 September 2002 55
56
T. Thomsen et al.
Figure 1. Right upper quadrant ultrasound shows the black anechoic stripe of free intraperitoneal fluid (white arrows) in Morison’s pouch, between the liver and the right kidney.
derness and moderate cervical motion tenderness but no masses were palpable. The rectal examination revealed no masses or tenderness; stool was brown and negative for occult blood. Radial pulses were absent, brachial pulses were weak, and femoral pulses were present and symmetrical. She was awake, alert and oriented; the remainder of her neurological examination was non-focal. Dr. Jonathan Adler: This is the type of patient who requires immediate intervention, before any diagnostic tests are performed. While we may not know the exact diagnosis, she is in shock with an acute abdomen; appropriate vascular access and aggressive fluid resuscitation are indicated. It seems as though her airway was intact, however, intubation equipment should be seriously entertained for any patient in shock. Additionally, emergent surgical and gynecological consultation should be obtained. Can you describe your initial management of this patient? Dr. Thomsen: Our first priority was to establish intravenous access. Two large-bore peripheral i.v.s were established, and a central venous line was placed in the right femoral vein. Four liters of normal saline were rapidly infused, and her blood pressure rose to 102/80 mm Hg and her heart rate decreased to 100 beats/min. Cefotetan 1 g i.v. was administered empirically. A por-
table chest X-ray study revealed no evidence of acute cardiopulmonary disease or pneumoperitoneum. A bedside ultrasound revealed a large black anechoic stripe in Morison’s pouch, highly suggestive of free intraperitoneal fluid (Figure 1). The electrocardiogram showed sinus tachycardia. A basic metabolic panel and liver panel were normal, the white blood cell count was 22,000 cells/mm3, and the hematocrit was 28%. The quantitative [beta] human chorionic gonadotropin level was 100,787 IU/L. Surgical and gynecological consultations were immediately obtained. Before we continue with her course, I would like to open a discussion of the differential diagnosis. Dr. James Takayesu: Abdominal pain of acute onset that is associated with signs of peritoneal irritation and hemodynamic instability is often secondary to rupture of a hollow viscus or to a rupture or occlusion of a major artery. Perforated appendicitis or diverticulitis are possibilities, as is a perforated duodenal ulcer. Cholecystitis should be considered as well. Vascular etiologies of the acute abdomen include ruptured aortic aneurysm and mesenteric ischemia. Given the instability of the patient, I suspect her diagnosis will be made in the operating room rather than via computed tomography (CT) scan or other diagnostic test.
First Trimester Abdominal Pain
Dr. Vicki Noble: The differential diagnosis must also include ectopic pregnancy, or more precisely, heterotopic pregnancy (as we know this patient has a viable IUP). Though this entity was once thought to be exceedingly rare, patients undergoing IVF or similar procedures are at higher risk of developing this condition. Dr. Eric Nadel: I agree that the leading diagnosis in this pregnant woman in shock with an acute abdomen is a ruptured ectopic pregnancy. I would consider early transfusions of packed red blood cells in order to improve the oxygen-carrying capacity to her own vital organs and to her fetus. Dr. Thomsen: Our colleagues from the gynecology service felt that the most likely diagnosis was ruptured heterotopic pregnancy, and the patient was taken to the operating room emergently for exploratory laparotomy 40 min after arrival in the ED. Upon entering her peritoneal cavity, the gynecologists found approximately 3 L of clotted and liquid blood. A ruptured ectopic pregnancy was found at the fimbria of the right fallopian tube, and a distal salpingectomy was performed. Her intraoperative hematocrit fell to 12%, and she required the transfusion of four units of packed red blood cells. She recovered from the surgery without complication, but unfortunately an ultrasound on post-operative day 3 revealed demise of the previously viable intrauterine pregnancy; a dilatation and evacuation was subsequently performed. Dr. David Brown: Can you describe the incidence and clinical features of heterotopic pregnancy? Dr. Thomsen: Heterotopic pregnancy is defined as the simultaneous occurrence of two or more pregnancy implantation sites (1). While classical teachings suggest this condition is exceedingly rare, recent studies suggest that the incidence of heterotopic pregnancy is increasing, and knowledge of this potentially fatal disorder is mandatory for the practicing emergency physician. The incidence of heterotopic pregnancy can be estimated by multiplying the incidence of dizygous twinning by the incidence of ectopic pregnancy. In 1948, the twinning rate was 0.8% and the ectopic pregnancy rate was 0.37%, and thus the rate of heterotopic pregnancy was 1 in 30,000 pregnancies (2). Over the past 5 decades the incidence of heterotopic pregnancy has dramatically increased (estimated to occur in one of every 3889 pregnancies in 1986), in part due to the increasing incidence of tubal disease in women (1). However, it is the development of assisted reproductive technologies (ART) such as IVF that has most dramatically affected the rate of heterotopic pregnancy. The reason for this is twofold. First, the prevalence of tubal disease in women utilizing ART is much higher than the general population, thus leading to higher rates of ectopic pregnancy. Secondly, many ARTs involve ovarian hyperstimulation or the transfer of multiple embryos, which results in higher
57
rates of dizygous twinning (or higher order births.) Recent data suggest that in ART the ectopic pregnancy rate is around 3%, and the multiple pregnancy rate is between 10 and 25%. This corresponds to a heterotopic pregnancy rate of 1 in 100 assisted pregnancies (2,3). In cases in which five or more embryos are transferred, the rate climbs to 1 in 45 pregnancies (1). Clearly, heterotopic pregnancy can no longer be considered a rare disorder, at least not in select patient populations. Although the transfer of multiple embryos is the primary reason for high heterotopic rates in ART pregnancies, other factors may be implicated as well. Altered tubal function due to elevated circulating hormone levels, embryo placement near the tubal ostia, and retrograde uterine contractions are theorized to be responsible as well (3). The vast majority of heterotopic pregnancies are diagnosed in the first trimester. Seventy percent are discovered during weeks 5– 8, 20% during weeks 9 and 10, and 10% are found after the 11th week. Discovery of a heterotopic pregnancy as late as week 26 has been reported (2). The symptoms of heterotopic pregnancy are similar to those of ectopic pregnancy. Abdominal pain and tenderness is the most common symptom, occurring in over 80% of cases. Vaginal bleeding occurs less frequently in heterotopic pregnancy (32%) than in ectopic pregnancy (79%). Patients with ruptured heterotopic pregnancy (as in our patient) may present with signs of shock or frank peritoneal irritation (4). In cases diagnosed early (usually by ultrasound), the patient may be asymptomatic (2). The diagnosis of heterotopic pregnancy can be difficult to make, but should be aggressively searched for in appropriate cases. Multiple authors report that fewer than 50% of heterotopic pregnancies are diagnosed via ultrasound; the remainder are discovered during emergent surgery for the acute abdomen (2,5). Several other points are worth emphasizing. Serial HCG measurements, a mainstay in the diagnosis of ectopic pregnancy, cannot be utilized in the diagnosis of heterotopic pregnancy due to the presence of the concomitant intrauterine pregnancy (5). Furthermore, the presence of an intrauterine pregnancy on ultrasound does not exclude the presence of a second, extra-uterine pregnancy in a woman undergoing ART (1,3). Recall that in our case, the 5-week ultrasound found only two of the three embryos transferred (an IUP and an empty intrauterine gestational sac). The third embryo, the source of the 16-point hematocrit drop, was not visualized. As with ectopic pregnancy, the majority of heterotopic pregnancies occur within the fallopian tube (5). However, there is a higher incidence of abdominal and cornual implantations with heterotopic pregnancies. Cornual heterotopic pregnancy (implantation at the site
58
where the fallopian tube enters the uterus) is especially problematic for several reasons. Ultrasound has a lower sensitivity for cornual pregnancies, pain may not be present due to the distensibility of the uterus, and rupture of the cornual region almost always leads to massive hemoperitoneum given the highly vascular gravid uterus (2). Thus, diagnosis is difficult, and delayed diagnosis is deadly. Surgical intervention is the most common treatment for heterotopic pregnancy (2). Laparoscopy is preferable over laparotomy (due to lower costs, shorter length of stay, quicker recovery, and higher rates of subsequent intrauterine pregnancies). However, in patients with unstable vital signs or multiple previous surgical procedures, laparotomy is the preferred method (6). Medical therapy, such as the use of systemic methotrexate, is gaining popularity in the treatment of uncomplicated ectopic pregnancy, but is of limited utility in the treatment of heterotopic pregnancy out of concerns for the IUP. Direct injection of toxic substances (such as methotrexate, potassium chloride, or hyperosmolar glucose) into the heterotopic gestational sac has been advocated in
T. Thomsen et al.
the literature as a safe alternative to surgery (7). When the diagnosis of heterotopic pregnancy is established in a timely fashion, maternal mortality is held to a minimum. Unfortunately, the intrauterine pregnancies do not fare as well, and as many as 33% end as fetal demise (2), as was the case for our patient who otherwise recovered well. REFERENCES 1. Habana A, Kokras A, Giraldo J, Jones E. Cornual heterotopic pregnancy: contemporary management options. Am J Obstet Gynecol 2000;182:1264 –70. 2. Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: a literature review from 1971 to 1993. Fertil Steril 1996;66:1–12. 3. Dumesic D, Damario M, Session D. Interstitial heterotopic pregnancy in a woman conceiving by in vitro fertilization after bilateral salpingectomy. Mayo Clin Proc 2001;76:90 –2. 4. Tay JI, Moore J, Walker JJ. Ectopic pregnancy. Br Med J 2000; 320:916 –9. 5. Pisarska M, Carson S. Incidence and risk factors for ectopic pregnancy. Clin Obstet Gynecol 1999;42:2– 8. 6. Tulandi T, Saleh A. Surgical management of ectopic pregnancy. Clin Obstet Gynecol 1999;42:31– 8. 7. Lipscomb GH, Stovall TG, Ling FW. Primary care: nonsurgical treatment of ectopic pregnancy. N Engl J Med 2000;343:1325–9.
doi:10.1016/S0736-4679(02)00666-2
Case Presentations of the Harvard Emergency Medicine Residency
ABDOMINAL PAIN IN FIRST TRIMESTER PREGNANCY Todd Thomsen,
MD,*
David F. M. Brown,
MD,*†
and Eric S. Nadel,
MD†‡
*Harvard Affiliated Emergency Medicine Residency, †Department of Emergency Medicine, Massachusetts General Hospital, and ‡Department of Emergency Medicine, Brigham & Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, CLN-115, Boston, MA 02114
intrauterine pregnancy (IUP) with a fetal pole, as well as a second intrauterine gestational sac without a fetal pole. No adnexal abnormalities were noted. The patient denied any vaginal bleeding during the course of the current pregnancy. Dr. Peter Pang: Are there any other significant factors in her medical or surgical history? Dr. Thomsen: She denied any chronic medical problems and had no previous surgeries. A prenatal vitamin supplement was her only medication and she had no drug allergies. She denied the use of alcohol, tobacco and illicit substances. Upon our initial evaluation, the patient was pale, profusely diaphoretic, and in obvious distress; she preferred to lay motionless on the gurney, as any movement seemed to exacerbate her symptoms. Vital signs were as follows: temperature 37.2°C (99.0°F), heart rate 126 beats per minute, systolic blood pressure 68 mm Hg, respiratory rate 22 breaths per minute, oxygen saturation 98% on 100% oxygen via face mask. The head and neck examinations were unremarkable. The lungs were clear. Cardiac examination revealed a normal S1 and S2 without a murmur or gallop. The abdominal musculature was held tight with voluntary and involuntary guarding; there was exquisite tenderness to palpation in all four quadrants and rebound tenderness was also present. The pelvic examination revealed a closed os with no vaginal bleeding or discharge. There was bilateral adnexal ten-
Dr. Todd Thomsen: Today’s case is that of a 6-week pregnant 37-year-old woman with a chief complaint of severe abdominal pain. She was feeling well until the morning of admission, when she experienced the acute onset of severe lower abdominal and pelvic pain. She described the pain as sharp, constant and severe. Shortly after the onset of the pain, she felt lightheaded and had several near-syncopal episodes. There was no malaise, anorexia or dull abdominal pain, and she denied recent trauma, nausea, vomiting, diarrhea, dysuria, flank pain, fever or chills. Her last bowel movement was earlier that morning and was normal. She had eaten a light breakfast of toast and juice several hours before the pain had begun. Dr. Nathan Mick: While the differential diagnosis of abdominal pain is large, the first diagnosis to consider in a woman in her first trimester is ectopic pregnancy. Can you tell us more about her obstetrical history? Was she experiencing any vaginal bleeding? Dr. Thomsen: The patient was G2P1. Her first pregnancy was approximately 10 years ago and was without complications. The current pregnancy was a result of in vitro fertilization (IVF), and three embryos had been transferred into her uterus 6 weeks prior to her Emergency Department (ED) visit. The cause of her infertility was unknown, and she had no history of tubal surgery or pelvic inflammatory disease. An ultrasound performed 1 week prior to presentation showed a normal 5-week-old
Case Presentations of the Harvard Emergency Medicine Residency are coordinated by David F. M. Brown, MD, and Eric S. Nadel, MD, of Harvard University Medical School, Boston, Massachusetts
RECEIVED: 20 September 2002; ACCEPTED: 21 September 2002 55
56
T. Thomsen et al.
Figure 1. Right upper quadrant ultrasound shows the black anechoic stripe of free intraperitoneal fluid (white arrows) in Morison’s pouch, between the liver and the right kidney.
derness and moderate cervical motion tenderness but no masses were palpable. The rectal examination revealed no masses or tenderness; stool was brown and negative for occult blood. Radial pulses were absent, brachial pulses were weak, and femoral pulses were present and symmetrical. She was awake, alert and oriented; the remainder of her neurological examination was non-focal. Dr. Jonathan Adler: This is the type of patient who requires immediate intervention, before any diagnostic tests are performed. While we may not know the exact diagnosis, she is in shock with an acute abdomen; appropriate vascular access and aggressive fluid resuscitation are indicated. It seems as though her airway was intact, however, intubation equipment should be seriously entertained for any patient in shock. Additionally, emergent surgical and gynecological consultation should be obtained. Can you describe your initial management of this patient? Dr. Thomsen: Our first priority was to establish intravenous access. Two large-bore peripheral i.v.s were established, and a central venous line was placed in the right femoral vein. Four liters of normal saline were rapidly infused, and her blood pressure rose to 102/80 mm Hg and her heart rate decreased to 100 beats/min. Cefotetan 1 g i.v. was administered empirically. A por-
table chest X-ray study revealed no evidence of acute cardiopulmonary disease or pneumoperitoneum. A bedside ultrasound revealed a large black anechoic stripe in Morison’s pouch, highly suggestive of free intraperitoneal fluid (Figure 1). The electrocardiogram showed sinus tachycardia. A basic metabolic panel and liver panel were normal, the white blood cell count was 22,000 cells/mm3, and the hematocrit was 28%. The quantitative [beta] human chorionic gonadotropin level was 100,787 IU/L. Surgical and gynecological consultations were immediately obtained. Before we continue with her course, I would like to open a discussion of the differential diagnosis. Dr. James Takayesu: Abdominal pain of acute onset that is associated with signs of peritoneal irritation and hemodynamic instability is often secondary to rupture of a hollow viscus or to a rupture or occlusion of a major artery. Perforated appendicitis or diverticulitis are possibilities, as is a perforated duodenal ulcer. Cholecystitis should be considered as well. Vascular etiologies of the acute abdomen include ruptured aortic aneurysm and mesenteric ischemia. Given the instability of the patient, I suspect her diagnosis will be made in the operating room rather than via computed tomography (CT) scan or other diagnostic test.
First Trimester Abdominal Pain
Dr. Vicki Noble: The differential diagnosis must also include ectopic pregnancy, or more precisely, heterotopic pregnancy (as we know this patient has a viable IUP). Though this entity was once thought to be exceedingly rare, patients undergoing IVF or similar procedures are at higher risk of developing this condition. Dr. Eric Nadel: I agree that the leading diagnosis in this pregnant woman in shock with an acute abdomen is a ruptured ectopic pregnancy. I would consider early transfusions of packed red blood cells in order to improve the oxygen-carrying capacity to her own vital organs and to her fetus. Dr. Thomsen: Our colleagues from the gynecology service felt that the most likely diagnosis was ruptured heterotopic pregnancy, and the patient was taken to the operating room emergently for exploratory laparotomy 40 min after arrival in the ED. Upon entering her peritoneal cavity, the gynecologists found approximately 3 L of clotted and liquid blood. A ruptured ectopic pregnancy was found at the fimbria of the right fallopian tube, and a distal salpingectomy was performed. Her intraoperative hematocrit fell to 12%, and she required the transfusion of four units of packed red blood cells. She recovered from the surgery without complication, but unfortunately an ultrasound on post-operative day 3 revealed demise of the previously viable intrauterine pregnancy; a dilatation and evacuation was subsequently performed. Dr. David Brown: Can you describe the incidence and clinical features of heterotopic pregnancy? Dr. Thomsen: Heterotopic pregnancy is defined as the simultaneous occurrence of two or more pregnancy implantation sites (1). While classical teachings suggest this condition is exceedingly rare, recent studies suggest that the incidence of heterotopic pregnancy is increasing, and knowledge of this potentially fatal disorder is mandatory for the practicing emergency physician. The incidence of heterotopic pregnancy can be estimated by multiplying the incidence of dizygous twinning by the incidence of ectopic pregnancy. In 1948, the twinning rate was 0.8% and the ectopic pregnancy rate was 0.37%, and thus the rate of heterotopic pregnancy was 1 in 30,000 pregnancies (2). Over the past 5 decades the incidence of heterotopic pregnancy has dramatically increased (estimated to occur in one of every 3889 pregnancies in 1986), in part due to the increasing incidence of tubal disease in women (1). However, it is the development of assisted reproductive technologies (ART) such as IVF that has most dramatically affected the rate of heterotopic pregnancy. The reason for this is twofold. First, the prevalence of tubal disease in women utilizing ART is much higher than the general population, thus leading to higher rates of ectopic pregnancy. Secondly, many ARTs involve ovarian hyperstimulation or the transfer of multiple embryos, which results in higher
57
rates of dizygous twinning (or higher order births.) Recent data suggest that in ART the ectopic pregnancy rate is around 3%, and the multiple pregnancy rate is between 10 and 25%. This corresponds to a heterotopic pregnancy rate of 1 in 100 assisted pregnancies (2,3). In cases in which five or more embryos are transferred, the rate climbs to 1 in 45 pregnancies (1). Clearly, heterotopic pregnancy can no longer be considered a rare disorder, at least not in select patient populations. Although the transfer of multiple embryos is the primary reason for high heterotopic rates in ART pregnancies, other factors may be implicated as well. Altered tubal function due to elevated circulating hormone levels, embryo placement near the tubal ostia, and retrograde uterine contractions are theorized to be responsible as well (3). The vast majority of heterotopic pregnancies are diagnosed in the first trimester. Seventy percent are discovered during weeks 5– 8, 20% during weeks 9 and 10, and 10% are found after the 11th week. Discovery of a heterotopic pregnancy as late as week 26 has been reported (2). The symptoms of heterotopic pregnancy are similar to those of ectopic pregnancy. Abdominal pain and tenderness is the most common symptom, occurring in over 80% of cases. Vaginal bleeding occurs less frequently in heterotopic pregnancy (32%) than in ectopic pregnancy (79%). Patients with ruptured heterotopic pregnancy (as in our patient) may present with signs of shock or frank peritoneal irritation (4). In cases diagnosed early (usually by ultrasound), the patient may be asymptomatic (2). The diagnosis of heterotopic pregnancy can be difficult to make, but should be aggressively searched for in appropriate cases. Multiple authors report that fewer than 50% of heterotopic pregnancies are diagnosed via ultrasound; the remainder are discovered during emergent surgery for the acute abdomen (2,5). Several other points are worth emphasizing. Serial HCG measurements, a mainstay in the diagnosis of ectopic pregnancy, cannot be utilized in the diagnosis of heterotopic pregnancy due to the presence of the concomitant intrauterine pregnancy (5). Furthermore, the presence of an intrauterine pregnancy on ultrasound does not exclude the presence of a second, extra-uterine pregnancy in a woman undergoing ART (1,3). Recall that in our case, the 5-week ultrasound found only two of the three embryos transferred (an IUP and an empty intrauterine gestational sac). The third embryo, the source of the 16-point hematocrit drop, was not visualized. As with ectopic pregnancy, the majority of heterotopic pregnancies occur within the fallopian tube (5). However, there is a higher incidence of abdominal and cornual implantations with heterotopic pregnancies. Cornual heterotopic pregnancy (implantation at the site
58
where the fallopian tube enters the uterus) is especially problematic for several reasons. Ultrasound has a lower sensitivity for cornual pregnancies, pain may not be present due to the distensibility of the uterus, and rupture of the cornual region almost always leads to massive hemoperitoneum given the highly vascular gravid uterus (2). Thus, diagnosis is difficult, and delayed diagnosis is deadly. Surgical intervention is the most common treatment for heterotopic pregnancy (2). Laparoscopy is preferable over laparotomy (due to lower costs, shorter length of stay, quicker recovery, and higher rates of subsequent intrauterine pregnancies). However, in patients with unstable vital signs or multiple previous surgical procedures, laparotomy is the preferred method (6). Medical therapy, such as the use of systemic methotrexate, is gaining popularity in the treatment of uncomplicated ectopic pregnancy, but is of limited utility in the treatment of heterotopic pregnancy out of concerns for the IUP. Direct injection of toxic substances (such as methotrexate, potassium chloride, or hyperosmolar glucose) into the heterotopic gestational sac has been advocated in
T. Thomsen et al.
the literature as a safe alternative to surgery (7). When the diagnosis of heterotopic pregnancy is established in a timely fashion, maternal mortality is held to a minimum. Unfortunately, the intrauterine pregnancies do not fare as well, and as many as 33% end as fetal demise (2), as was the case for our patient who otherwise recovered well. REFERENCES 1. Habana A, Kokras A, Giraldo J, Jones E. Cornual heterotopic pregnancy: contemporary management options. Am J Obstet Gynecol 2000;182:1264 –70. 2. Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: a literature review from 1971 to 1993. Fertil Steril 1996;66:1–12. 3. Dumesic D, Damario M, Session D. Interstitial heterotopic pregnancy in a woman conceiving by in vitro fertilization after bilateral salpingectomy. Mayo Clin Proc 2001;76:90 –2. 4. Tay JI, Moore J, Walker JJ. Ectopic pregnancy. Br Med J 2000; 320:916 –9. 5. Pisarska M, Carson S. Incidence and risk factors for ectopic pregnancy. Clin Obstet Gynecol 1999;42:2– 8. 6. Tulandi T, Saleh A. Surgical management of ectopic pregnancy. Clin Obstet Gynecol 1999;42:31– 8. 7. Lipscomb GH, Stovall TG, Ling FW. Primary care: nonsurgical treatment of ectopic pregnancy. N Engl J Med 2000;343:1325–9.