A. G. Adesiyun, B. Ayodele-Cole / Open Journal of Obstetrics and Gynecology 2 (2012) 325-327
326
the fetuses were lying transversely. She was delivered of
2 male fetuses that weighed 2.5 kg and 2.05 kg with
good apgar scores. She had primary postpartum haemor-
rhage due to uterine atony and lost about 2.2 litres of
blood despite rectal insertion of misoprostol, manual
uterine compression .and oxytocin drip. She had a total
of 5 units of blood transfusion intra and post operatively.
On the 8th post surgery day she was discharged home
following good recuperation and satisfactory general
condition.
3. DISCUSSION
Heterotopic pregnancy which was first described at an
autopsy study [3] was hitherto a rarity before the intro-
duction and widespread use of ART. In natural concep-
tion cycles low frequency ranging from 1 in 10,000 to 1
in 50,000 was reported and high rates of heterotopic
pregnancy from 1 in 100 to 1 in 500 was reported in ART
treatment cycles [4-6]. The later is attributable to super
ovulation induction, multiple embryo transfer with re-
sultant increase in multiple pregnancy and ectopic preg-
nancy. In this report the intrauterine pregnancy was a
twin. This is in conformity with authors that reported an
increase in and not in uterine twin gestation. In ART-
related heterotopic pregnancy and an exclusive singleton
intrauterine gestations in natural cycle related heterotopic
pregnancy [4]. In this case report, heterotopic diagnosis
was made at about seven weeks of gestation. This is
within the 5th to 8th week gestation reported to be the
commonest diagnostic period interval for heterotopic
pregnancies [4,7]. Furthermore, the type of cycle, be it
assisted or natural cycle did not affect the gestational age
at diagnosis [4]. The ectopic gestation in this report was
tubal, similar to finding in other series [4,7,8]. Though,
the ectopic gestation was in the right tube in this patient,
there is no predilection for right or left tube in hetero-
topic pregnancy [4,8]. In the evaluation of this patient
before index conception, she had hysterosalpingographic
tubal occlusion and therapeutic hydrotubation as earlier
described by these authors [9]. Studies have highlighted
the importance of previous pelvic pathology as a risk
factor for heterotopic pregnancy, especially in the cohort
that had heterotopic pregnancy following assisted con-
ception [4].
The clinical presentation in this case report includes
hypovolemic shock, tubal rupture and haemoperitoneum.
Being a case of heterotopic pregnancy fo llowing assisted
conception this finding are in contrast to that of a series
that reported on outcome of heterotopic pregnancies and
found a significantly lower rate of low systolic blood
pressure, tubal rupture and haemoperitoneum in the as-
sisted conception group compared to spontaneous con-
ception group [4]. A high miscarriage rate have been
reported in multiple pregnancy and pregnancy compli-
cated by heterotopic implantation with higher rate of
miscarriage documented in heterotopic pregnancy com-
plicating assisted conception than spontaneous concep-
tion [4,10-12]. The aggregate of these predisposing fac-
tors did not result in miscarriage in the case presented.
Mu ltiple pregnancy and Heterotopic pregnancy are kn own
to individually predispose to preterm births [4,7,13]. This
patient was delivered of 2 male babies by caesarean
section at 36 weeks due to preterm spontaneous rupture
of fetal membranes. In heterotopic pregnancy, survival
rate of the intrauterine gestation range from 35% to
66.2% [7,14,15]. This rates are influenced by variables
that hovers round ear ly diagnosis and treatment viz- a-viz
treatment before tubal rupture and development of hae-
moperitoneum and hypovolemic shock that may result in
hypoxic challenge to the intrauterine fetus [4]. A high
survival rate translate to improve live birth rate. The poor
clinical condition in this case as exhibited by tubal
rupture, haemoperitoneum and shock did not affect the
survival of the two fetuses which is in accord with
another study that did not demonstrate a relationship
between intra uterine fetal mortality and presence of
haemoperitoneum [7]. Though with figure that was not
statistically significant, live birth rate was reported to be
two-fold higher in the subgroup that had heterotopic
pregnancy following assisted conception compared to
spontaneous conception [4]. Although, studies have not
demonstrated a link between heterotopic pregnancy and
fetal congenital anomalies, one of the twin in this report
had an upper respiratory tr act obstructive pathology with
no definitive diagnosis up till th e time of this report [4,7].
In conclusion, this report recorded a favourable fetal
outcome.
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