Intra-uterine twin pregnancy and right tubal ectopic pregnancy following intra-uterine insemination (IUI): A case report

Abstract

Abstract Objective: Diagnosis is usually made when surgical treatment is needed following rupture in heterotrophic pregnancy which is rare among natural pregnancies. Therefore early diagnosis is of vital importance for the patient. Herein, we aimed to report a case of heterotrophic pregnancy that was presented with ruptured tubal pregnancy and intra-uterine live dichorionic-diamniotic twin pregnancy. Case: A 30-year-old nulli-parous woman who had 6 weeks and 3 days of intra-uterine insemination (IUI) pregnancy according to the last date of menstruation was admitted with abdominal pain. Physical examination revealed the findings of acute abdomen. Dichorionic-diamniotic intra-uterine twin pregnancy with positive fetal heart beat (FHB) consistent with 6 weeks and 5 days, and 6 weeks and 6 days was detected on trans-vaginal ultra-sonography. Approximately 6-7 cm of free fluid was observed in Douglas pouche and also an image that could represent an ectopic focus was observed in the right adnexial region. Laparatomy was planned as hemoglobin was 10.5 gr/dl, beta-HCG was 15000 mIU/ml and the patient had rebound and defense on abdominal examination. Right tubal ruptured ectopic focus and about 500-600 cc blood and coagulum were seen in laparotomic exploration. Uterus and both ovaries looked in normal appearance and volume. Right total salpingectomy was performed and the procedure was terminated following inra-abdominal wash. Pathologic examination of the right tuba was reported as “ectopic pregnancy, hemato-salpinx”. Intra-uterine dichorionic-diamniotic twin pregnancy with positive fetal heart beat (FHB) consistent with 6 weeks and 5 days, and 6 weeks and 6 days was detected to continue on trans-vaginal ultra-sonography performed on post-operative day 2. The patient was discharged uneventfully on post-operative day 4 and invited for outpatient clinic control. Conclusion: Diagnosis and treatment may delay due to the rarity of heterotrophic pregnancy. Ectopic pregnancy may be overlooked particularly in the patients who did not have additional problems on ultra-sonography examination for intra-uterine pregnancy. We wanted to pull attention particularly to this issue. Key words: Hetero-trophic pregnancy, twin pregnancy, tubal ectopic pregnancy