7675 Tri-Topic Pregnancy: A Case of Spontaneous Triplets in Three Distinct Locations

Abstract

<h3>Study Objective</h3> To present a case of spontaneous triplet pregnancy consisting of a single intra-uterine pregnancy and two distinct ectopic pregnancies and review the literature regarding interstitial pregnancy management. <h3>Design</h3> Case report. <h3>Setting</h3> Tertiary care hospital. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> 29-y/o G3P2002 at approximately seven weeks gestational age by LMP with history significant for two prior full-term cesarean sections presented to the emergency department with severe, sudden onset abdominal pain. Beta-HCG was greater than 200,000. Bedside transabdominal ultrasound was limited by degree of pain; however, it revealed a fetal pole measuring eight weeks with cardiac activity surrounded by a sizable layer of myometrium, as well as an additional fetal pole with cardiac activity laterally with a thin surrounding layer of myometrium. Given severe pain in early pregnancy, ruptured ectopic pregnancy was presumed and the patient was consented for a diagnostic laparoscopy and removal of ectopic pregnancy. Intraoperatively, approximately 500cc of hemoperitoneum and both an interstitial pregnancy and an ampullary pregnancy were appreciated. Laparoscopic unilateral salpingectomy and cornuectomy were performed. Ultrasound postoperatively surprisingly demonstrated a third remaining viable intrauterine pregnancy. The patient denied any history of ART. <h3>Measurements and Main Results</h3> Pathology confirmed ectopic pregnancies in both specimens. Laparoscopic excision of two ectopic pregnancies was safely performed in this patient with maintenance of a viable, intrauterine pregnancy. Excision of the interstitial pregnancy posed greatest risk to both the patient and concurrent intrauterine pregnancy. Care was taken during cornuectomy to minimize entry depth into surrounding myometrium and blood loss. <h3>Conclusion</h3> The incidence of heterotopic pregnancy without ART is approximately 1 in 30,000. Furthermore, interstitial pregnancies make up only 1-4% of ectopic pregnancies. Laparoscopic management of interstitial pregnancies has been repeatedly demonstrated as a safe approach. We present a rare case of a ruptured triplet heterotopic pregnancy with minimal risk factors managed successfully with laparoscopic removal technique and maintenance of intrauterine pregnancy.