A case of heterotopic pregnancy with intrauterine and cervical pregnancy coexisting: intrasacular KCl injection, intrauterine pregnancy being preserved, and then massive bleeding at 32 weeks

Andrea Espiau Romera,Belén Rodríguez Solanilla,Carlos De Bonrostro Torralba,Javier Navarro Sierra,María Jesús Franco Royo,María Jesús Puente Luján,Rebeca Herrero Serrano

doi:10.31083/j.ceog4901012

Abstract

Background: Heterotopic pregnancy is the condition in which intrauterine and ectopic pregnancy coexist. The conservative management of the ectopic pregnancy, with the intrauterine pregnancy preserved, has been reported. Case(s): Here, we report a very rare case: intrauterine and cervical pregnancy coexist: intrasacular Potassium chloride (KCL) injection successfully terminated cervical pregnancy with intrauterine pregnancy preserved, but later massive bleeding occurred from the cervix. A 39-year-old woman at 7+1 weeks was diagnosed with a heterotopic cervical gestation, with intrauterine and cervical sac, both with live embryos. The ectopic pregnancy was successfully terminated with intrasacular injection of KCl, preserving the intrauterine pregnancy. At 32+4 weeks of gestation the patient started with a profuse bleeding from the cervical sac, causing maternal hypotension (80/45 mmHg) and tachycardia (160 bpm) and a decelerative pattern in the cardiotocographic fetal monitoring, prompting us to perform caesarean section. The cessation of bleeding was achieved using a double balloon intracervical catheter, which was withdrawn 24 hours after its insertion without observing a new bleeding episode. The patient was discharged after 8 days and the newborn after 35 days of life, both in good health. Conclusions: Conservative treatment of a heterotopic gestation is possible, managing to preserve the viability of the intrauterine pregnancy.

Highlights

Heterotopic pregnancy (HP) is a clinical situation in which an intrauterine pregnancy and an ectopic pregnancy coexist. It is a rare condition with an incidence of 1/30000, but after the generalization of assisted reproductive techniques (ART), it amounts to 0.15–1% [1,2]
A recent review of the main guidelines on the management of ectopic pregnancies suggests that cervical ectopic pregnancies with viable embryo exceeding 9 weeks with serum β-human chorionic gonadotrophin (β-hCG) levels greater than 10.000 IU/L or a crown-rump length greater than 10 mm, should be treated with a combination of intramuscular methotrexate (MTX) with other procedures (such as curettage or cervical blocking or uterine artery embolization (UAE) or local injection of MTX or potassium chloride)
HP is an unusual entity that rarely appears in spontaneous pregnancies; its incidence has increased in recent years due to the use of Assisted Reproductive Techniques (ART), especially in those techniques that involve embryo transfer [1,2]

Summary

Introduction

Heterotopic pregnancy (HP) is a clinical situation in which an intrauterine pregnancy and an ectopic pregnancy coexist. It is a rare condition with an incidence of 1/30000, but after the generalization of assisted reproductive techniques (ART), it amounts to 0.15–1% [1,2]. Surgical methods should be restricted to women with life-threatening bleeding [7]. This management could be different in cases of cervical heterotopic pregnancies in order to preserve the intrauterine gestation. A case of cervical heterotopic pregnancy with live embryo treated conservatively with sacular aspiration and puncture with KCl guided by ultrasound, achieving the preservation of intrauterine pregnancy, is presented. Conservative management of severe vaginal bleeding occurring in third trimester as a secondary complication to cervical pregnancy using a double balloon catheter is described

Case presentation

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Discussion

Conclusions