Abstract
BackgroundHeterotopic pregnancies are increasing in prevalence and this case highlights the importance of excluding the diagnosis in patients with pelvic pain following miscarriage. A known pre-existing intrauterine pregnancy can be falsely reassuring and delay the diagnosis of a potentially life-threatening concurrent ectopic pregnancy.Case presentationIn this report, we describe a case of spontaneous heterotopic pregnancy in a woman who had initially presented with pelvic pain and vaginal bleeding, and was diagnosed on pelvic ultrasound with a missed miscarriage; a non-viable intrauterine pregnancy. She re-presented 7 days later with worsening pelvic pain and bleeding, and a repeat pelvic ultrasound identified a ruptured tubal ectopic pregnancy in addition to an incomplete miscarriage of the previously identified intrauterine pregnancy. She underwent an emergency laparoscopy where a ruptured tubal ectopic pregnancy was confirmed.ConclusionBeing a time critical diagnosis with the potential for an adverse outcome, it is important that the emergency physician considers heterotopic pregnancy as a differential diagnosis in patients presenting with pelvic pain following a recent miscarriage. The same principle should apply to pelvic pain in the context of a known viable intrauterine pregnancy or recent termination of pregnancy. A combination of clinical assessment, beta human chorionic gonadotropin levels, point of care ultrasound and formal transvaginal ultrasound must be utilized together in these situations to explicitly exclude heterotopic pregnancy.
Highlights
Heterotopic pregnancies are increasing in prevalence and this case highlights the importance of excluding the diagnosis in patients with pelvic pain following miscarriage
Being a time critical diagnosis with the potential for an adverse outcome, it is important that the emergency physician considers heterotopic pregnancy as a differential diagnosis in patients presenting with pelvic pain following a recent miscarriage
The same principle should apply to pelvic pain in the context of a known viable intrauterine pregnancy or recent termination of pregnancy
Summary
Delayed diagnosis of a HP is pertinent for the Emergency Physician as the consequences to the patient can be dire. This case highlights the importance of maintaining a high index of suspicion for a HP in patients with pelvic pain after miscarriage, with the same principle applied to those with a recent termination of pregnancy or known IUP. A combination of history, examination, β-hCG levels, PPOCUS and formal TV US should be considered to explicitly exclude HP in these patients
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