Spontaneous heterotopic pregnancy and acute appendicitis treated by laparoscopy

Abstract

The occurrence of concurrent intrauterine and extrauterine pregnancies, or heterotopic pregnancy (HP), has been estimated at 1 in 30,000 spontaneous pregnancies [1,2]. On the other hand the incidence of acute appendicitis, a condition that may increase the risk of maternal death, is estimated at 1 per 1500 pregnancies [3]. To these authors' knowledge, no case of combined spontaneous HP and appendicitis treated by laparoscopy has been reported on so far. A 35-year-old woman (gravida 4, para 0) was admitted to the Department of Operative and Endoscopic Gynecology, Polish Mothers' Memorial Hospital and Research Institute, Lodz, Poland, for lower abdominal pain 7 weeks and 4 days after her last menstruation. A transvaginal ultrasonographic scan revealed a live intrauterine pregnancy of 8 weeks' duration as well as a 42mm mass in the right adnexa. Heterotopic pregnancy was suspected, and the patient was qualified for laparoscopic exploration. The exploration revealed an enlarged fallopian tube and a visibly inflamed appendix. Appendectomy and a right salpingectomy were performed. No intraoperative complications occurred. The patient was discharged from the hospital with a live intrauterine pregnancy following an uneventful postoperative course. Histologic studies revealed the presence of decidua with immature and necrotic chorionic villi in the resected fallopian tube as well as acute appendicitis, with inflammation of the entire wall of the appendix. At 39 weeks of pregnancy, the patient was delivered of a healthy female infant. Eleven months later she reported to the department with a 14-week amenorrhea, and a live 14-week intrauterine pregnancy was detected. Until now, only Barnett and colleagues [4] have reported on a case of HP concomitant with acute appendicitis. This case occurred following in-vitro fertilization and entailed a ruptured appendix. The main task in the treatment of HP is to preserve the developing intrauterine pregnancy. In the surgical management of ectopic pregnancy, the benefits of salpingectomy over salpingotomy are uncertain. Salpingectomy may be easier and safer, especially in the presence of a live intrauterine pregnancy. It reduces the risk of complications such as the persistent bleeding or retention of trophoblastic tissue that can occur after salpingotomy [1]. In the present case, laparoscopy led to the surprising finding of appendicitis concomitant with HP. It has been suggested that ectopic pregnancies may induce periappendicitis, but the histopathologic findings ruled out periappendicitis as well as inflammation in the fallopian tube. In conclusion, laparoscopy provides good outcomes in the diagnosis and treatment of HP and appendicitis, and laparotomy should be reserved for life-threatening conditions. In the case of HP, salpingectomy should be considered when the contralateral fallopian tube is healthy as this treatment does not preclude future fertility.