Ruptured spontaneous heterotopic pregnancy

The coexistence of intrauterine and ectopic pregnancy (heterotopic pregnancy) occurs in 1/30,000 of spontaneous pregnancies, 1/900 in Clomiphene citrate induced pregnancies and rises to 1% in assisted reproduction. It is a life-threatening condition with diagnostic and therapeutic complexities. There is strong association between infertility and ectopic pregnancy. Risk factors for ectopic pregnancy are past history, assisted reproduction, and adhesions due to pelvic infection or surgery. Our patient was diagnosed initially as having an intrauterine singleton pregnancy, with urinary tract infection. At presentation pain out of proportion to primary diagnosis led to urgent ultrasonographic review that diagnosed heterotopic pregnancy. It was followed by laparoscopic salpingectomy. Human chorionic gonadotrophin (HCG) after laparoscopy in the subsequent days along with a sonographic evaluation revealed a viable intrauterine pregnancy. This ended in missed miscarriage and medical expulsion at 16 weeks of gestation. Issues discussed here are rarity, delayed, or misdiagnosis with its sequel.