Heterotopic pregnancy: a report of two cases

Background: A heterotopic pregnancy is defined as the presence of a concomitant intrauterine and extrauterine pregnancy. Its estimated incidence is 1/30,000 in spontaneous pregnancies. It is also reported to be as high as 1 in 3900 when the pregnancy is a result of assisted reproductive technology (ART). However, clomiphene citrate (CC) could be associated with a higher rate of heterotopic pregnancy as it amplifies the rate of twinning. Furthermore, heterotopic pregnancies are a diagnostic and therapeutic challenge for obstetricians. If undiagnosed, they are associated with significant maternal morbidity and mortality. Case presentation: We present two cases of coincidental intra and extra-uterine pregnancy. In the first case, heterotopic pregnancy was a result of induction of ovulation with CC. There was a delay in the diagnosis of the ectopic pregnancy component resulting in an emergency laparoscopy. Fortunately, after the laparoscopy the intrauterine pregnancy was not affected and it is progressing satisfactorily. Alternatively, the second case occurred spontaneously and was treated with methotrexate as the intrauterine pregnancy miscarried on its own accord. Conclusions: These cases highlight the fact that as clinicians, we should be aware of the possibility of a heterotopic pregnancy in any patient presenting with pelvic pain, even when an intrauterine pregnancy has been confirmed. This is even more imperative after induction of ovulation by CC or ART. We would also like to emphasise that an early diagnosis is critical to safeguard the intrauterine pregnancy and avoid maternal morbidity and mortality due to the ectopic pregnancy.