SUCCESSFUL MANAGEMENT OF A HETEROTOPIC PREGNANCY FOLLOWING OVULATION

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SUCCESSFUL MANAGEMENT OF A HETEROTOPIC PREGNANCY FOLLOWING OVULATION Powered By Docstoc
					              Continental J. Medical Research 5 (2): 14 - 18, 2011                         ISSN: 2141 – 4211
              © Wilolud Journals, 2011                                           http://www.wiloludjournal.com
                                                 ` Printed in Nigeria


      SUCCESSFUL MANAGEMENT OF A HETEROTOPIC PREGNANCY FOLLOWING OVULATION
                 STIMULATION WITH CLOMIPHENE CITRATE: A CASE REPORT

                                  Nyengidiki TK1, Allagoa DO2, HAA Ugboma1
  1
      Department of Obstetrics and Gynaecology, *University of Port Harcourt Teaching Hospital, Rivers state,
            Nigeria and 1Niger Delta University Teaching Hospital Okolokuma, Bayelsa state, Nigeria.

      ABSTRACT
      Background
      Second order pregnancies are common occurrence in this environment; however the presence of an
      intrauterine pregnancy and an extrauterine pregnancy is a rare occurrence which poses a major
      management dilemma for the attending physician. The increasing use of ovulation induction agents
      makes this presentation commoner.
      Aim
      To present a successful management of a case of ruptured tubal ectopic and intrauterine pregnancy
      following ovulation induction resulting in a live birth.
      Case report.
      A 30year old Para 0+2 undergraduate who presented with lower abdominal pain and bleeding per
      vaginam following amenorrhoea of six weeks after intake of clomiphene citrate. A diagnosis of
      ruptured extrauterine with an intrauterine pregnancy was made. She had an emergency exploratory
      laparotomy with right partial salpingectomy with continuation of intrauterine pregnancy. She had an
      emergency caesarean section in labour at 40 weeks with a live birth of a 3.4kg female baby.
      Conclusion.
       A high index of suspicion should be exercised in a patient presenting with lower abdominal pain with
      history of ovulation induction. Early diagnosis of heterotopic pregnancy using high resolution
      ultrasound scan would reduce both maternal and fetal morbidity and mortality.

      KEYWORDS. Heterotopic pregnancy; ovulation induction; laparotomy.

INTRODUCTION
Multiorder pregnancies are a common occurrence in Nigeria especially in certain regions of the
country.(Umeora et al.,2011;Onyiriuka,2003;Bassey et al.,2004) However, the presence of extra uterine and
intrauterine pregnancies is a rare type of multiple pregnancy which is becoming more common and poses a
diagnostic as well as a management dilemma for the gynaecologist(Chisara et al.,2005;Ramadevi et al., 2008;
Menakaya et al., 2008) The first episode of such was identified in literature in 1708 (Mistry et al.,2000; Perkins
et al 2004) and the incidence of this condition range from 1:7,000-30,000 pregnancies (Abbas et al.,2008) The
incidence is on the increase with many infertile couples resorting to assisted conception options and amongst
those who used ovulation induction agents (Abbas et al., 2008;Glasser et al., 1990) It must however be stated
that even in spontaneous cycles heterotopic pregnancies have being identified.(Govindarayan et al., 2008)

The need for early diagnosis in this condition cannot be overemphasized to avoid a maternal mortality and
improve the chances of continuation of the intrauterine pregnancy.(Espinosa et al., 1997) Early diagnosis avails
the attending physician various management options that may improve the overall outcome of this condition
ranging from medical to more conservative surgical options.(Talbot et al., 2011) Nevertheless most patients do
not have such opportunities in the developing countries because of late presentation.(Anorlu et al., 2005;Musa et
al., 2000)

There is need to bring into focus the risk of heterotopic pregnancies and its complications especially in an
environment where ovulation drugs are readily procured off the counter by most infertile couples and used.



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                  Nyengidiki TK et al.,: Continental J. Medical Research 5 (2): 14 - 18, 2011


Case report
Mrs NE is a 30year old Para 0+2 undergraduate who presented at a specialist gynaecological hospital on the 16th
of November, 2010 with history of lower abdominal pain and bleeding per vaginam of one day duration prior to
presentation. Her last normal menstrual period was on the 28th of September, 2010 and her expected date of
delivery was on the 5th of July 2011 with gestational age of six weeks. Vaginal bleeding was bright red, not
associated with clots. She was dizzy but had no fainting spells.

There was increased frequency of vomiting of already ingested food material prior to the occurrence of
bleeding. She had had two missed miscarriages at six and eight weeks respectively for which she had suction
evacuation in theatre. There were no known post evacuation complications. Six weeks prior to presentation
patient had earlier obtained from a pharmacy clomiphene citrate on the recommendation of a relative to achieve
a pregnancy.

At presentation at the hospital she was anxious looking, moderately pale, afebrile to touch with no pedal
oedema.

Her lung fields were clinically clear. The radial pulse rate was 90 beats per minute, full volume and regular with
a blood pressure of 110/80mmHg.The heart sounds were normal.

The abdomen was full, soft and moves with respiration with tenderness localized at the suprapubic region. The
liver, spleen and kidneys were not palpable and there was no demonstrable evidence of free peritoneal fluid.
Bowel sounds were normal. There was a normal vulva and vagina, the cervix was soft, central and closed. The
uterine size was eight weeks. The examining fingers were stained with altered blood.

An impression of threatening miscarriage with possible urinary tract infection was made and the following
investigations were ordered: urgent packed cell volume which was 28%, blood film for malaria parasite was
negative, urinalysis; microscopy and culture did not grow any organism following 48 hours incubation.

An abdominal ultrasound scan done showed a slightly bulky uterus harbouring a single gestational sac with no
obvious fetal pole. ( Figure 1) There was a complex ill defined structure noted in the right adnexum (Figure 2).
The right ovary had a 21mm septated cyst with a 1.3mm developing follicle on the left ovary. There was
significant free peritoneal fluid in the Morrison’s pouch and paracolic gutters.

A diagnosis of a right ruptured ectopic pregnancy with an intrauterine gestation was made.
The clinical condition, the need for an emergency exploratory laparotomy and possible risk of a spontaneous
miscarriage of the intrauterine pregnancy were explained to the patient. An informed consent was obtained for
the above stated and two units of compatible blood were made available for the surgery. The findings at
laparotomy were: a bulky uterus approximately 10weeks size with a ruptured right ampullary ectopic gestation
with bilateral ovarian cysts. Haemoperitonuem of 1000mls was identified.

She had a right partial salpingectomy and minimal uterine handling was exercised during the surgery.

Postoperatively she was placed on nil per oral, intravenous infusion of 5% dextrose saline 1litre 8hourly,
intravenous ceftriaxone 1gramme daily for 48hours.She had an intravenous infusion of 0.5mg of salbutamol in
1litre of normal saline infused at 20drops per minute for the next 24hours.On the second postoperative day a
packed cell volume estimation done was 24% and she was converted to oral cefuroxime 500mg twice daily,
ferrous sulphate 200mg twice daily, folic acid 5mg daily, salbutamol tablets 4mg thrice daily and
acetaminophen tablet 1gm thrice daily. On the fourth day she had a repeat ultrasound scan which identified a
viable pregnancy with no evidence of free peritoneal fluid. Patient’s clinical condition remained stable and was
discharged home on the seventh postoperative day to report back in two weeks for follow up.

She presented two weeks later and complained of a mild generalised abdominal pain and a repeat ultrasound
scan done showed a viable intrauterine pregnancy with crown rump length of 22mm and a gestational age of
9weeks.There was significant bowel gas with no evidence of dilated bowel. She was placed on antacids and was
advised on her diet.

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                   Nyengidiki TK et al.,: Continental J. Medical Research 5 (2): 14 - 18, 2011


Patient continued her care under our supervision without any significant complaint and presented in labour at 8th
of July, 2011 at 40 weeks. She eventually had an emergency caesarean section (Figure 3) for fetal distress in
labour and was delivered of a live female baby weighing 3.3kg. She was discharged home five days after in
satisfactory clinical state.

DISCUSSION
Any condition associated with increase rate of multiple pregnancy would also be linked to an increased rate of
heterotopic pregnancy as is noted in patients with ovulation induction.(Abbas et al., 2008; Glasser et al., 1990)
The patient presented had self administration of clomiphene citrate with a resultant pregnancy but did not
present until she had lower abdominal pain and vaginal bleeding. The diagnosis was made easier by the use of a
high resolution ultrasound scan and the presence of free peritoneal fluid at the point of rupture in the presence of
an intrauterine pregnancy. However, in the absence of rupture a high index of clinical suspicion must be
exercised in any patient with lower abdominal pain and history of ovulation induction in making a diagnosis of
heterotopic pregnancy.(Azza et al., 2009)

The early localization of such pregnancies would give the practitioner a wider scope of management options
which may be less invasive methods and improve the outcome of the intrauterine pregnancy. Such management
options include the use of laparoscopy which minimises contact with the uterus however concerns have being
raised about the complications of C02 to the intrauterine pregnancy.(Zhang et al., 2004; Zhang et al., 2008) The
option of ultrasound guided inoculation of the gestational sac with some foeticidal agents such as potassium
chloride and hypertonic glucose have being tried in some series (Goldstein et al., 2006; Aboutghar et al.,
1990).However, concerns are raised on the possibility of persistent trophoblastic disease. Most patients with
extrauterine pregnancy in the third world present late with features of rupture (Anorlu et al., 2005; Musa et al.,
2000) which makes the above modalities of management impossible hence the need for the traditional approach
of a laparotomy for this patient who had a partial salpingectomy with success. During the surgery there was
need to ensure minimal handling of the uterus to improve the chances of continuation of the pregnancy avoiding
uterine stimulation. In addition to the above the patient had administration of intravenous salbutamol to prevent
uterine contractions.

The condition of heterotopic pregnancy thought to be uncommon has fatal consequences for the mother if
misdiagnosed and poor pregnancy outcome for the intrauterine pregnancy. Hence a high index of clinical
suspicion must be exercised in a patient on ovulation induction agents which are increasingly being used in
Nigeria for treatment of infertility. (Obiechina et al., 2011) Thus the dictum should be that a coexisting
extrauterine pregnancy should always be excluded in the presence of any intrauterine pregnancy by a careful
look at the adnexae to identify this minor faction of patients to reduce maternal mortality.

REFERENCES
Abbas H, Elhams K, Simin M. heterotopic pregnancy following ovulation induction by clomiphene citrate and a
healthy live birth: a case report Med case Report. 2008. 2:390-392.

Aboutghar M, Mansour RT, Serrour GI. Transvaginal injection of KCL and methotrexate for the treatment of
tubal pregnancy with a live fetus. Hum Reprod 1990.5(7):887-8.

Anorlu R, Oluwole A, Abudu OO, Adebayo S. Risk factors for ectopic pregnancy in Lagos, Nigeria. Acta
Obstet Gynaecol Scand.2005. 84(2):184-8

Azza GI, Faiza B, Muna T. Heterotopic pregnancy: a growing diagnostic challenge. BMJ case
Rep.2009.10:1136-40.

Bassey EA, Abasiattam AM, Udoma EJ, Asuquo EE. Outcome of Twin Pregnancy in Calabar, Nigeria.GL Med
Sci. 2004.3(1-2):13-15.

Chisara CU, Paul AF. Heterotopic pregnancy with spontaneous vaginal Delivery at 36 weeks and laparotomy at
Term- A case Report. Afr J Reprod Health.2005; 9(1): 162-165.



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Espinosa PM, Alcantar MA. Heterotopic pregnancy: a report of a case and review of literature. Ginecol Obstet
Mex.1997; 65:482-6.

Glasser MJ, Aron E, Esikin BA. Ovulation induction with clomiphene citrate and the risk in heterotopic
pregnancies: A report of two cases. J Reprod Med.1990;35:175-8.

Goldstein JS, Ratts VS, Philpot T, Dahan MH. Risk of surgery after use of KCL for treatment of tubal
heterotopic pregnancy. Obstet Gynaecol.2006.107 (2):506-508.

Govindarayan MJ, Rajan R. Heterotopic pregnancy in natural conception. J Hum Reprod Sci. 2008.1(11):37-38.

Menakaya UA, Agoreyo FO. Unusual presentation of spontaneous heterotopic pregnancy: A case report. Int J
Biomed Health Sci.2008.4 (2):61-63.

Mistry BM, Balasubramaniam S, Silverman R, Sakabu SA, Troop BR. Heterotopic pregnancy as an acute
abdomen: a diagnostic masquerade.AM Surg 2000; 56 (3): 307-308.

Musa J, Darup H, Mutiher JT, Ujah IA: ectopic pregnancy in Jos, Nigeria. Niger J Med.2000.18(1)35-38.

Obiechina NJ,Okolie VE, Eleje GU, Okechukwu ZC, Anemeje OA. Twin versus singleton pregnancies: the
incidence, pregnancy complications and obstetric outcome in a Nigerian tertiary Hospital. Int J women Health.
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Onyiriuka AN. Twin delivery, comparison of incidence and fetal outcome in Health Institutions in Benin City
Nigeria. Nig Q J. Hosp Med. 2003. 16(3):88-92.

Perkins JD, Mitchell MR. Heterotopic pregnancy in a larger city Hospital a report of 2 cases. Nati Med
Assoc.2004 96:363-366.

Ramadevi VW, Sami AT: Heterotopic pregnancy in a natural cycle-probably Not rare. Mid East J Fam Med.
2008.6(6):28-31.

Talbot K, Simpson R, Price N, Jackson SR. Heterotopic pregnancy: increasing role of ultrasound and use of
conservative. J Obstet Gynaecol .2011.1(1):7-12.

Umeora OU, Anezikoro EA, Egwuata VE. Higher order multiple births in Abakakiki, South East, Nigeria.
Singapore Med J. 2011. 52(3):163-7.

Zhang Gl, Huang QI, Xing FQ. Application of laparoscopy in ectopic pregnancy complicating intrauterine
pregnancy: a report of 5 cases. J first Mil Med Univ. 2004.24(9):1089-1098

Zhang N, Wang S, Sang C. heterotopic pregnancy: unilateral tubal and intrauterine pregnancy after IVF-ET
ended in term singleton delivery. J Chinese Clini Med.2008.7 (3):7-10.




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                   Nyengidiki TK et al.,: Continental J. Medical Research 5 (2): 14 - 18, 2011




Figure 1: Ultrasound image showing a                     Figure 2: Ultrasound image showing an echocomplex
          gestational sac in the uterus.                         mass (ectopic gestation) in the right adnexum.




Figure 3: Uterus during caesarean section showing post right salpingectomy tubal remnants

Received for Publication: 24/10/2011
Accepted for Publication: 10/12/2011

Corresponding Author
HAA Ugboma Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital,
Nigeria.
Email: haugboma@gmail.com




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