Heterotopic pregnancy, the coexistance of intraueterine and extrauterine gestation, is very rare in natural conception and reported to be 1:30000 pregnancies. We report a case presented with haemoperitoneum from ruptured tubal pregnancy with no life of intrauterine gestation. This give a challenges to the managing team especially in detecting the sources of bleeding especially if they miss the extrauterine pregnancy.
A 33 years old lady 6 weeks of amenorrhea presented with clinical features of shock. Urine pregnancy test was positive. Transabdominal ultrasound revealed free fluid in the abdomen. Left extrauterine sac seen with fetal heart present. Intrauterine sac was seen without fetal heart. Provisional diagnosis of a heterotopic pregnancy with ruptured left ectopic gestation was suggested. The patient underwent emergency exploratory laparotomy salphingectomy.There was ruptured left sided tubal pregnancy with haemoperitoneum.
DISCUSSION AND CONCLUSION
A heterotopic pregnancy is difficult to diagnose clinically because the clinical symptoms is lacking. It can be life threatening condition and can be easily missed. Usually sign of extrauterine pregnancy predominates. Sign and symptoms may include abdominal pain, adnexal mass, peritoneal irritation, enlarged uterus and vaginal bleeding. Vaginal bleeding may be retrograde from the ectopic pregnancy due to intact endometrium of the intrauterine pregnancy. Challenges in the emergency setting lie in the identifying of ectopic pregnancy with the presence of the large heamoperitoneum. Haemodynamic instability in ruptured ectopic pregnancy need to be addressed appropriately by the managing team and intervention is life saving. This requires high index of suspicion from the emergency personnel to identify this condition.