Keywords : clomiphene, heterotopic pregnancy, tubal pregnancy
The occurrence of heterotopic pregnancy (simultaneous intrauterine and extrauterine pregnancies) following induction of ovulation with clomiphene for infertility is rare. It represents a life-threatening complication of pregnancy and its diagnosis is often difficult. When an ectopic pregnancy is suspected after induced ovulation or assisted reproductive technologies, the presence of an intrauterine pregnancy should not be considered reassuring and the patient should be evaluated rigorously to rule out heterotopic pregnancy which otherwise can have serious adver se effects on the intrauterine fetus and the mother.
A. 22 year old nulliparous woman conceived after three cycles of ovulation induction with clomiphene. She presented to her private physician at 6 weeks of gestation with lower abdominal pain. Ultrasound examination showed an intrauterine pregnancy of corresponding period of gestation. At 9 weeks, she had one episode of vaginal spotting and a viable fetus of 8 weeks arid 5 days was obvious on ultrasound. She received human chorionic gonadotrophin (hCG) but continued to have pain. Four days later, she had acute abdominal pain followed by a syncopal attack. Her general condition deteriorated in the next 24hours when an ultrasound repeated by a sonologist showed a non-viable intrauterine fetus and free fluid in the peritoneal cavity .She was subsequently referred to us. On examination she had pallor. Her pulse was 124/min and supine blood pressure 140/90 mm Hg. There was a generalized abdominal distention and tenderness. Bimanual examination revealed a tender cervix. All the forniceswere full and tender. Uterine size could not be made out. Ultrasound showed free fluid in the peritoneal cavity (Figure 1),a nonviable intrauterine pregnancy and a 5 ems x 5 ems heterogenous mass in relation to the left adnexa (Figure 2) . Abdominal paracentesis yielded hemorrhagic fluid. Her hemoglobin was 7 gm/ dL and coagulation parameters were normal. On exploratory laparotomy there were approximately lL ofhe'moperitoneum and a ruptured left tubal pregnancy. The uterus was of 8 weeks size. Left salpingectomy and therapeutie abortion of non-viable intrauterine pregnancy were performed. Pathological examination confirmed a ruptured left tubal pregnancy and a intrauterine pregnancy. Her postoperative recovery was smooth.
Heterotopic pregnancy represents a form of dizygotic twinning with separate sites of implantation of blastocyst. The incidence of spontaneous heterotopic pregnancy has been estimated to be 1 in 30,000 gestations'. The first case of heterotopic pregnancy following clomiphene induced ovulation was reported in 197F. Clomiphene by hyperstimulating the ovaries and probably by altering the myoelectrical activity responsible for propulsive action of fallopian tubes, is associated with increased rate of twinning and ectopic pregnancy and thus could be associated with a higher rate of heterotopic pregnancyv'. An early diagnosis of heterotopic pregnancy is important for the intrauterine fetus and the mother. In an early case conservative management with laparoscopy or by injecting potassium chloride solution in the ectopic gestation sac under vaginal sonography is advised.
The signs and symptoms of heterotopic pregnancy have been reviewed by Reece et a15 Heterotopic pregnancy has been a rare cause of acute abdominal pain", Ultrasound is helpful and vaginal ultrasound is superior to abdominal ultrasound for the diagnosis of ectopic pregnancies. A diagnostic laparoscopy should be performed whenever the diagnosis remains unclear".
The present case emphasizes the possibility of heterotopic pregnancy following clomiphene therapy and the adverse consequences of missed diagnosis. Further observations on such cases would define the risk. Gynecologists, primary care physicians, sonologists, radiologists and emergency room physicians should have a high index of suspicion of heterotopic pregnancy in women who conceive after using ovulation inducing agents.
