Background: The incidence of rudimentary heterotopic uterine horn pregnancy varies from 1:76,000 to 1:140,000. However the incidence of twin pregnancy i.e. intrauterine pregnancy in unicornuate uterus and its associated rudimentary horn pregnancy is estimated to be around 1 in 10 million gestations. Case: Here, we present 19 year old pramigravida women with acute haemoperitoneum with diagnosis of unruptured rudimentary horn pregnancy combined by intrauterine pregnancy. The patient was managed with emergency laparatomy and resuscitation. Rudimentary horn containing foetus was excised and intrauterine pregnancy was left untouched. The intrauterine pregnancy was supported with progesterone and tocolytics and the patient delivered a newborn of 2.8 kg through spontaneous labor at 37 weeks of gestation. Conclusion: Heterotopic pregnancies incidence have increased in comparison to past and there should be high level of suspicion for this rare event as this is often associated with high maternal and fetal morbidity and mortality where diagnosis is difficult and challenging and easily missed. . Timely intervention provides survival of intrauterine pregnancy in case of twin pregnancy, even in low resource settings where usually the diagnosis is missed before acute event.

Unruptured rudimentary horn pregnancy presenting with acute haemoperitoneum with combined intrauterine pregnancy: A case report.

Background: Heterotopic abdominal pregnancy is a rare entity which poses unique management challenges. 
Case: A 24-year-old Gravida 1 woman with history of two years infertility and treatment with clomiphene citrate presented with acute right lower quadrant abdominal pain. Heterotopic abdominal pregnancy was recognized at 16 weeks gestation by transvaginal ultrasound scan. We aimed to remove ectopic pregnancy with prevention of maternal complications and preservation of intrauterine pregnancy (IUP). Surgical removal of the ectopic fetus and placenta was done. Abdominal pregnancy removed successfully without intra- or post-procedural complications but the IUP was aborted spontaneously on the second postoperative day. 
Conclusion: Gynecologists should consider the possibility of heterotopic pregnancy following ovulation induction with clomiphene citrate which is increasing in recent years. A high index of suspicion to heterotopic pregnancy may be followed by a nonsurgical approach safely and affectively if they are clinically stable and the abdominal pregnancy is recognized early in gestation.

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Heterotopic abdominal pregnancy following ovulation induction with clomiphene citrate

Background: Heterotopic abdominal pregnancy is a rare entity which poses unique management challenges. Case: A 24-year-old Gravida 1 woman with history of two years infertility and treatment with clomiphene citrate presented with acute right lower quadrant abdominal pain. Heterotopic abdominal pregnancy was recognized at 16 weeks gestation by transvaginal ultrasound scan. We aimed to remove ectopic pregnancy with prevention of maternal complications and preservation of intrauterine pregnancy (IUP). Surgical removal of the ectopic fetus and placenta was done. Abdominal pregnancy removed successfully without intra- or post-procedural complications, but the IUP was aborted spontaneously on the second postoperative day. Conclusion: Gynecologists should consider the possibility of heterotopic pregnancy following ovulation induction with clomiphene citrate which is increasing in recent years. A high index of suspicion to heterotopic pregnancy may be followed by a nonsurgical approach safely and affectively, if they are clinically stable and the abdominal pregnancy is recognized early in gestation.

Case report Heterotopic abdominal pregnancy following ovulation induction with clomiphene citrate

Background: Use of methotrexate (MTX) as a nonsurgical management of unruptured ectopic pregnancies has been well accepted. However, use of it in high serum chorionic gonadotropin concentration and in live fetus has been considered as relative contraindication for medical therapy. The aim of this report is to emphasize that these contraindications can be revisable in some situations and discuss about this fact that the success rate can be affected by the type of protocols used for medical treatment.

Case presentation: A 31 years old primigravid woman was admitted to our hospital due to a sonogram's report of ectopic pregnancy with a high initial serum B-hCG concentration (26900) and presence of fetal cardiac activity. Her vital signs were stable and she did not agree with operative intervention. Two-dose protocol was scheduled but appropriate response to treatment was obtained after receiving the third dose of methotrexate. Negative serum B-hCG (< 1 mIu/ml) was achieved on day 80 without any related treatment complication on follow up.

Conclusions: Use of double- dose protocols of MTX in medical treatment of ectopic pregnancy increase the chance of successful and nonsurgical treatment even in live fetus with high B-hCG titers.

Successful Management of Live Ectopic Pregnancy with High B-Hcg Titres by Systemic Methotrexate Injection: A Case Report

Background: Ectopic pregnancy is one of the pathologic entities that it destroys the fallopian tube and impairs the future pregnancy. There are different medical and surgical therapies in order the treatment and reserve of fertility. The aim of this report is discuss a case of successful intrauterine after management of ectopic pregnancy with local injection of KCL in an infertile PCOD patient. Case: The patient was a PCOD woman with gestational age of 8.5 weeks. One gestational sac and alive fetus with normal heart beat was seen in the right adnexa. Hemodynamic situation was stable. 0.5cc KCL 10% was injected to the fetal heart and the extracted tissue sent for pathology. We evaluated the effects of this treatment by measuring serial human chorionic gonadotropin (hCG) titers. Moreover, we used hysterosalpingogrphy to diagnose and to evaluate the patency of the tubes. Induction ovulation and intrauterine insemination was done and pregnancy occurred. Patient passed the pregnancy very good and she delivered by cesarean section due to breech presentation at 39 weeks of gestational age. There was no sign of pathologic finding in the tubes or adhesion or sequel of ectopic pregnancy. Conclusion: The beneficial outcomes of this kind of treatment suggest that local injection of KCL as a low invasive treatment can be the choice treatment for alive and progressed ectopic pregnancy or heterotopic pregnancy. Because of rarity of this management and successful intrauterine we reported the usefulness of local KCL injection for the successful conservative treatment of alive ectopic pregnancy in Iran.

/pdf/tubal-patency-after-ultrasound-guided-local-injection-of-kcl-5g9nwenc07.pdf

Mohamad Hashemi

Papers

Tubal patency after ultrasound guided local injection of KCL to tubal ectopic pregnancy with alive fetus