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Table of Contents
CLINICAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 102-105

Case study on heterotopic pregnancy


Department of Obstetrics and Gynaecology Nursing, Narayana Hrudayalaya College of Nursing, Bengaluru, Karnataka, India

Date of Submission03-Nov-2018
Date of Acceptance25-Mar-2019
Date of Web Publication01-Jun-2020

Correspondence Address:
Prof. C Sangeetha
Narayana Hrudayalaya College of Nursing, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_14_20

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  Abstract 

Heterotopic pregnancy (HP) is a rare form of pregnancy that is characterised by the coexistence of intra-uterine and extra-uterine pregnancy. The simultaneous presence of two gestational sacs is a rare event but with the advent of assisted reproductive technology, it is now an increasingly common complication. The prognosis for the extra-uterine foetus is very poor, having an estimated 90%–95% mortality rates. The mortality rate for the intra-uterine pregnancy is approximately 35%. Nurses have a challenging role to play in the management of women during acute and rehabilitative phase when HP occurs. For a comprehensive understanding of the disease condition, the definition, incidence, causes, clinical manifestation diagnostic criteria and management along with case report focusing on nursing management are presented in this article.

Keywords: Assisted reproductive technology, heterotopic pregnancy, nursing management


How to cite this article:
Sangeetha C. Case study on heterotopic pregnancy. Indian J Cont Nsg Edn 2019;20:102-5

How to cite this URL:
Sangeetha C. Case study on heterotopic pregnancy. Indian J Cont Nsg Edn [serial online] 2019 [cited 2020 Jul 14];20:102-5. Available from: http://www.ijcne.org/text.asp?2019/20/2/102/285582


  Introduction Top


In medicine, the term 'heterotopia' refers to the presence of a particular tissue type at a non-physiological site but usually coexisting with original tissue in its correct anatomical location.[1] In other words, it implies ectopic tissue, in addition to retention of the original tissue type. Heterotopic pregnancy (HP) is a condition characterised by implantation of one or more viable embryos into the uterine cavity while another one is implanted ectopically, particularly into the uterine tube or rarely with cervical or ovarian pregnancy.[2] HP is more common following assisted reproductive technology (ART) procedure.[3] The incidence of HP is about one in 10,000–30,000 pregnancies.[4] Its occurrence has increased drastically over the past few years due to assisted reproduction procedures and has stabilised at approximately 1:100 pregnancies with these procedures.[5] Sometimes, with early diagnosis and skilful treatment, the outcome of the intra-uterine pregnancy is favourable and the survival rate of foetus increases.[4]


  Aetiology Top


There are many factors associated with HP, and one of the most common factor is the increasing incidence of ectopic pregnancy.[6] The common causes for ectopic pregnancy are summarised as follows:

  • Presence of pelvic adhesions
  • Effects of diethylstilbestrol on the genital tract
  • Antibiotic-induced tubal disease
  • Use of an intrauterine device
  • Voluntary restriction of family size
  • Iatrogenic curettage of intra-uterine pregnancy during surgery for ectopic pregnancy
  • Termination of pregnancy
  • History of surgery to treat infertility, ectopic pregnancy or tubal adhesions.
  • Tubal malformation and
  • Endometriosis.


Other than ectopic pregnancies, the greatest rise in HP is seen in ART. When multiple embryos are transferred for better success of ART specifically with the procedure gamete intra-fallopian transfer, the incidence of HP is higher.[7]


  Clinical Features of Heterotopic Pregnancy Top


A woman experiencing a HP may or may not have symptoms. This is especially concerning since half of these pregnancies are only diagnosed when the fallopian tube ruptures. The signs and symptoms are similar to ectopic pregnancy. If symptoms are present, they may include:

  • Abnormal vaginal bleeding
  • Mild-to-severe abdominal pain or cramping
  • Dizziness
  • Fainting
  • Nausea
  • Vomiting
  • Persistent pain after spontaneous or induced abortion
  • Persistent pregnancy-related signs even after abortion or laparotomy for ectopic pregnancy
  • Foetal heart rates heard over different areas.



  Diagnosis Top


Majority of heterotopic pregnancies are generally diagnosed between 5 and 11 weeks of gestation.[5]

  • Serum beta-human chorionic gonadotropin (HCG) – production of beta-HCG begins as early as the day of implantation and can be detected at 7–10 days after the conception, the measurable level was 50 mIU/ml. There is linear rise in HCG during 1st 6 weeks of pregnancy, usually doubles every 1.3–2 days. Beta-HCG levels peak about 100 mIU/ml between the 60th and 80th day of gestation. According to the American Pregnancy Association, the HCG level of every woman could raise differently, rather than the levels, the changes in the level to be considered.[5],[8],[9] In HP, the rise in beta-HCG levels vary and are unpredictable. The levels may remain normal due to the presence of normal intra-uterine pregnancy.[10] Therefore, the role of beta-HCG in the diagnosis of HP is debatable [11]
  • Ultrasonic examination reveals the simultaneous presence of an intra-uterine pregnancy and a coexisting ectopic pregnancy [Figure 1].
Figure 1: Ultrasound image showing heterotopic pregnancy

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However, in a review of 80 patients with HP, ultrasonography findings were definitively diagnostic in only 25% of patients; laparoscopy or laparotomy was diagnostic in the remaining 75% of patients.[1] Transvaginal ultrasonography in the early pregnancy is recommended in all women who have undergone ART. Ultrasound scanning of extra-uterine anatomy is vital to detect HP.[12]

  • Exploratory laparotomy – an exploratory laparotomy for suspected rapture of ectopic pregnancy or haemodynamically compromised state in a pregnant woman may prove to be a diagnostic indication in many women who were not suspected to have a HP.[10]


Differential diagnosis

Other conditions such as ruptured ectopic pregnancy, ovarian torsion, spontaneous abortion and acute appendicitis can mimic the clinical features of HP and should be considered while diagnosis.


  Treatment Top


Any foetus located outside the uterus cannot survive, and its presence could cause potentially life-threatening bleeding in the mother if there is spontaneous rupture of the sac. Therefore, the extra-uterine pregnancy needs to be terminated. The good news is that it is often possible to do so without terminating the intra-uterine pregnancy. This typically involves surgery, which may or may not require the removal of the affected fallopian tube if the ectopic pregnancy is in the fallopian tube. If it is detected early and was unruptured, treatment option includes aspiration and installation of potassium chloride or hyperosmolar glucose or prostaglandin in to the gestational sac which have been tried in some places.[13],[14],[15] Systemic methotrexate or local injection of methotrexate cannot be used in HP.[7] HP may also be treated with surgical removal of the ectopic gestation by salpingectomy or evacuation of ectopic sac when needed. However, the surgical procedure has to be performed with minimal manipulation of the uterus with viable foetus to prevent intra-uterine pregnancy-related complications.[11] Successful salpingocentesis has also been reported.


  Case Report Top


Mrs. B, G2A1 at 8 weeks + 4 days of gestation got admitted with complaints of lower abdominal pain for the past 5 days and presented with hypotension and fatigue. A physical examination of her abdomen revealed severe abdominal tenderness. Her blood pressure was 80/60 mmHg and the pulse rate was 110 beats/min. She was immediately started on intravenous fluid support. With an initial diagnosis of suspected ectopic pregnancy, she underwent blood investigations and had an ultrasonography. Her blood investigations revealed a high serum HCG level of 119,150.0 IU/ml, indicating a probable HP. The ultrasonography examination evidenced single live intra-uterine gestation of 9 weeks and a right ectopic pregnancy with haemoperitoneum. She underwent an emergency right salpingectomy and evacuation of haemoperitoneum for the ectopic pregnancy while her intra-uterine pregnancy was preserved. The post-operative period was uneventful. Mrs. B was given injection proluton depot 500 mg intramuscular to prevent the premature labour. She was discharged in good general condition. She was advised to come for regular antenatal care.

1. Nursing diagnosis

Acute pain related to rupture of fallopian tube as evidenced by complaints of severe abdominal pain and profound tenderness.

Expected outcome

Mother verbalises reduced pain.

Nursing interventions

  • Assess the mother's general condition and the level of pain
  • Monitor vital signs
  • Explain the potential cause of pain
  • Provide comfort measures such as back rub and deep breathing exercises
  • Administer analgesics as per order
  • Assist in completing diagnostic and therapeutic procedures promptly
  • Provide comfortable position and gentle handling during procedures.


Evaluation

Although the comfort measures were helpful, she continued to complaint of pain.

2. Nursing diagnosis

Compensated shock as evidenced by low blood pressure and high pulse rate.

Expected outcome

Mother remains haemodynamically stable as evidenced by the heart rate and blood pressure within the normal limits.

Nursing interventions

  • Establish intravenous (IV) access and initiate fluid replacement
  • Complete blood tests including haemoglobin levels, grouping and cross-matching
  • Connect to monitor to assess vital signs closely, assess capillary refill
  • Continue to monitor vital signs every 15 min to ½ h
  • Maintain an accurate intake and output record
  • Make necessary preparations for blood transfusions so blood can be transfused when needed
  • Complete diagnostic procedures under emergency mode
  • Support with oxygen administration when needed.


Evaluation

Her blood pressure became normal but the pulse rate remained between 100 and 110 beats/min.

3. Nursing diagnosis

Anxiety related to the pregnancy and its outcome as evidenced by her persistent questions about her pregnancy and foetus.

Expected outcome

Mother verbalises that she is relieved of fear.

Nursing interventions

  • Assess the level of fear and anxiety by allowing her to ventilate her feelings
  • Evaluate the mother's understanding of events to provide clarification or any misconceptions
  • Provide calm environment, competent attitude to aid in decreasing anxiety
  • Explain about various ways of outcome of pregnancy
  • Explain about need for surgical interventions and care
  • Explain about pre- and post-operative interventions
  • Allow the mother to verbalise feelings to permit clarification of information and promote trust
  • Continue to assess the vital signs or other clinical indicators of hypovolemic shock to evaluate if the psychological response of anxiety intensifies physiologic indicators.


Evaluation

Mother verbalised that she understood the disease process and the treatment modalities. She verbalised comfort and diminished anxiety.

4. Nursing diagnosis

The risk for post-operative complications such as pain, bleeding, shock and peritonitis related to surgical intervention.

Expected outcome

Mother will not develop any post-operative complications.

Nursing interventions

  • Assess vital signs every ½ h in the initial 4 h after surgery
  • Monitor for signs of bleeding, pallor, tachycardia and restlessness
  • Measure pain and administer pain medication appropriately
  • Assess for abdominal pain and tenderness
  • Maintain an accurate intake and output chart
  • Administer IV fluids as ordered
  • Document all observations.


Evaluation

Mother did not develop any complications in the post-operative period.

5. Nursing diagnosis

Grief related to foetal loss as evidenced by mother expressing that she could have had twins.

Expected outcome

Mother understands grieving as a normal process and will be able to move towards planning for care of the live foetus.

Nursing interventions

  • Assess the mother for her mental status and ability of coping with the outcome
  • Allot a private room if possible, with regular contact by care providers. Encourage visiting by family and friends
  • Support free flow of emotional expression. Only restrict behaviour that is dangerous to well-being of patient/couple (e.g., pulling out IV line, using fists to pound on abdomen)
  • Consider the individual nature of movement through the stages of grief; tell patient/couple that delays in the grief process or relapses of grief are normal
  • Include spouse in planning care. Grant opportunity for the spouse to assist in care. Reinforce the discussion of concerns
  • Discover magnitude of the loss for the couple. Regard how strongly couple desired this pregnancy
  • Provide accurate information and correct misconceptions based on couple's readiness and ability to listen effectively
  • Talk about anticipated physical and emotional responses to loss. Evaluate coping skills.
  • Consider religious beliefs and ethnic background and provide culture-specific support.


Evaluation

Mother was taking efforts to come to terms with the current situation and was able to decide plans for future of the live foetus.

6. Nursing diagnosis

Deficient knowledge related to antenatal care.

Expected Outcome

Mother will demonstrate knowledge related to all aspects of antenatal care.

Nursing interventions

Emphasise the importance of care of the live foetus by encouraging her to:

  • come for regular antenatal check as per schedule
  • take a well-balanced diet
  • include iron and folic acid supplementation
  • perform antenatal exercises
  • learn about newborn care.


Evaluation

The mother at the time of discharge was relieved of pain and her fear regarding the foetal loss had reduced.


  Conclusion Top


HP, although rare, is an obstetric emergency which needs prompt diagnosis and treatment. The nurses' responsibility is multifold, as she has to address the challenge of safeguarding the pregnancy and at the same instant assist in evacuation of non-viable foetus. Early recognition of the condition and managing the mother based on the priority needs will help reduce the mortality of mother and child.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Heterotopic Pregnancy. 2019. Available from: https://en.wikipedia.org/wiki/Heterotopic_pregnancy. [Last accessed on 2019 Feb 25].  Back to cited text no. 1
    
2.
Dutta DC. Text Book of Obstetrics: Including Perinatology and Contraception. India: New Central Book Agency; 2004.  Back to cited text no. 2
    
3.
Pippit K, Stoesser K. Women with Heterotopic Pregnancy after Natural Conception. 2011. Available from: https://www.obgyn.net/pregnancy-and-birth/woman-heterotopic-pregnancy-after-natural-conception. [Last accessed on 2019 Feb 25].  Back to cited text no. 3
    
4.
Danielsson K. Heterotopic Pregnancy Causes, Signs, and Diagnosis. 2017. Available from: https://www.verywellfamily.com/heterotopic-pregnancy-2371476. [Last accessed on 2019 Feb 25].  Back to cited text no. 4
    
5.
Wallach EE, Tal J, Haddad S, Gordon N, Tritsch IT. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: A literature review from 1971 to 1993. Int J Fertil Steril 1996;66:1-2.  Back to cited text no. 5
    
6.
7.
Beyer DA, Dumesic DA. Heterotopic pregnancy: An emerging diagnostic challenge. Obstet Gynecol Int 2002;14:36-46.  Back to cited text no. 7
    
8.
Rao KA. Textbook of Midwifery and Obstetrics for Nurses. India: Elsevier; 2011.  Back to cited text no. 8
    
9.
Cunningham F, Leveno K, Bloom S, Hauth J, Rouse D, Spong C. Williams Obstetrics. New York: McGraw Hill; 2010.  Back to cited text no. 9
    
10.
Mer'i ZB. Heterotopic pregnancy: A case report. JRMS 2008;15:51-3.  Back to cited text no. 10
    
11.
Ciebiera M, Jóźwiak AS, Zaręba K, Jakiel G. Heterotopic pregnancy – How easily you can go wrong in diagnosing? A case study. J Ultrason 2018;18:355-8.  Back to cited text no. 11
    
12.
Li JB, Kong LZ, Yang JB, Niu G, Fan L, Huang JZ, et al. Management of heterotopic pregnancy: Experience from 1 tertiary medical center. Med (Baltimore) 2016;95:e2570.  Back to cited text no. 12
    
13.
Strohmer H, Obruca A, Lehner R, Egarter C, Husslein P, Feichtinger W. Successful treatment of a heterotopic pregnancy by sonographically guided instillation of hyperosmolar glucose. Fertil Steril 1998;69:149-51.  Back to cited text no. 13
    
14.
Lang P, Weiss PM, Mayer H, Haas J, Hönigl W. Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin-F2α: A prospective randomised study. Lancet 1990;336:78-81.  Back to cited text no. 14
    
15.
Goldstein JS, Ratts VS, Philpott T, Dahan MH. Risk of surgery after use of potassium chloride for treatment of tubal heterotopic pregnancy. Obstet Gynecol 2006;107:506-8.  Back to cited text no. 15
    


    Figures

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Abstract
Introduction
Aetiology
Clinical Feature...
Diagnosis
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Case Report
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