Open Journal of Obstetrics and Gynecology, 2012, 2, 325-327 OJOG Published Online September 2012 (
Heterotopic tubal pregnancy with live twin birth
complicating ovulation induction assisted cycle
Adebiyi Gbadebo Adesiyun1*, Benson Ayodele-Cole2
1Department of Obstetrics & Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2Echo-Scan Services, Kaduna, Nigeria
Email: *
Received 10 April 2012; revised 14 May 2012; accepted 31 May 2012
Het erotopic pregnancy is an uncommon clinica l ent ity
in Nigeria even though some of the risk factors are
highly prevalent in the population. We report a case
of heterotopic pregnancy following ovulation induc-
tion with clomiphene citrate. A favourable outcome
resulting in live twin birth was recorded despite the
presence of poor clinical features that affects preg-
nancy and foetal outcome.
Keywords: Heterotopic Pregnancy; Ovulation Induction;
Clomiphene Citrate; Laparotomy; Twin Birth
Heterotopic pregnancy is said to occur when there is
simultaneous coexistence of two or more intrauterine and
extra uterine implantation sites. Heterotopic pregnancy
could follow an assisted conception cycle or a natural
conception cycle. Interestingly, there has been an in-
crease in the incidence of assisted conception related
heterotopic pregnancy since the introduction of assisted
conception technology into the treatment array of infer-
tile couples [1]. Heterotopic pregnancy is an uncommon
clinical condition in Nigeria probably due to under-
reporting or missed diagnosis, because the risk factors
like pelvic inflammatory disease, ectopic pregnancy and
multiple pregnancy are highly prevalent in the population
[2]. We report a case of heterotopic tubal pregnancy
following ovulation induction with clomiphene citrate,
resulting in twin live birth.
A 36-year old Nigerian woman presented with a year
history of infertility. She was para 1 + 1. Her last child
birth was 23 months prior to presentation; she had a
vaginal delivery of a live female baby and the placenta
was manually removed under anaesthesia. She had stop-
ped breastfeeding 11 months earlier. Evaluation revealed
a normal pelvic ultrasound scan, serum prolactin of 26.2
ng/ml, normal semen analysis and the hysterosalpingo-
graphy showed a normal size uterine cavity, left cornual
tubal occlusion and right fimbrial end tubal occlusion.
She was commenced on treatment with cabergoline and
had therapeutic hydrotubation. After a month treatment
w ith cabergoline, a r epeat serum prolac tin was 12.3 ng /ml .
She subsequently had ovulation induction with clomi-
phene citrate, followed with follicular tracking and timed
intercourse after human chorionic gonadotrophin inject-
tion was given whenever the lead fo llicle was at least 18
mm. She conceived at the fourth assisted conception
treatment course with the last menstrual period being on
the 13th of December, 2010. Pregnancy was confirmed
with a positive serum human chorionic gonadotrophin
hormone and an ultrasound scan that showed two viable
intrauterine fetuses at gestational age of 6 weeks and 4
She suddenly felt a sharp lower abdominal pain when
the pregnancy was 7 weeks, the pain progressed and ne-
cessitated her to present in the hospital the next day. As-
sessment revealed severe pallor, signs of hypovolemia
and features of intra abdominal fluid collection. A diag-
nosis of rup tured ectopic pregnancy was made. An urgent
sonography revealed twin viable intrauterine fetuses and
ruptured adnexial ectopic pregnancy, thus confirming the
diagnosis of heterotopic pregnancy. She was resuscitated
and had an urgent laparotomy. Intra operative findings
were haemoperitoneum of 2 litres and a ruptured right
ampullary tubal ectopic pregnancy; she had right sal-
pingectomy. In all she had 4 units of whole blood trans-
fused and post operative treatment include antibiotics,
analgesia and progesterone injection. Post-operative
period was uneventful. Sonography done on 7th day post
surgery showed viable intrauterine twin fetuses.
Thereafter pregnancy remained uneventful until 36
weeks when she had spontaneous rupture of fetal mem-
branes. She had emergency caesarean section because
*Corresponding a uthor.
A. G. Adesiyun, B. Ayodele-Cole / Open Journal of Obstetrics and Gynecology 2 (2012) 325-327
the fetuses were lying transversely. She was delivered of
2 male fetuses that weighed 2.5 kg and 2.05 kg with
good apgar scores. She had primary postpartum haemor-
rhage due to uterine atony and lost about 2.2 litres of
blood despite rectal insertion of misoprostol, manual
uterine compression .and oxytocin drip. She had a total
of 5 units of blood transfusion intra and post operatively.
On the 8th post surgery day she was discharged home
following good recuperation and satisfactory general
Heterotopic pregnancy which was first described at an
autopsy study [3] was hitherto a rarity before the intro-
duction and widespread use of ART. In natural concep-
tion cycles low frequency ranging from 1 in 10,000 to 1
in 50,000 was reported and high rates of heterotopic
pregnancy from 1 in 100 to 1 in 500 was reported in ART
treatment cycles [4-6]. The later is attributable to super
ovulation induction, multiple embryo transfer with re-
sultant increase in multiple pregnancy and ectopic preg-
nancy. In this report the intrauterine pregnancy was a
twin. This is in conformity with authors that reported an
increase in and not in uterine twin gestation. In ART-
related heterotopic pregnancy and an exclusive singleton
intrauterine gestations in natural cycle related heterotopic
pregnancy [4]. In this case report, heterotopic diagnosis
was made at about seven weeks of gestation. This is
within the 5th to 8th week gestation reported to be the
commonest diagnostic period interval for heterotopic
pregnancies [4,7]. Furthermore, the type of cycle, be it
assisted or natural cycle did not affect the gestational age
at diagnosis [4]. The ectopic gestation in this report was
tubal, similar to finding in other series [4,7,8]. Though,
the ectopic gestation was in the right tube in this patient,
there is no predilection for right or left tube in hetero-
topic pregnancy [4,8]. In the evaluation of this patient
before index conception, she had hysterosalpingographic
tubal occlusion and therapeutic hydrotubation as earlier
described by these authors [9]. Studies have highlighted
the importance of previous pelvic pathology as a risk
factor for heterotopic pregnancy, especially in the cohort
that had heterotopic pregnancy following assisted con-
ception [4].
The clinical presentation in this case report includes
hypovolemic shock, tubal rupture and haemoperitoneum.
Being a case of heterotopic pregnancy fo llowing assisted
conception this finding are in contrast to that of a series
that reported on outcome of heterotopic pregnancies and
found a significantly lower rate of low systolic blood
pressure, tubal rupture and haemoperitoneum in the as-
sisted conception group compared to spontaneous con-
ception group [4]. A high miscarriage rate have been
reported in multiple pregnancy and pregnancy compli-
cated by heterotopic implantation with higher rate of
miscarriage documented in heterotopic pregnancy com-
plicating assisted conception than spontaneous concep-
tion [4,10-12]. The aggregate of these predisposing fac-
tors did not result in miscarriage in the case presented.
Mu ltiple pregnancy and Heterotopic pregnancy are kn own
to individually predispose to preterm births [4,7,13]. This
patient was delivered of 2 male babies by caesarean
section at 36 weeks due to preterm spontaneous rupture
of fetal membranes. In heterotopic pregnancy, survival
rate of the intrauterine gestation range from 35% to
66.2% [7,14,15]. This rates are influenced by variables
that hovers round ear ly diagnosis and treatment viz- a-viz
treatment before tubal rupture and development of hae-
moperitoneum and hypovolemic shock that may result in
hypoxic challenge to the intrauterine fetus [4]. A high
survival rate translate to improve live birth rate. The poor
clinical condition in this case as exhibited by tubal
rupture, haemoperitoneum and shock did not affect the
survival of the two fetuses which is in accord with
another study that did not demonstrate a relationship
between intra uterine fetal mortality and presence of
haemoperitoneum [7]. Though with figure that was not
statistically significant, live birth rate was reported to be
two-fold higher in the subgroup that had heterotopic
pregnancy following assisted conception compared to
spontaneous conception [4]. Although, studies have not
demonstrated a link between heterotopic pregnancy and
fetal congenital anomalies, one of the twin in this report
had an upper respiratory tr act obstructive pathology with
no definitive diagnosis up till th e time of this report [4,7].
In conclusion, this report recorded a favourable fetal
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