Heterotopic pregnancy is simultaneous occurrence of pregnancy at two or more
implantation sites, often a combination of intrauterine and ectopic pregnancy. It has an
incidence between 1:8000 and 1:30,000. Hypogonadotropic hypogonadism is the failure
or disruption of pulsatile secretion or action of gonadotropic releasing hormone, can be
congenital or acquired.
A 31 yr old female known case of hypogonadotropic hypogonadism was referred from endocrinology for primary infertility of 4yrs.Work up for infertility was normal. So she was started on ovulation induction protocol with human menopausal gonadotropin with IUI. She conceived in her second cycle of ovulation induction but was diagnosed to have a left unruptured ectopic pregnaktcy at six weeks of gestation in February 2007. She was successfully managed medical"Pith injection methotrexate 50mg/ m2 single dose.
After six months she was again started on the same protocol of ovulation induction. She conceived in her fourth cycle and at eighth week of gestation she presented with vague right lower abdominal pain. Her tTansabdominal & transvaginal ultrasound was done which suggested an early intrauterine pregnancy of seven weeks along with a right unruptured tubal pregnancy i.e, a heterotopic pregnancy, with minimal free fluid in pouch of douglas.
Patient was admitted and expectant management with vitals monitoring and abdominal girth charting was started. Her baseline investigations were normal. Her repeat ultrasound after one week showed marginal reduction in size of the unruptured ectopic pregnancy and normal growth of the intrauterine pregnancy. She was discharged and was followed up with weekly ultrasound that showed a gradually resolving ectopic gestation.She continued with her normal antenatal visits at the high risk pregnancy clinic.
At thirty seven completed weeks she underwent an elective cesarean for Breech presentation. She delivered a healthy female child of 2.7kg.
Using a clinical pathway ensures discipline and prevents a missed diagnosis of a simulated condition. Additionally it directs and restricts the use of investigations. A set protocol also reassures patients.