Case Report

Heterotopic pregnancy presenting with acute left chest pain

Abstract

Heterotopic pregnancy is the simultaneous existence of intrauterin and ectopic gestations. Heterotopic pregnancy is an extremely rare entity in natural cycle; however, it is increasing due to widespread use of assisted reproductive techniques. Early diagnosis and intervention are crucial in avoiding short- and long-term morbidity and mortality. Unfortunately, early diagnosis is often difficult due to the presence of intrauterin pregnancy that impedes the diagnosis and early treatment for ectopic component. Clinical symptoms are not generally helpful in diagnosis, and signs of the Ectopic pregnancy usually predominate. Patients will most likely present with abdominal pain, adnexial mass, enlarged uterus, peritoneal irritation signs, and a positive pregnancy test. We present a case, admitted to the emergency department, with atypical symptoms including acute left chest pain radiating to left shoulder, at 5 weeks’ gestation.

A 38-year-old female patient, G3P1, at 5 weeks’ gestation, presented to the emergency department (ED) with sudden onset of left chest pain radiating to left shoulder for 3 hours. She described her pain as severe, sharp, and constant and stated that she had fear of death. The pain was not associated with nausea, emesis, dyspnea, cough, and position. Her medical history included a left laparoscopic salpingostomy for a left tubal ectopic pregnancy (EP), a caesarean section, a Spontaneous miscarriage without complications, and no cardiopulmonary diseases. She stated that she experienced pain similar to her previous EP. On initial physical examination, her vital signs were as follows: blood pressure, 110/70 mm Hg; heart rate,

60 beats per minute; temperature, 36.2 ?C; and oxygen saturation, 98% in room air. She was alert and anxious, yet had a nontoxic appearance. On palpation, she had minimal tenderness on left lower quadrant of abdomen. Other physical examination findings were unremarkable. The patient’s hemoglobin level, white blood cell count, and platelet count on admission were 13.0 g/dL, 8.1 x 10 x 3/uL 272 x 10 x 3/uL, respectively. Serum ?-human chorionic gonadotropin was 2026 mIU/mL, and D-Dimer

was 500.8 ng/mL. Doppler ultrasound of lower extremities; electrocardiography; and serum creatine kinase, creatine kinase isoenzyme-MB, and troponin I were normal. The transvaginal and transAbdominal ultrasonography (USG), which identified an intrauterine Gestational sac measuring approximately 5 weeks of gestation, were performed. The adnexa were poorly visualized, and no extrauterin gesta- tional sac and free fluid were seen in the pelvis. Fentanyl was given intravenously in a dose of 75 ug for analgesia in the ED. The patient was admitted to obstetric department for close follow-up. The initial management strategy was conservative. The following day, the patient complained of abdominal pain. Her vital signs were still stable. Examina- tion revealed moderate tenderness without obvious guard- ing. Hemoglobin dropped to 9.8 g/dL, and ?-human chorionic gonadotropin dropped to 1064 mIU/mL. Trans- vaginal USG was reperformed and revealed irregular intrauterin gestational sac and a small amount of free fluid in the peritoneal cavity. The patient was taken to the operating room. An EP in the left salpinx was identified with Diagnostic laparoscopy. A left laparoscopic salpin- gectomy and curettage were performed without complica- tion. Histological examination confirmed a tubal EP.

Heterotopic pregnancy (HP) was first described in 1708 as an autopsy finding [1]. The incidence of HP is estimated at approximately 1/30 000 pregnancies [2]. This rare entity is increasing with increased incidence of PElvic inflamma- tory disease, the common use of ovarian stimulation and assisted reproductive techniques. The rate of HP after In vitro fertilization has been reported to be as high as 1% [3]. The risk factors for an HP are similar to EP, and these risks can be listed as histories of EP and/or Pelvic inflammatory disease, previous abdominal or pelvic surgery, uterine malformation, the use of intrauterin devices, and assisted fertilization techniques [4,5]. The diagnoses of HP can easily be overlooked in the absence of risk factors. Our patient had a history of tubal surgery for EP as a risk factor.

Clinical symptoms are not generally helpful in diag- nosis. Heterotopic pregnancy may present with nonspecific findings, including abdominal pain, adnexal mass, perito- neal irritation signs, and enlarged uterus [4]. While presenting to the ED, our patient complained solely of acute left chest pain radiating to left shoulder. Chest pain is one of the most common complaints in the EDs. The

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Life-threatening causes of chest pain such as acute coronary syndrome and pulmonary embolism must quickly be ruled out in the ED. Acute chest pain may be misleading in potentially serious intra-Abdominal pathology, as it was the case with our patient. Our patient’s pain was presumed referred pain. Referred shoulder pain has been reported to occur with traumatic liver and biliary tract injury, subdiaphragmatic endometriosis, adrenal hematoma, as well as peritonitis, pancreatitis, and other lesions [6].

?-Human chorionic gonadotropin is often misleading and falsely reassuring in the presence of an intrauterin gestation [2,3]. The USG visualization of extrauterin and intrauterin gestations together is important for diagnosis but rarely occurs [3]. In a review, it is stated that after in vitro fertilization and embryo transfer, in 58% of the cases, HPs were missed at the initial USG examination [4]. In another study, it is reported that 26.25% of HPs are diagnosed by USG and 73.75% are diagnosed by surgery [3]. In our patient, the initial transvaginal and transabdominal USG did not detect an adnexal mass or free fluid in abdominal cavity.

Heterotopic pregnancy is often diagnosed late and has significant morbidity and some mortality [5]. It is reported that whereas approximately 73.25% of HPs are diagnosed between 5 and 8 weeks, 10% are diagnosed between 9 and 10 weeks and 10% after 11 weeks [1,3]. The gold standard for the treatment of EP is surgery: either a salpingostomy or a salpingectomy. If treatment is performed earlier, the prog- nosis for intrauterin pregnancy will be much better. There has been a reported survival rate of 35% to 54% for intrauterin gestation after treatment of EP [1].

In conclusion, HP is a Rare condition but increasing in frequency. Heterotopic pregnancy after spontaneous con- ception still remains a difficult problem in terms of diagnosis and management. Symptoms and signs may be confusing because they were with our patient’s. The emergency physicians taking care of women at reproductive ages should never underestimate the potential life-threatening HP in a way our case endeavoured to present.

Fikret Bildik MD Ahmet Demircan MD Ayfer Keles MD

Gul Pamukcu MD Gazi University Medical Faculty Department of Emergency Medicine

Ankara, Turkey E-mail address: [email protected]

Aydan Biri MD Gazi University Medical Faculty Department of Obstetrics and Gynecology

Ankara, Turkey

Emine Bildik MD

Dr. Sami Ulus Children’s Health and Diseases Training and Research Hospital

Department of Anesthesiology

Ankara, Turkey

doi:10.1016/j.ajem.2007.12.013

References

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