heterotopic pregnancy is the coexistence of a living or dead intrauterine pregnancy , single or multiple , and extrauterine pregnancy located in the oviduct , ovary , uterine corner , cervix or peritoneal cavity .
the first case was described in 1708  at that time the diagnosis was established during autopsy . in the latter years
together with assisted reproductive techniques and the ultrasound techniques improvement , the incidence of heterotopic pregnancies increased from 1:500 to 1:100 of pregnancies . in this
study the case of the coexistence of inter- and extrauterine pregnancies has been presented in a patient , who had been stated no increased risk of heterotopic pregnancy and who conceived in the course of natural menstrual cycle .
a 25-year - old primipara in 6 week of the second pregnancy ( the first one ended with miscarriage in 6 week 6 months before ) came do the clinic at night ( 1 november 2007 ) because of lasting for 24 hours vaginal bleeding and abdominal pain . in medical interview regular menstrual cycles  every 30 days , quite abundant , lasting 5 days , with accompanying abdominal pain .
the patient had not undergone surgeries , suffered from no chronic diseases , no extrauterine pregnancy risk factors were stated in the medical interview . on admission do the clinic satisfactory general condition , arterial blood pressure 130/70 mm hg , pulse 78/min , body temperature 36.5c .
the patient before the admission to the ward had been consulted by a surgeon who did not state indications for urgent surgical procedure . in physical examination
the abdomen was soft , tender to palpation , mainly in the right hypogastric area , with no pathological resistance and surgical abdomen symptoms , peristalsis slow .
in gynecological examination : perineum and vulva as in nullipara , smooth - walled vagina , brownish discharge in vagina visible in speculum examination , with no symptoms of active bleeding from cervix canal .
bimanual examination : uterus in retroflexion , slightly tender , slightly enlarged , adnexa bilaterally with no pathological resistance , painless .
laboratory tests on admission : wbc 14.210/l , rbc 3.5010/l , hb 11.3 g / dl , hct 32.8% , plt 28610/l , normal general urine test . in the transvaginal ultrasound examination
the following was stated : gestational sac in the uterine cavity of the diameter of 9 mm , with a yolk sac of 3.1 mm , no embryo visualized ; left ovary 4730 mm ; right ovary 3021 mm , translocated behind the uterus , over the superior pole a well - defined thick - walled vesicle visible , of the diameter of 20 mm , with visible peripheral vascularization of medium resistance flow character which can refer to the gestational sac implanted in the oviduct .
because of the suspicion of intra- and extrauterine pregnancy the patient was admitted to the gynecology ward .
the following treatment was introduced : duphaston , kaprogest , no - spa . on the next day the patient in satisfactory general condition , cardiovascularly and respiratorily stable , arterial blood pressure 100/60 mm hg , pulse 80/min , slight vaginal bleeding sustained .
laboratory tests : wbc 13.910/l , rbc 3.5910/l , hb 11.7 g / dl , crp 46 mg / l , -hcg 23 173 miu / ml .
tvs examination was performed one more time : in the uterine cavity the gestation sac of the diameter of 11 mm visible , with yolk sac of the diameter of 3.5 mm , the embryonic structures were still not visualized ; ovaries of normal size bilaterally , over the superior pole a well - defined thick - walled vesicle visible , of the diameter of 20 mm , with an increased vascularization ; no pathological changes over left adnexa ; trace amount of fluid in the pouch of douglas  ultrasound image suggests the coexistence of inter- and extrauterine pregnancy on the right side , of the gestational age about 5/6 weeks ( fig .
on the 4 november 2007 control -hcg 27 393 miu / ml , in the us examination a gestational sac containing a single living embryo was stated in the uterine cavity , crl ( crown - rump length ) 4.2 mm , which referred to the 6 week of gestation , fhr(+ ) 110/min , with no trophoblast shearing off symptoms , in the area of the right adnexa of the uterus visible thick - walled vesicle of the diameter of 30 mm , with quite abundant peripheral vascularization ; with the absence of free fluid collection in the pouch of douglas ( figs . 2 , 3 ) .
because of the diagnosis of living intrauterine pregnancy and the suspicion of the coexistence of the right extrauterine pregnancy , the patient was qualified for surgical treatment .
intraoperatively the following was stated : body of the uterus enlarged , smooth , mobile , with the size referring to the 6 week of pregnancy ; right oviduct livid , dilated to 23 cm , right ovary normal , left adnexa of normal size , with no pathological lesions ; abdominal cavity organs macroscopically normal . because of macroscopic symptoms of tubal pregnancy presence , the right oviduct was removed .
postoperative course not complicated : the patient in satisfactory general condition , cardiovascularly and respiratorily stable , normal body temperature , no vaginal bleeding .
on the 5 day after surgery in tvs examination the following was stated : body of the uterus enlarged on the whole surface , of even outline , gestation sac visible in uterine cavity gs equals 25 mm , with visible embryo of crl 10 mm , which refers to 7 week of gestation , with regular heart rate of 140 bpm , trophoblast with no symptoms of shearing off .
ultrasound image of intrauterine and extrauterine pregnancy located in the right oviduct registered embryonic heart rate in the intrauterine pregnancy peripheral trophoblast vascularization in the extrauterine pregnancy
basing on the studies of natural cycle stated that it can refer to 1/7963 of cases . among the risk factors of intra- and extrauterine pregnancies one can list : chronic inflammation in the region of lesser pelvis , surgical procedures on adnexa of uterus , undergone extrauterine pregnancies , sexually transmitted diseases , the use of intrauterine device and assisted reproductive techniques ( art ) .
walker at al . proved that in patients treated because of infertility and who underwent in vitro fertilization the risk of heterotopic pregnancy increases 400-fold in comparison to natural conception .
it is also thought that the incidence of this pathology after the use of art oscillates from 0.75% to 1.3% .
the most frequent location of extrauterine pregnancy coexisting with intrauterine pregnancy are oviducts ( 93.9% ) , definitely more rarely the pregnancy is located in the ovary ( 6% ) .
more frequent incidence of pregnancies in the left oviduct in comparison to the right oviduct has been observed ( 31.8% vs. 36.3% ) . in the described case
the authors also report about incidences of single or multiple intrauterine pregnancy and extrauterine pregnancy localized in cervix , uterine corner or peritoneal cavity and also the coexistence of pathological intrauterine pregnancy , e.g. blighted ovum and living extrauterine pregnancy .
heterotopic pregnancy diagnosis is one of the most difficult clinical problems . to the most frequent symptoms
body of the uterus enlargement  42% , vaginal bleeding  32% . according to tal et al .
the major symptoms are abdominal pain  83% , surgical abdomen symptoms and shock  13% and vaginal bleeding  50% of cases . in the presented case the majority of symptoms occurred 
the patient reported abdominal pain and vaginal bleeding . because of the early period of pregnancy development no pathological resistance in gynecological examination was stated .
nevertheless , precise imaging of the adnexa of the uterus area by means of transvaginal ultrasound enabled to visualize a pathological structure which might have referred to a pregnancy implanted in the oviduct ( thick - walled , peripherally vascularized fluid reservoir , characteristic for implanting trophoblast ) .
this confirms the opinion that the basic diagnostic method in case of heterotopic pregnancy is transvaginal ultrasound examination , particularly recommended in patients after art between 4 and 6 week of pregnancy , however , some authors say that the sensitivity of this method is insufficient and equals about 56% .
report that heterotopic pregnancies in 70% of cases are diagnosed between 5th and 8th week of gestation , similarly as in the pregnancy described by us , in 20% between 9 and 10 week and in 10% in 11 week of gestation .
it seems that the assessment of beta unit of chorionic gonadotropin in the diagnostics of such cases is little useful because the dynamics of concentration changes of this marker is not characteristic for this abnormality and additionally the presence of developing intrauterine pregnancy makes the result interpretation difficult .
it should be hence thought that the most efficient diagnostic method , confirming final diagnosis and being at the same time a form of treatment is laparoscopy , more rarely laparotomy , performed in cases of intraperitoneal bleeding with shock symptoms .
it should be also mentioned about the possibilities of conservative treatment in selected cases . among these methods
one can number inter alia fine needle aspiration of the embryo from the oviduct with simultaneous application of 50% glucose under the us control and in case of intramural pregnancy localized in the uterine corner  local methotrexate application ; in cervical pregnancy there are trials of placing hemostatic sutures or local hypertonic nacl solution .
there are also reports about the use of prostaglandins . in these cases , however , because of their teratogenicity , this method is not widely accepted .
it is estimated that intrauterine pregnancy after the abortion of extrauterine pregnancy develops normally in 6592% of cases .
reece et al . submitted for analysis 37 patients with diagnosed heterotopic pregnancy after surgical treatment of extrauterine pregnancy 
75.6% gave birth around their expected delivery date , 16.2% prematurely and 3% of pregnancies ended with a miscarriage .
on the other hand , it should be remembered that the coexistence of extrauterine pregnancy with intrauterine pregnancy may be threatening not only for the developing fetus in the uterus but also for the mother because the mortality of women in such cases equals 1% .
concluding , we think that the visualization of normal pregnancy in the uterus in ultrasound examination does not release a doctor from a necessity of precise imaging of adnexa of the uterus . thanks to this we can establish the diagnosis earlier and introduce adequate procedure , limiting the possibility of complication occurrence and assuring optimal conditions for the developing intrauterine pregnancy .
 heterotopic pregnancy is the coexistence of living or dead intrauterine pregnancy , single or multiple , and extrauterine pregnancy located in the oviduct , ovary , uterine corner , cervix or peritoneal cavity . 
 this condition is very rare ( 1:30 000 pregnancies ) . 
 nevertheless , in the latter years because of the development and accessibility of assisted reproductive techniques , the incidence of heterotopic pregnancies increased to 1:100 of pregnancies . 
 the aim of this report is to present a case of early recognized intrauterine and extrauterine pregnancy . 
 the case refers to 25-year - old patient , pregnant for the second time , in more or less 6th week of gestation , who had not been stated any heterotopic pregnancy incidence risk factors . 
 after the observation lasting for several days in the clinic , the presence of a living intrauterine and coexisting extrauterine pregnancy located in the right oviduct was stated . 
 the patient had her right oviduct removed by means of laparoscopy . 
 after the surgery the patient with the living intrauterine pregnancy was released from the clinic . 
 normal further course of intrauterine pregnancy . 
 the patient gave birth around her expected delivery date . 
 the presented case indicates the significance of correctly and carefully performed ultrasound examination . 
 moreover , it is a warning for the doctors performing ultrasound examinations in the early weeks of pregnancy  the visualization of a normal pregnancy in the ultrasound examination does not release the examiner from a necessity of precise imaging of adnexa of the uterus . 
 early diagnosis of this pathology , thanks to a precise ultrasound examination , decreases the risk of complication incidence as well as women mortality . 