Tuesday, August 11, 2009

Heterotopic Pregnancy

A heterotopic pregnancy is where you have an intrauterine pregnancy (normal) and an ectopic pregnancy (preg in the fallopian tube) at the same time. I remember Dr. Robert Wright, an ER attending in residency, stressing the point of making sure to think about this so you don't miss it. From what I read, the frequency of this is between 1:2600 and 1:30000, it is rare, but it happens and we saw it here recently. Christina came in with abd pain and was found to be 10wks pregnant. However on ultrasound she had a lot of fluid in her pelvis and free fluid in her abdomen. We were discussing the options of was this ascites, from something like an ovarian tumor, was it blood from a heterotopic pregnancy, or something else. When her hemoglobin came back at 7, it made us worry more that she was bleeding. The patient was not really interested in keeping her pregnancy and wanted Jim to just remove it all. He had no desire to do that, but wanted to do surgery if she needed it. One of the difficulties in her case was she was a Jehovah's Witness. So she doesn't receive blood products. After further discussion amongst her family and church elder, it was decided since she wasn't baptized yet in the church, she could receive blood. So we gave her blood and watched. When her hemoglobin remained stable after the blood and the amount of fluid in her abd/pelvis wasn't changing, we were encouraged, but she started to have worsening RLQ abd pain. I found a RLQ mass on US now along with this fluid. Further discussion with Bill and Jim determined that it was necessary to go in and see what she had, and do as much as needed, but little as possible to keep the baby growing inside the uterus. When Jim went in, he found a ruptured ectopic along with the intrauterine pregnancy. So she did have the heterotopic pregnancy. Thankfully she is doing well and, for now, her baby is still growing inside. We pray that the baby would continue to grow and develop, and that she would come to accept this baby, and the baby that came to save us all, Christ.