HETEROTOPIC PREGNANCY

A TRUE SUCCESS STORY OF A MISSING TWIN

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A TRUE SUCCESS STORY OF A MISSING TWIN

Another missing twin caused panic at operation, as the first twin was delivered, the second could not be found.

Photo by Jonathan Borba on Pexels.com

The surgeon and his assistant shifted their gaze from the site of operation in a callisthenic manner and focused on each other in a kind of stare that asked the question; what have we got ourselves into? There  was panic and commotion in the operating room as each group of health workers in the theatre moved even closer to see for themselves a miracle they will never wish to be associated with.

This was happening at a time when a similar incident involving one of the tertiary health centres in the country was still making the  air waves that, the health workers allegedly connived  to steal one  of their patient’s twin baby after a cesarean section delivery. Stay with me as I take you through the  journey of how we got here.

WHEN THE MISSING TWIN MYSTERY STARTED

My team was on call duty the day the patient came to us with a 5 months old  pregnancy and a referral letter for our expert care on account of anemia in a woman pregnant with twins. We investigated her and found that she had malaria,  urinary tract infection and her blood volume was severely low. She was treated for both malaria, urinary tract infection and she also had 3 pints of blood transfused over a 3 day period. A repeat test done after the treatment showed she was free from the malaria infestation and urinary tract infection that were the supposed causes of her low blood volume which was still low though, not as bad as the one she came with. There was a 3% increase in her blood volume from what she came with which was far below expectation.

With this new challenge, my team called in the experts in blood medicine; the hematologist. They ran a barrage of tests for her and could not find the cause of the low blood volume. They however order another round of blood transfusion, this time she got 2 more pints and a repeat blood volume check was same as the value we got after she received the 1st 3 pints of blood.

Both my team and the hematologist were perplexed by this and sadly, we did not know what is causing this blood shortage. She also had several scans done which only showed she was carrying twins and nothing else. A meeting of both the hematologist and the obstetrician was called to brainstorm on her case for a possible cause because one can only fight an enemy he knows. At the end of this meeting there was no answer but more unanswered questions. Later she developed pregnancy induced hypertension for which she was managed with medication.

By the 7th month plus, she starting passing protein in her urine with the hypertension uncontrolled despite being on medication. The decision was made to have a Cesarean section done the next day which happened to be my team’s operation day. She was counselled and consent for surgery taken, materials needed were made available for  the surgery.

MISSING TWIN MYSTERY CONTINUED

Well the day never signaled that it would be a dramatic one but, one can never tell how each day will be until it ends. In my usual way I first get to the room where patients for surgery stay before I changed into my theatre outfit. The patient was already there and was happy to see me because she could not wait to see her babies.

As the theatre nurses were setting up the operation table and instrument tray, the anaesthetists were at their corner preparing their medication to ensure the patient will not feel any pain during the operation. The team Involved in the surgery which comprised of the obstetricians, anaesthetists, neonatologist and scrub nurses introduced themselves to the patient. The operation check list was read and the patient was taken into the theatre to the operation table. The anaesthetists did what they know how to do best, then, here comes the unsuspecting surgeons to begin the  surgery. The operation began and after 5 minutes, the palatable cry of the first twin elated the staff in the operation room. The baby was handed over to the neonatologist who was patiently waiting to receive the baby. The surgeon went back to deliver the second twin both there was no second twin in the womb.

THE MOMENT OF PANIC

The surgeon and his assistant looked at each other and announced that there is no second baby since they could not  see any other one and the womb is empty. The scrub nurse and the anaesthetist came closer to confirm what they just heard and  were in awe. “This is just a joke right?” the anaesthetist said. “Your operation list said twin pregnancy, the scan she did what did it say?, where is the patient record let’s take a look at the scan again”. All questions asked in panic as the medical world was still trying to recover from the story aired about a patient with twins who was told after her operation that it was only one baby.

The unit head was called and in few minutes he appeared in the theatre fully dressed in his theatre outfit. They checked between the mother’s legs if she might have delivered the baby herself while the operation was going on, though she was not in labour and should not be a possibility, but still that did not stop the checking.

SOLVING THE MYSTERY

 Exploration of the abdomen was done and a huge ‘angry’ looking bloody mass was seen behind the womb. “This explains the reason why her blood volume does not increase as expected despite the 8 pints of blood transfusion” said one of the surgeons. More pints of blood were requested from the blood bank on seeing that mass and the general surgeons were called in to inspect the mass for removal. The surgery was temporarily halted while awaiting the arrival of the general surgeons.

The lead surgeon decided to take a second look at the mass and as he moved the mass his finger poked it then, he notice fluid mixed with blood coming from the poked site. He said  this might be the baby, with the general surgeon on ground and enough blood made available he decided to open up the mass and there the missing twin was found. The second twin was then delivered and handed to the neonatologist though, he weighed slightly lower than the one from the womb. The second twin had been in the abdomen growing instead of the womb. This is a type of ectopic pregnancy called “heterotopic pregnancy”. This is a huge success story as far as ectopic pregnancy is concerned. That’s why an early scan is very important not only to know where the pregnancy is but also to know how many babies are there.

To know more about ectopic pregnancy, read here.

SYMPTOMS, SIGNS, CAUSES AND TREATMENT OF ECTOPIC PREGNANCY

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SYMPTOMS, SIGNS, CAUSES AND TREATMENT OF ECTOPIC PREGNANCY

FEMALE REPRODUCTIVE ORGAN. ALPHABETS SHOWS ECTOPIC PREGNANCY SITES ON THE TUBE

The word ectopic is derived from the Greek word “Ektopos” meaning out of place. After fertilization which is the union of the egg and sperm, the fertilized egg moves to the womb and gets implanted. In ectopic pregnancy this does not happen instead, it is implanted outside the womb.

The prevalence is estimated at 1 in 40 pregnancies or 25 cases per 1000 pregnancies according to the United States centre for disease control and prevention. The incidence has been rising due to improvement in early diagnosis, resulting in the discovery of those that would have resolved naturally without treatment. However, some authorities might argue that the increased incidence is as a result of previous pelvic infection. However, the death rate is falling due to early diagnosis and treatment.

Ectopic pregnancy commonly occurs in the fallopian tubes, other areas in descending order of occurrence includes; the abdomen, ovary and cervix though they rarely occur here. Rarely a normal pregnancy can co-exist with an ectopic pregnancy; this is called heterotopic pregnancy. It is one of the common causes of severe bleeding and death in early pregnancy hence the need for an early scan to locate the pregnancy. The exact cause is not known but there are risk factors that predispose to having ectopic pregnancy.

RISK FACTORS FOR ECTOPIC PREGNANCY

Some women who had ectopic pregnancy had no risk factors however, anything that stops or delays the movement of the fertilised egg to the womb where it normally implants can result in ectopic pregnancy.

  •  Non-treatment or poorly treated pelvic inflammatory disease (PID) which is sexually transmitted.
  • Adhesions from pelvic surgeries.
  • Endometriosis.
  • Previous surgery on the fallopian tube.
  • When the tubes have been tied and it fails.
  • Smoking.
  • Some hormonal contraceptives when they fail.
  • Women with inability to conceive who then use assisted reproductive technology, example in-vitro fertilization (IVF) or use of clomiphene. (Do not abuse clomiphene because you want twins)
  • Previous history of ectopic pregnancy has a 10 to 20% chance of recurrence.
  • Age ≥ 35 years is associated with a higher rate of ectopic pregnancy.
  • A scared womb.
  • Fibroid.

SYMPTOMS AND SIGNS OF ECTOPIC PREGNANCY

There are three common symptoms 50% of women with ectopic pregnancies might have such as;

  • History of Loss of menses.
  • Abdominal pain.
  • Sudden vaginal bleeding.

Some symptoms might be like those of early pregnancy such as;

  • Nausea
  • Vomiting
  • Tiredness

Others symptoms may be;

  • Dizziness
  • Weakness
  • Sudden collapse/fainting
  • There may be a swelling at the site where the pain is maximum
  • Sudden recent pain during sex
  • Shoulder pain
  • Diarrhoea
  • Pain while defecating
  • Fever.

You do not have to notice all the above symptoms or all the major symptoms before you go to the hospital.

At the emergency room, the doctor will ask a few questions to establish the symptoms of ectopic pregnancy and carry out examination to elicit signs that will help make the diagnosis. These signs will give an idea whether it has ruptured or not and the severity of the situation. When the ectopic pregnancy ruptures, the blood accumulate in the abdomen and cause irritation resulting in the following signs;
-Fast breathing.
-Low blood pressure and high pulse.
-A painful abdomen when pressure is applied on it and when the pressure is quickly remove.
-A very rigid abdomen.
-Pain when the cervix is moved.
Ectopic pregnancy is “a black cat masquerading in the dark” because other disease state mimics it. A high index of suspicion is required as it can be mistaken for an appendicitis, PID, urinary tract infection,ovarian torsion or cyst.

TREATMENT OF ECTOPIC PREGNANCY

The treatment for ectopic pregnancy depends on when it was diagnosed and the clinical state of the woman. When discovered incidentally early in pregnancy during routine scan the treatment might be expectant or medical treatment for ectopic pregnancies that have not ruptured.

 When a woman meets the criteria for expectant treatment, which is assessed from the result of the pregnancy hormone called β-Chorionic gonadotrophin (β-HCG), other blood tests, ultrasound scan, her general clinical state (which should be stable) and her understanding of her condition, then, an expectant treatment can be undertaken. She will be adequately counselled by her healthcare provider on the possible chances of the ectopic pregnancy rupturing and the need to come for follow up visits as scheduled to check for blood levels of the pregnancy hormone (β-HCG) which is expected to be falling. Medications are usually not given; the pregnancy is observed for spontaneous resolution.

When a woman meets the criteria for medical treatment, she will be advised by her healthcare provider to avoid alcohol, vitamins containing folic acid, sexual intercourse and nonsteroidal anti-inflammatory drugs(NSAIDS) example diclofenac during the course of her medical treatment. She will be treated using methotrexate which is the common medication used, other medications include; potassium chloride or hypertonic saline. She will be counselled of the possibility of the ectopic pregnancy rupturing and the need to seek immediate care if she feels strange symptoms. At follow-up visits, the blood level of β-HCG would be checked and it is expected to be decreasing.

Furthermore, treatment could be surgical which could be conservative or non-conservative surgery. The decision to do either one will depend on if the fallopian tube has ruptured or not, the desire for future fertility and the state of the other tube as seen during the surgery. This could either be open surgery or minimally invasive surgery such as laparoscopy. Laparoscopy is the goal standard as it can be used both for diagnosis and treatment. It also has the advantage of less pain after surgery and short hospital stay. The demerit is that, is it expensive and requires a highly skilled operator. The conservative surgeries where the fallopian tube affected is preserved are for unruptured ectopic pregnancies but they constitute risk factors for a repeat ectopic pregnancy. The non-conservative surgeries are for ruptured ectopic pregnancy where the affected tube is removed.

The duration of stay in the hospital depends on the nature of the surgery or presence of any complication arising from blood loss or the surgery. Most patients treated with laparoscopy are discharged within 24 hours. Thereafter, the blood level of the β-HCG will continue to be monitored weekly until it becomes normal especially with some conservative surgeries. Ectopic pregnancy is a gynaecological emergency; the outcome is best when diagnosed early. Once a home or hospital pregnancy test turns out positive, the next thing to do is to confirm the location of the pregnancy.

I hope this article was helpful, you can leave a question or comment and I will surely get back to you.

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