Spontaneous heterotopic pregnancy is rare and is reported to occur in between 1:10 000 and 1:50 000 pregnancies (Figure 8.5).11 They are
often missed as once an intrauterine pregnancy has been visualized it is often assumed that an ectopic pregnancy cannot be present. However women who have undergone assisted reproductive techniques (ARTs) have an incidence of heterotopic pregnancy as high as 1%." Therefore, if an intrauterine sac is confirmed on TVS in these women, the adnexae must be carefully inspected to exclude tubal pathology. In women who have undergone ARTs, even with a confirmed intrauterine gestational sac, if they have ongoing abdominal pain with or without haemodynamic compromise, a hetero-topic pregnancy should always be considered. These pregnancies do represent a management problem. Conservative management is difficult as hCG levels cannot be interpreted in the presence of a viable intrauterine pregnancy and surgery is usually the treatment of choice.
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