Diagnosis and management of multiple-site heterotopic pregnancy with acute appendicitis: Case report

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BACKGROUND: Heterotopic pregnancy (HP), characterized by coexisting intrauterine (IUP) and ectopic pregnancy (EP), poses diagnostic challenges due to overlapping symptoms with conditions like acute appendicitis in pregnancy (AAIP). This case highlights the complexities of managing HP with concurrent AAIP and bilateral tubal pregnancies following ovulation induction. CASE PRESENTATION: A 32-year-old female with a history of clomiphene-induced ovulation presented at 9 weeks' amenorrhea with vaginal bleeding and right lower abdominal pain. Transvaginal ultrasound revealed an IUP, a left adnexal mass with embryonic cardiac activity, and a right lower abdominal mixed-echoic lesion suggestive of appendicitis. Laparoscopic left salpingectomy and appendectomy were performed in the first operation, and the diagnosis was confirmed by postoperative pathology. Postoperatively, β-hCG remained elevated (161,134 IU/L), and a right adnexal mass enlarged progressively. A second laparoscopic surgery was performed to remove the right fallopian tube and successfully preserve intrauterine pregnancy, and a healthy male baby was delivered by cesarean section at 38 weeks and 5 days of gestation. CONCLUSION: This case underscores the diagnostic complexity of overlapping HP and AA symptoms, emphasizing the role of serial biomarker assessment and early surgical intervention in high-risk populations. Bilateral tubal ectopic pregnancies, though rare, warrant heightened vigilance in assisted reproductive technology (ART) patients. Dynamic imaging and intraoperative exploration are critical to avoid missed diagnoses. Timely laparoscopic surgery, coupled with threatened abortion management, can optimize maternal and neonatal outcomes.

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