Spontaneous Heterotopic Pregnancy Ruptured in the Second Trimester

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Background: Spontaneous heterotopic pregnancy is an extremely rare entity, especially in the second trimester and at the isthmic location, where it typically ruptures earliest as compared to other sites.This report presents a rare case of heterotopic pregnancy at the isthmic location, which was diagnosed when intrauterine pregnancy progressed to the second trimester.Case description: 26-year-old primigravida at 14 +6 weeks gestation was referred from a secondary care hospital to our tertiary care institute in gynecological emergency.She presented with acute left lower abdominal pain and dizziness from 8 hours.She was restless, had severe pallor, with a pulse rate of 150/minute and blood pressure of 90/60 mm Hg.Abdominal guarding and rigidity were also present.Urine output was minimal on bladder catheterization.She was infused with intravenous crystalloids and inotropes for stabilization.Transabdominal ultrasound at the bedside revealed an intrauterine fetal demise, with significant hemoperitoneum reaching up to Morrison's pouch, and paracolic gutters.The left side of the abdomen could not be assessed due to a heterogeneous collection of clots, raising suspicion of a possible ruptured hemorrhagic cyst or ectopic pregnancy.Ascitic tap confirmed hemoperitoneum.Emergency laparotomy revealed ruptured left tubal ectopic pregnancy at the isthmic region, with massive hemoperitoneum.Left salpingectomy and peritoneal lavage were performed, whereas intrauterine pregnancy was left undisturbed.She received multiple blood transfusions and fresh frozen plasma.The patient was shifted to the ICU for further monitoring.On postoperative day 2, the patient started vaginal bleeding, managed medically and surgically for retained product of conception to minimize blood loss.She recovered fully with multidisciplinary care and was discharged on day 8 of surgery after giving an injection depot medroxyprogesterone acetate for contraception.Conclusion: Heterotopic pregnancy should be kept as one of the differential diagnoses even in the second trimester, particularly when clinical and imaging findings do not align.Early recognition of hemorrhage, effective multidisciplinary collaboration, particularly with the anesthetist, and timely exploratory laparotomy in patients with deteriorating vital signs are essential to prevent massive hemoperitoneum, disseminated intravascular coagulation (DIC), the need for ICU care, and to ensure favorable maternal and fetal outcomes.

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