Spontaneous Heterotopic Pregnancy after Four Previous Caesarean Sections: Successful Salpingectomy and Inta-Uterine Term Pregnancy

Heterotopic pregnancy is rare under natural circumstance (conception). We report the first case of heterotopic pregnancy in spontaneous conception with four previous caesarean sections and ruptured tubal ectopic with resultant successful normal intra-uterine pregnancy delivered at term after salpingectomy. A 32-year-old gravida 5 para 4+0 with 3 living children, with 4 previous caesarean sections, presented to the Accident and Emergency unit of Nnamdi Azikiwe University Teaching Hospital, Nnewi at a gestational age of 9 weeks + 2 days, with recurrent vaginal spotting of 2 weeks duration, lower abdominal pain as well as nausea and vomiting of 3 days duration. Initial transvaginal ultrasound scan confirmed intrauterine gestation at 9 weeks of gestational age, with right adnexal mass which was misdiagnosed as corpus luteum. Later, a diagnosis of heterotopic pregnancy was made and she had laparotomy with right salpingectomy. The intrauterine pregnancy was continued till term. She subsequently had elective repeat caesarean section with the outcome of a live male baby of Apgar scores of 8 and 10 in the first and the fifth minutes respectively, and birth weight of 4.3 kg. This demonstrates that spontaneous heterotopic pregnancy can occur after four previous caesarean sections, and that the presence of corpus luteum in early ultrasound scan should raise the suspicion of possible heterotopic pregnancy.  Early detection and prompt intervention is necessary for the safety of both the mother and the normal intrauterine gestation.