Avoiding Patient Harm in Diagnosing Heterotopic Pregnancy

Abstract

Despite the extremely rare incidence of
Heterotopic pregnancy outside of women undergoing assisted
reproduction treatments, simultaneous intra and extra-uterine
pregnancies are often suspected or unnecessarily included in
the differential diagnosis in emergency departments in the
United States. This has led to patient injuries,
including unnecessary surgical intervention as well as
unindicated salpingectomy and salpingotomy. We sought
out to devise a simple protocol to aid both the
emergency medicine practitioner and gynecologist in
the management of a suspected heterotopic pregnancy.

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OriginalResearch
The B.S. (Be Safe) Protocol: Avoiding Patient
Harm in Diagnosing Heterotopic Pregnancy
Greg J. Marchand, MD, FACS, FICS, FACOG,Katelyn Sainz, MS4, Lisa Rials,MS1,Rachel Pile,MS1
OBJECTIVE: Despite the extremely rare incidence of
Heterotopic pregnancy outside of women undergoing assisted
reproduction treatments, simultaneous intra and extra-uterine
pregnancies are often suspected or unnecessarily included in
the differential diagnosis in emergency departments in the
United States. This has led to patient injuries,
including unnecessary surgical intervention as well as
unindicated salpingectomy and salpingotomy. We sought
out to devise a simple protocol to aid both the
emergency medicine practitioner and gynecologist in
the management of a suspected heterotopic pregnancy.
METHODS: We reviewed two recent cases
involving heterotopic pregnancy at large emergency
departments in Arizona. One case involved a
misdiagnosis of heterotopic pregnancy resulting in an
unnecessry salpingectomy. The other case involved the
diagnosis and treatment of a true heterotopic pregnancy
that resulted in a full term delivery after salpingectomy at 8
weeks gesation. We attempted to devise a protocol that
would greatly reduce the risk of patient harm while not
increasing the morbidity or mortality of a true
heterotopic pregnancy.
RESULTS: We developed a protocol for diagnosing
Heterotopic pregnancy. The protocol focuses on repeating the
ultrasound in cases of truly suspected ectopic pregnancy, while
encouraging observation in lieu of surgical intervention in
hemodynamically stable patients who have a pregnancy of
unknown location.
From the Department of Surgery, Marchand OBGYN PLLC, Mesa,
Arizona, USA
Accepted for presentation at the World Congress On Obstetrics and
Gynecology, July 16th 2018, Bangkok, Thailand.
Corresponding author: Greg J. Marchand, MD, FACS, FICS, FACOG,
Accredited Master Surgeron, Department of Surgery, Marchand
OBGYN PLLC, 1520 South Dobson, Mesa, Arizona, USA 85202-4708;
email: gm@gregmarchandmd.com
Financial Disclosure:
The authors did not report any potential conflicts of interest.
© 2018 by Marchand OBGYN PLLC. Published by Marchand OBGYN
PLLC. All rights reserved.
Published Ahead of Presentation, MAY 2018
Marchand OBGYN PLLC 1
CONCLUSION: The authors believe the
proposed algorithm to be both memorable and useful to
the case of suspected heterotopic pregnancy. With
further peer validation we would encourage
adaptation of our algorithm into educational systems.
DOI: 10.13140/RG.2.2.20329.19046/2
H eterotopic Pregnancy occurs when a pregnancy
coexists in the uterus with a pregnancy outside of the
uterus. Outside of reproductive technology, incidence of
heterotopic pregnancy is extremely rare. An estimation has
put incidence of heterotopic pregnancy at approximately 1 in
30,000 pregnancies not associated with reproductive
technology. Despite the extremely rare nature of heterotopic
pregnancy, radiographic reports, especially ultrasound, often
cite the possibility of heterotopic pregnancies when adnexal
masses are seen in pregnant women. As a result, ectopic
pregnancy may be over diagnosed in the presence of an
intrauterine pregnancy, leading to possible catastrophe,
including unnecessary salpingectomy as well as unnecessary
exposure of an intrauterine pregnancy to anesthesia. Our
practice has had two experiences with heterotopic pregnancies
in the last 12 months, including one extremely unusual de-
novo heterotopic pregnancy. In order to avoid the serious
sequela of failing to diagnose a heterotopic pregnancy, or
performing an unnecessary surgery, we have come up with a
simple, memorable algorithm to guide the practitioner.
In the last 12 months, our private OBGYN practice has had
two experiences dealing with heterotopic pregnancy. First was
a genuine case of naturally occurring heterotopic pregnancy,
when a patient known to our practice presented with
intrauterine and extra-uterine pregnancy at 8 weeks gestation.
This was dealt with with emergent salpingectomy and patient
is still seeing our practitioners for obstetrical care. A second
case, which came to the attention of our practice through the
peer review process, involves a radiologic diagnosis of a
heterotopic pregnancy followed by a surgical partial
salpingectomy despite the presence of an intrauterine
pregnancy. In the second case the woman unfortunately
suffered the loss of the intrauterine pregnancy as well. Our
analysis of these two cases has led us to propose a decision
making algorithm for this rare and sometimes over
diagnosed occurrence. Our proposed algorithm proposes that a
true heterotopic pregnancy is a rare enough occurrence to
always justify a second ultrasound, and favors observation and
hospitalization over surgical intervention in cases where the
diagnosis is not clear.

MATERIALS AND METHODS
We reviewed the two cases in great detail and consider
different strategies in order to attempt to propose a step
by step algorithm that would prevent any possibility of
what we considered the two most important significant
catastrophic events. We considered an unnecessary
surgery with or without salpingectomy to be one of these
events, and the other event was considered to be a failure
to diagnose the heterotopic pregnancy leading to rupture
of the fallopian tube and the associated sequela and
mortality. As a secondary goal we attempted to keep the
algorithm as cost effective as possible, without any
unnecessary tests or hospitalizations. We feel this
algorithm to be indicated in any situation where a
heterotopic pregnancy is considered part of the
differential diagnosis.
DISCUSSION CONSENSUS
The authors believe the proposed algorithm to be both
memorable and useful to the case of suspected
heterotopic pregnancy. With further peer validation we
would encourage adaptation of our algorithm into
educational systems.
Table 1. Proposed Protocol
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Marchand et al Avoiding Patient Harm in Diagnosing Heterotopic Pregnancy Marchand OBGYN PLLC 2
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