Second Trimester Heterotopic Triplet Pregnancy with Intraute
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Heterotopic pregnancy is defined as the occurrence of simultaneous intrauterine and extrauterine pregnancies. It is a rare, potentially life-threatening condition and infrequent in natural conceptions.

A 34-year-old at 18 weeks of gestation with a history of 2 prior cesarean deliveries was transferred.Her history was also remarkable for pregnancy on IUD contraception. She was seen with a history of sudden onset severe abdominal pain followed by general body weakness and was referred to a district hospital where ultrasound showed miscarriage of an intrauterine twin pregnancy at 18 weeks of gestation and an additional intra-abdominal fetus dead as well. Travel time was approximately 3 hours, and she reached 12 hours after the onset of symptoms in hypovolemic shock with tachypnea and tachycardia of 144 bpm. Point of care ultrasound showed an intrauterine twin pregnancy with no cardiac activity for both fetuses. A third fetus was seen outside the uterus without cardiac activity and there was free fluid in the abdomen.

The patient was immediately taken to the operating room for explorative laparotomy, and consent for possible hysterectomy was signed. Intraoperatively, approximately 4 L of blood and clots was aspirated. A right side interstitial ruptured pregnancy with a dead male fetus in the abdomen with its placenta still attached to the ruptured site was found. The uterus was not reparable because of the extent of the cornual rupture, and a subtotal hysterectomy was performed.

Postoperatively, the uterus was opened and a monochorionic-diamniotic twin intrauterine pregnancy was noted . The patient received blood products intraoperatively and postoperatively. She fully recovered on her 4th day post operation.

In conclusion, a high index of suspicion is essential to diagnosis of heterotopic pregnancy especially in spontaneous pregnancies, and clinicians should be aware that confirming an intrauterine pregnancy does not exclude the risk of ectopic pregnancy. Clinicians performing antenatal ultrasound scans should thoroughly scan the pelvis to rule out an extrauterine pregnancy despite having confirmed the intrauterine pregnancy.

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