CASE REPORT: HETEROTOPIC PREGNANCY IN A 12-YEAR-OLD ADOLESCENT

Abstract

Background: Heterotopic pregnancy is a rare entity in which it is defined by a topical (intrauterine) pregnancy concomitant with an ectopic pregnancy (outside the uterus, usually in fallopian tubes). While hydatidiform mole is characterized by a benign tumor that develops in the uterus as a result of a non-viable pregnancy. The diagnosis is made by means of β-HCG measurements and ultrasound examination. Therapeutic management is based on the viability of the topical pregnancy and the patient's conditions. OBJECTIVE: To emphasize the importance of diagnosing heterotopic pregnancy, to decide the best management that includes therapeutic success, fertility preservation, and maintenance of intrauterine pregnancy. Case Report: A 12-year-old patient with no history of morbidity, primiparous, smoker, complaining of mild lower abdominal pain, especially in the right iliac fossa, and denying transvaginal bleeding, had transvaginal ultrasonography (US) showing a 12-mm left attached image with fluid and 7-mm yolk bladder. The patient had beta-hCG > 15,000 mIU/mL and an adnexal mass of 12 mm with no intrauterine alterations, and exploratory laparotomy was performed, at which time the presence of a moderate amount of blood in the abdominal cavity was identified, but normal fallopian tubes and ovaries bilaterally, and no gestational sac in the abdominal inventory. On the first postoperative day, the patient developed diffuse abdominal pain of moderate intensity without peritonism. On the second postoperative day, the patient evolved with significant improvement in abdominal pain and bowel movements. With the result of the new Beta-HCG (>15,000 mIU/mL), presenting the same value as before, a new transvaginal ultrasound is requested: uterine cavity with echogenic endometrium, thickened of 27 mm, irregular and with anechoic areas intermingled. Therefore, gestational trophoblastic disease/Ovular remains/Heterotopic pregnancy were listed as the diagnostic hypothesis. Thus, MVA was performed with material sent to the pathological anatomical specimen, which presented a sample of decidualized stroma, blood and hydropic chorionic villi, consistent with complete hydatidiform mole and absence of malignant signs. On the fifth day of post-surgical hospitalization, the patient was discharged from the hospital and referred to the Regional Hospital of Asa Norte - DF, where there is a specialized service in the follow-up of patients with trophoblastic diseases. Comments: We observed the importance of serial laboratory follow-up of beta-hCG for the evolution of gestational trophoblastic disease, since when well managed, these women have a good prognosis. This patient also had a recent previous diagnosis of ectopic pregnancy, in which fertilization occurs outside the uterus. In the last three decades, there has been a greater number of cases of ectopic pregnancy, with an approximate fivefold increase. This is basically due to the higher incidence of PID, the more liberal use of the IUD, microsurgeries on the tubes and in vitro fertilization. Thus, heterotopic pregnancy, a rare condition, is a differential diagnosis that should be part of the specialist's arsenal, since the presence of a topical pregnancy does not exclude a concomitant ectopic pregnancy.