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Heterotopic Pregnancy Presenting as Spontaneous Hemothorax

Tracey H DeYoung, Julie R Whittington and Timothy E Sayles

Introduction: Heterotopic pregnancy is rare, occurring in 1 in 30,000 spontaneously conceived pregnancies. Hemothorax as a presenting sign of ectopic pregnancy is also rare, with only a few case reports in the literature. We present a case of a spontaneous heterotopic pregnancy presenting as a hemothorax.

Case: A 36-year-old gravida 3 para 1 at 9 weeks 5 days by last menstrual period with reported twin intrauterine pregnancy presented with chest pain, shortness of breath, and syncope. A transabdominal ultrasound revealed an enlarged multi-fibroid uterus with an intrauterine pregnancy and a second ectopic pregnancy; however, it was unclear if this was located within the right cornua or adnexa. Given her severe shortness of breath, a computed tomography scan of the chest was completed which revealed a right pleural effusion. She additionally underwent pelvic magnetic resonance imaging for preoperative planning which confirmed a right adnexal ectopic pregnancy along with an intrauterine pregnancy. She had a right chest tube placed which evacuated 1700 mL of hemothorax. She underwent diagnostic laparoscopy followed by exploratory laparotomy with removal of the right fallopian tube and ovary.

Discussion: Heterotopic pregnancy may be rare, but must be considered even when a patient reports an intrauterine pregnancy. In the setting of acute blood loss of unexplained source, heterotopic must remain high on the differential. This patient’s complex anatomy and presentation with a hemothorax contributed to the difficulty in diagnosing the heterotopic pregnancy.