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2011-06-03-10 Answer to the case of the week #303 © Hamza

Answer to the case of the week #303

September 29, 2011 - October 13, 2011

Amr Hamza, MD.

Schwarzwald-Baar Lehrklinikum, Vöhrenbacher Strasse, 78050 Villingen-Schwenningen,Germany.

Case report

A 31-year old patient, G3P1 presented to our department for an acute abdominal pain at 27 weeks of a twin pregnancy. She had a previous cesarean section due to a cephalo-pelvic disproportion and 1 spontaneous abortion. This current pregnancy was after in vitro fertilization. It was first diagnosed as a singleton pregnancy. The follow-up ultrasound revealed a twin dichorionic diamniotic pregnancy.

The clinical examination of the patient revealed a tender rigid abdomen, unstable vital signs, vomiting and vaginal bleeding. We also diagnosed a fetal bradycardia and performed an emergency cesarean section for a suspicion of placental abruption or uterine wall rupture. 

During the surgery, we found only one of the twins inside the uterus. The second twin was found outside of the uterine cavity, on the right uterine tube. 
The placenta was attached to the right uterine cornu and to the right uterine tube. The right uterine cornu was destroyed by the heterotopic pregnancy. There were almost 3 liters of the blood in the abdominal cavity and we had to perform an emergency hysterectomy. 

The intrauterine twin weighted 1180 grams and his clinical examination did not reveal any abnormalities. The ectopic twin was smaller, his weight was 700 grams and had hypoplastic earlobes with absent ear canal. No additional abnormalities were detected. Unfortunately, the intrauterine neonate died due to a neonatal sepsis. The ectopic twin was discharged from the hospital and is doing well.
The prenatal ultrasound examinations described this pregnancy as an intrauterine twin pregnancy with the uterine septum separating both fetuses. We did not know about the heterotopic pregnancy until the emergency surgery. The suspected intrauterine septum which was detected during he ultrasound exam was actually the uterine wall separating both twins. Only one of them developed inside the uterine cavity and the second one developed as an ectopic pregnancy outside of the uterine cavity.

Images 1,2: Images show the twin B which was actually located outside of the uterine cavity, placenta was attached to the right uterine cornu and uterine tube.


Image 3: The arrow shows the uterine wall which was thought to be the intrauterine septum between the twins.  


Images 4,5: Images of the uterus and placenta after emergency hysterectomy. Placenta of the twin B was attached to the right uterine cornu and the right uterine tube. Image 5 shows the detail of the right uterine cornu with attached placenta.


Images 6-8: The right uterine cornu with placenta.


Similar, nicely documented, case has been sent us by Elena Andreeva (Research Institute of Obstetrics and Gynecology, Medical-Genetics Department, Moscow, Russia).


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