A 31-year-old woman who conceived by IVF presents at 7 weeks with right iliac fossa pain. Ultrasound shows a viable intrauterine gestation and a separate 2 cm right adnexal ring with cardiac activity. Serum beta-hCG is 32,000 mIU/mL. Which statement best guides her management?

• A The intrauterine sac excludes ectopic pregnancy, so she needs only reassurance
• B Systemic methotrexate is the first-line treatment for the adnexal lesion
• C Termination of the entire pregnancy is advised because of dual implantation
• D Laparoscopic removal of the adnexal gestation is required, avoiding methotrexate ✓

Explanation

This is a heterotopic pregnancy, whose incidence rises to roughly 1 in 100 after assisted reproduction versus about 1 in 4,000 spontaneous conceptions. A demonstrated intrauterine sac does not exclude a simultaneous ectopic in this setting. Surgical excision of the ectopic, usually laparoscopic salpingectomy, preserves the intrauterine pregnancy. Methotrexate is contraindicated because it is a folic acid antagonist that would harm the coexisting viable fetus, and termination is not indicated when the ectopic can be removed selectively.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.