A 29-year-old woman who conceived by IVF presents at 6 weeks gestation with mild pelvic pain. Transvaginal ultrasound shows one intrauterine gestational sac containing a yolk sac, and a separate 2 cm left adnexal ring with a fetal pole demonstrating cardiac activity. She is haemodynamically stable. What is the most appropriate next step?

• A Repeat ultrasound in 2 weeks to confirm viability of both gestations
• B Laparoscopic salpingectomy for the adnexal ectopic ✓
• C Single-dose systemic methotrexate 50 mg/m2
• D Suction evacuation of the uterus

Explanation

This is a heterotopic pregnancy, a coexisting intrauterine and extrauterine gestation. Its spontaneous incidence is about 1 in 30,000, rising to roughly 1 in 100 after assisted reproduction, so an adnexal mass in an ART pregnancy never rules out an intrauterine pregnancy. Surgery treats the ectopic while preserving the intrauterine gestation. Methotrexate is contraindicated here because it would also destroy the wanted intrauterine pregnancy.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.