Spontaneus quadruplets – intrauterine triplets plus one ectopic pregnancy

Due to the widespread use of assisted reproductive technology the incidence of multifetal gestation has shown to increase rapidly (1). The incidence of spontaneous intrauterine twin pregnancy is about 1 in 80 and the incidence of spontaneous triplet pregnancy ranges from 1 in 6000 to 8000 births (2). In triplet and quadruplet pregnancies the risks of obstetric complications as well as maternal morbidity tend to be higher than in twin pregnancies (3). Therefore we present an even more infrequent case of spontaneous quadruplets as in intrauterine triplets plus a forth ectopic pregnancy.

In this case a 31 year old Afro-American woman got admitted to our department with a spontaneously conceived triplet pregnancy with vaginal bleeding in gestational week 8. She had previously undergone a caesarean section of twins and a vaginal delivery. Via transvaginal ultrasound two intrauterine fetuses were seen to be vital and of normal development with a crown-rump length of 15 and 11 mm. The third intrauterine fetus showed no fetal heart action. Two days later the third amniotic sac seemed to be filled with blood, even though the vaginal bleeding diminished.

On day six after admission the woman reported strong pain during defecation with pressure on the rectum. In transvaginal ultrasound an ectopic pregnancy (the forth fetus) probably located in the Douglas cavity or in the right fallopian tube with a positive fetal heart action was diagnosed.

In the afterwards performed laparoscopy both tubes seemed unaffected, but in the Douglas cavity there were blood clots and suspicion of pregnancy tissue. In the following pathology report the suspected diagnosis was confirmed showing trophoblastic and synzytiotrophoblastic cellular elements.

Multifetal gestation still exists independently from assisted reproduction and an ectopic pregnancy in addition to singlet, twin of multiple pregnancies. Although very infrequent, this should be a point of consideration.