Can You Have Both a Blighted Ovum and Ectopic Pregnancy Simultaneously?
Yes, a woman can have both a blighted ovum (anembryonic intrauterine pregnancy) and an ectopic pregnancy at the same time—this is called heterotopic pregnancy, though it is extremely rare in spontaneous conceptions. 1
Understanding Heterotopic Pregnancy
Heterotopic pregnancy is defined as the simultaneous presence of an intrauterine pregnancy and an ectopic pregnancy. 2, 3 While this condition is exceedingly rare in spontaneous conceptions (occurring in less than 1% of cases), it becomes more common in patients undergoing assisted reproductive techniques. 4, 5
The intrauterine component can be either viable or nonviable—including a blighted ovum (anembryonic pregnancy). 1 The case literature confirms that heterotopic pregnancy can present with a blighted ovum coexisting with a tubal ectopic pregnancy, even in the absence of predisposing factors like fertility treatments. 1
Critical Diagnostic Pitfall
The most dangerous clinical error is assuming that detection of an intrauterine pregnancy (even a nonviable one like a blighted ovum) excludes the possibility of a simultaneous ectopic pregnancy. 1, 2 This false reassurance can lead to delayed diagnosis and potentially life-threatening rupture of the ectopic component.
When to Maintain High Suspicion
- Patients with assisted reproductive technology history: The adnexa must be carefully evaluated with transvaginal ultrasound even when intrauterine pregnancy is confirmed, as heterotopic pregnancy is more common in this population. 4, 2
- Persistent or worsening symptoms despite confirmed intrauterine findings: Lower abdominal pain, vaginal bleeding, or adnexal tenderness should prompt thorough evaluation of both adnexa regardless of intrauterine findings. 1, 2
- Any adnexal mass or free fluid on ultrasound: These findings warrant investigation even when an intrauterine gestational sac (viable or nonviable) is present. 2, 3
Diagnostic Approach
The 2025 Society of Radiologists in Ultrasound consensus guidelines emphasize that ectopic pregnancy is defined as a pregnancy implanted in an abnormal location, and can coexist with an intrauterine pregnancy (heterotopic pregnancy). 6
Essential Ultrasound Evaluation
When evaluating any early pregnancy, transvaginal ultrasound must assess:
- Intrauterine cavity: Look for gestational sac with or without yolk sac/embryo 6, 4
- Both adnexa systematically: Evaluate for extraovarian masses, tubal rings, or complex cystic structures 4, 5
- Cul-de-sac: Assess for free fluid, particularly with internal echoes suggesting hemoperitoneum 4, 5
The presence of an intrauterine gestational sac—even an empty one consistent with a blighted ovum—should not preclude careful examination of the adnexa. 1, 2
Management Implications
If heterotopic pregnancy is diagnosed or suspected:
- Immediate surgical consultation is required for the ectopic component if there is hemodynamic instability, peritoneal signs, or confirmed ectopic pregnancy with fetal cardiac activity. 4
- The intrauterine component (blighted ovum) may require separate management after addressing the ectopic pregnancy, though spontaneous resolution often occurs. 2
- Serial β-hCG monitoring alone is unreliable in heterotopic pregnancy, as the intrauterine component may cause rising hCG levels that mask the ectopic component. 4, 7
Key Clinical Pearls
- Heterotopic pregnancy can occur without any predisposing factors, though it is more common with assisted reproduction. 1, 2
- Never use β-hCG value alone to exclude ectopic pregnancy in patients with indeterminate ultrasound findings, even when an intrauterine pregnancy is present. 4, 7
- The term "blighted ovum" is now replaced by "anembryonic pregnancy" in modern terminology, defined as a gestational sac ≥25 mm mean sac diameter without an embryo. 6
- Transvaginal ultrasound is superior to transabdominal scanning for detecting both intrauterine and ectopic components of heterotopic pregnancy. 2