New insights gained from a decade long multi-center retrospective study on the management strategy for heterotopic pregnancy: expectant management is worth considering in patients without vaginal bleeding.

Background: Heterotopic pregnancy (HP) is a rare but clinically challenging condition because treatment of the ectopic component must be balanced against preservation of the coexisting intrauterine pregnancy. The optimal management strategy remains controversial, particularly for clinically stable patients. Methods: This multicenter retrospective cohort study included women diagnosed with heterotopic pregnancy over a 10-year period. Patients were managed either expectantly or surgically according to clinical presentation, hemodynamic status, serial transvaginal ultrasound findings, and physician judgment. Baseline characteristics, treatment details, and intrauterine pregnancy outcomes were compared between groups. Multivariable logistic regression and subgroup interaction analyses were performed to explore factors associated with live birth. Results: A total of 159 women with heterotopic pregnancy were included, with a mean age of 31.9 ± 3.7 years. Overall, intrauterine pregnancy outcomes did not differ significantly between the operative and expectant management groups. However, patients selected for expectant management had more favorable baseline characteristics, including smaller ectopic masses, less pelvic fluid, higher hemoglobin levels, and absence of ectopic fetal cardiac activity. In subgroup analysis, among patients without vaginal bleeding, expectant management was associated with a higher live birth rate than surgical intervention (89.7% vs. 63.2%). Some subgroup estimates were accompanied by wide confidence intervals and should therefore be interpreted cautiously. Conclusion: Expectant management may be considered in carefully selected, hemodynamically stable patients with heterotopic pregnancy, particularly in those without vaginal bleeding. However, because of the retrospective design and baseline differences between treatment groups, these findings should be interpreted as supporting a feasible alternative in selected patients rather than proving superiority over surgical intervention.