Case Reports in Obstetrics and Gynecology

Introduction. Heterotopic pregnancy (HP) refers to the simultaneous presence of intrauterine pregnancy (IUP) and ectopic pregnancy, which is very rare but potentially life-threatening. The spontaneous incidence of HP in the general population is 1/30,000. With the widespread use of assisted reproductive technology (ART), the incidence rises to 1/1,000. Aims and Methods. This is a prospective case series looking at the cases of heterotopic pregnancies presenting to the early pregnancy unit (EPU) in a tertiary maternity hospital, from November 2015 to November 2016. The clinical presentation, ultrasound findings, and laparoscopy findings were all documented. The incidence of HP was calculated and compared with the quoted incidence in the literature. Outcomes. Five women with HP presented to the EPU over the course of a year. The first case describes a spontaneous HP with a previous salpingostomy. The second case describes an HP following ovulation induction. The third case describes a spontaneous HP with no known risk factors. The fourth and fifth cases describe heterotopic pregnancies following in vitro fertilisation with more than one embryo. All five cases of HP underwent laparoscopy and salpingectomy with uneventful recovery. The three women who had a viable IUP had no further complications in their pregnancies. Conclusion. Early and accurate diagnosis of HP can be challenging. An early transvaginal ultrasound plays an important role in making the diagnosis in women with risk factors and following ART. A high index of suspicion is required for timely diagnosis and appropriate intervention, especially in spontaneous HP.

Background. Cervical pregnancy, an uncommon type of ectopic pregnancy, can lead to devastating consequences if not diagnosed and treated early. Despite this, there are no specific guidelines on how to treat such pregnancies especially in advanced gestational ages (GAs). Case. This is a 35-year-old patient who presented to our hospital at 13 weeks GA after failing systemic multidose methotrexate therapy for a cervical ectopic pregnancy. Given desire to preserve fertility, a minimally invasive conservative approach was taken involving potassium chloride (KCl) and methotrexate injections into the gestational sac, followed by immediate Cook intracervical double balloon placement under direct ultrasound visualization, with removal of the balloon after 72 hours, and ultimately resolution of the pregnancy 12 weeks after the removal. Conclusion. Advanced first trimester cervical ectopic pregnancy after failure of methotrexate therapy was managed successfully with minimally invasive KCl and methotrexate injections in combination with cervical ripening balloon.

A correct management of cesarean scar pregnancy (CSP) is mandatory to avoid further complications. There is no consensus for the standard therapy and the most frequent methods used are not free from failures and sequelae. A 38-year-old woman was admitted referring amenorrhea lasting 9 weeks, pelvic pain, and vaginal bleeding. She had three previous cesarean sections. Transvaginal ultrasound showed a gestational sac of 16 mm in the cervico-isthmic site and inside the thickness of the uterine wall, and the dosage of beta-human chorionic gonadotropin was 12,770 mU/mL. A diagnosis of CSP was done, and an ultrasound-guided removal after uterine artery cervical branch ligation was performed. The follow-up was uneventful. Even if not yet codified in the literature, our therapeutic procedure should be considered in other similar cases in the future, as it potentially limits the possible iatrogenic problems and reduces intraoperative and postoperative bleeding to a minimum.

In this case series, we present five cases of pregnant women who sought medical attention for reduced fetal movements with an ongoing mild maternal Covid-19 infection at a Stockholm hospital in Spring of 2021. At the time of admission, the patients were in gestational week between and . Abdominal ultrasound at the hospital showed no fetal movements, and cardiotocography (CTG) was pathological. All women delivered via cesarean section within 24 hours after admission. Placental pathology in all cases showed massive perivillous fibrin deposition and extensive histiocytic intervillositis. All placentas were Covid-19 polymerase chain reaction (PCR) positive. The infants were Covid-19 PCR negative. Consistent with other published case reports, we hypothesize that Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can affect the placenta resulting in massive perivillous fibrin deposition and histiocytic intervillositis leading to acute placental insufficiency and fetal hypoxia. The absence of intrauterine growth restriction also augments the theory of an acute onset of placental insufficiency due to the Covid-19 infection.

Intestinal obstruction rarely occurs after uncomplicated vaginal deliveries. Here, we present a case of a multiparous woman with a history of prior appendectomy presenting with generalized, nonspecific abdominal pain that was out of proportion to exam findings. Initial abdominal X-ray was nonspecific, and subsequent computed tomography (CT) abdomen showed closed small bowel obstruction requiring surgical repair. We present a case of intestinal obstruction occurring within 24 hours of uncomplicated vaginal delivery with a risk factor of a prior appendectomy surgery and the use of CT abdomen and pelvis to expedite diagnose.

Myomatous erythrocytosis syndrome (MES) is a rare gynecological condition, defined by the presence of the clinical triad of erythrocytosis, uterine fibroids, and normalization of red blood cell counts after the surgical removal of uterine fibroids. Herein, we report the case of a woman, in the postmenopausal stage, with the clinical triad of MES. She had a history of erythrocytosis of unknown etiology and underwent phlebotomy for a year prior to visiting our hospital. Pre-operative hemoglobin (Hb) level, hematocrit (Hct) level, and red blood cell (RBC) count were 18.1 g/dL, 56.1%, and 6.52 million cells/μL, respectively. She underwent exploratory laparotomy, transabdominal hysterectomy, and bilateral salpingo-oophorectomy. The operative findings revealed a large uterine myoma, and the pathology result was compatible with uterine leiomyoma. All hematologic parameters returned to the normal range on post-operative day 1. Her hematologic parameters returned to normal values 4 weeks after surgery with a Hb level of 13.5 g/dL, Hct level of 41.2%, and RBC count of 4.92 million cells/μL. The exact pathophysiology of this condition remains unknown. However, surgical removal of uterine myoma is the mainstay of treatment. Despite the rarity of this condition, its diagnosis should be considered in patients presenting with erythrocytosis and uterine masses.