Viable Intrauterine Pregnancy Research Articles

Serum calponin 2 is a novel biomarker of tubal ectopic pregnancy

To evaluate serum protein calponin 2 (CNN2) as a candidate biomarker for tubal ectopic pregnancy (EP). Retrospective study. Single University affiliated tertiary hospital. Serum samples were obtained from 84 patients with EP, 39 with viable intrauterine pregnancy (vIUP), and 42 with miscarriage. Moreover, 10 fallopian tube and corresponding villous tissue samples from patients with EP, 6 villous tissue samples from patients with vIUP, and 10 villous tissue samples from patients with miscarriage were collected. Serum CNN2 concentrations were measured using enzyme-linked immunosorbent assay; CNN2 expression in tissues was evaluated via immunohistochemistry and quantitative real-time polymerase chain reaction analysis. The diagnostic performance of serum CNN2 to discriminate an EP from vIUP and miscarriage. CNN2 was highly expressed in villous stromal cells isolated from patients with EP, and CNN2 messenger ribonucleic acid expression was upregulated in villous tissues from women with EP compared with that in women with vIUPs and miscarriages. Serum CNN2 concentration was higher in women with EP than that in women with vIUP and miscarriage. The serum CNN2 predicted EP from vIUP and miscarriage with areas under the curve (AUCs) of 0.931 (95% confidence interval: 0.889-0.975). For discriminating EP from miscarriage only, the AUC was 0.906 (95% confidence interval: 0.835-0.977). In contrast, the AUCs for serum human chorionic gonadotropin were 0.809 and 0.637, respectively. Our data highlight the possibility of serum CNN2 as a single biomarker for the diagnosis of EP. ChiCTR 1900020483.

Predictive value of hyperglycosylated human chorionic gonadotropin for pregnancy outcomes in threatened abortion in first-trimester viable pregnancies.

To investigate the value of a single determination of hyperglycosylated hCG (hCG-H) for predicting the clinical outcome of patients with threatened abortion in the first trimester of pregnancy. Prospective study performed on 86 consecutively selected women with a diagnosis of threatened abortion and viable intrauterine pregnancy in the first trimester of pregnancy, conducted in two tertiary care hospitals. All patients underwent a single blood sample to determine hCG-H and total hCG serum levels and a transvaginal ultrasound 12-24 hours after diagnosis. Patients were monitored to determine whether the outcome was a miscarriage before the 20th week of pregnancy. Forty-three women (50%) had a miscarriage during the follow-up. We observed a very high correlation between hCG-H and total hCG (r?=?0.91, p?<?0.001). Median hCG-H and total hCG from pregnancies with normal outcome was signif-icantly higher than those ending in abortion. hCG-H and total hCG were very similar predictors of pregnancy outcomes (AUC: 0.90 and 0.89, respectively). The ratio hCG-H / total hCG was a poor predictor (AUC: 0.64). A single hCG-H assay is helpful for predicting pregnancy outcomes in women with first trimester threatened abortion and viable or potentially viable pregnancy at the time of presentation. However, hCG-H is not a better predictor than total hCG.

Handheld transabdominal ultrasound, after limited training, may confirm first trimester viable intrauterine pregnancy: a prospective cohort study

Objectives Handheld point-of-care abdominal ultrasound (POCUS) may be used by primary care physicians while vaginal ultrasound is limited to use in specialist care. We aimed to compare abdominal handheld ultrasound to vaginal ultrasound in determining first trimester viable intrauterine pregnancy and estimate gestational length. Design Prospective cohort study. Setting Gynaecologic outpatient clinic; women referred from GPs during early pregnancy. Handheld ultrasound using VscanExtend® was performed by fourth-year medical students with limited training. Transvaginal ultrasound using high-end devices was performed by ordinary hospital staff. Subjects Women in the first trimester of pregnancy referred for termination of pregnancy or with symptoms of early pregnancy complications. Main outcome measures Rate of confirming vital intrauterine pregnancy (visualizing foetal heart beats) and measurement of crown-rump length (CRL) using handheld abdominal versus vaginal ultrasound. Results In all 100 women were included; 86 confirmed as viable intrauterine pregnancies and 14 pathological pregnancies (miscarriages/extrauterine pregnancies). Handheld abdominal ultrasound detected fetal heartbeats in 63/86 (73% sensitivity) of healthy pregnancies and confirmed lack of fetal heartbeats in all pathological pregnancies, total positive predictive value (PPV) 100% and total negative predictive value (NPV) 38%. From gestational week 7, handheld abdominal ultrasound confirmed vitality in 51/54 patients: PPV 100% and NPV 79%. CRL (n = 62) was median 1 mm shorter (95% confidence interval 1–2 mm) measured by handheld abdominal versus vaginal ultrasound. Conclusion Handheld ultrasound has an excellent prediction confirming viable intrauterine pregnancy from gestational week 7. Validation studies are needed to confirm whether the method is suitable in primary care assessing early pregnancy complications. KEY POINTS When early pregnancy vitality needs to be confirmed, women will traditionally be referred to secondary care for transvaginal comprehensive ultrasonography performed with high-end devices by imaging specialists. In this study personnel with limited former training (fourth-year medical students) performed transabdominal POCUS using a handheld device, investigating 100 first trimester pregnancies for confirmation of viability. Using handheld ultrasound viable pregnancy was confirmed from gestational week 7 with 79% positive and 100% negative predictive value. If handheld ultrasound used in primary care confirms vital intrauterine pregnancy, the need for specialist referral could be reduced.

Gestational age-specific normative values and determinants of serum progesterone through the first trimester of pregnancy

Progesterone is a steroid hormone that is critical for implantation and maintenance of pregnancy, and low levels are associated with higher miscarriage risk. However, little is known about its trajectory during early pregnancy. We sought to determine the gestational age-specific normative values of serum progesterone on a week-by-week basis, and its associated maternal and fetal factors, during the first trimester of a viable low-risk pregnancy. A cross-sectional study was conducted at KK Women’s and Children’s Hospital from 2013 to 2018. 590 women with a single viable intrauterine low-risk pregnancy, between gestational weeks 5 and 12, were recruited. Serum progesterone showed an increasing trend during the first trimester, with a transient decline between gestational weeks 6–8, corresponding to the luteal–placental shift. Lowest levels were seen at week 7. Maternal age, BMI, parity, gestational age and outcome of pregnancy at 16 weeks’ gestation were found to be associated with progesterone levels. Normative values of serum progesterone for low-risk pregnancies would form the basis for future work on pathological levels of serum progesterone that may increase risk of miscarriage. Larger studies are required to validate these normative values, and personalize them to account for maternal age, BMI, parity and gestational age.

Abnormal rate of human chorionic gonadotropin rise: a case series of patients with viable intrauterine pregnancies after embryo transfer

ObjectiveTo report three cases of viable intrauterine pregnancies after embryo transfer with lower quantitative human chorionic gonadotropin (hCG) rates of rise than that expected in 99% of normal intrauterine pregnancies, based on current guidelines.DesignCase series.SettingTertiary care center.Patient(s)Three patients underwent in vitro fertilization for ovulatory dysfunction or male factor infertility and had successful live births after an unusually low rate of hCG rise following embryo transfer.Intervention(s)In vitro fertilization was utilized for all three patients.Main Outcome Measure(s)Serial hCG levels.Result(s)Three cases of abnormally rising hCG levels were described. All cases presented achieved pregnancy through assisted reproductive technologies. The lowest documented rate of rise for each case, over 48 hours, was 22.1%, 23.3%, and 26.9%. All three cases resulted in live births. Literature on this topic was reviewed.Conclusion(s)Based on the cases presented, we recommend conservative management for patients found to have abnormally low rise hCG levels after embryo transfer; a high clinical suspicion for ectopic pregnancy should be maintained.

The live birth in a woman with resistant ovary syndrome after in vitro oocyte maturation and preimplantation genetic testing for aneuploidy.

We report the pregnancy and live birth achieved after in vitro maturation (IVM) of oocytes and PGT-A in a 23-year-old patient suffering from ovarian gonadotropin resistance. A woman with resistant ovary syndrome (ROS) had secondary amenorrhea, high FSH levels (25.34 mIU/mL) and LH (29.6 mIU/mL), low estradiol levels (15.2 pg/mL), and high serum AMH levels (38.0 ng/mL), associated with an increased antral follicle count (AFC) of 45. Without gonadotropin priming and HCG trigger, ultrasound-guided transvaginal oocyte retrieval was performed. Aspiration of antral-stage follicles allowed the retrieval of 15 immature oocytes. After oocyte collection, immature oocytes were cultured in the IVM medium. Following IVM, six of them reached metaphase II stage. Resultant matured oocytes were fertilized by intracytoplasmic sperm injection (ICSI). Embryos obtained were cultured to the blastocyst stage. On day 5, three embryos reached blastocyst stage. Trophectoderm biopsy and PGT-A were performed on two better quality embryos on day 5 after fertilization. Two biopsied embryos were reported to be euploid. PGT-A was performed utilizing next-generation sequencing (NGS\MPS). One embryo was transferred in an artificial thaw cycle and resulted in a viable intrauterine pregnancy and live birth. Our experience indicates that there is no requirement for gonadotropin stimulation and use of b-hCG trigger prior to IVM in patients with ROS. The results suggest that oocytes obtained with IVM in patients with ROS are capable of meiotic and mitotic division, fertilization, and generation of euploid embryos. IVM appears to be a valuable approach in patients with ROS, allowing them to have genetically connected offspring.

The diagnostic utility of placental growth factor in ectopic pregnancy.

Ectopic pregnancy is a condition of enormous gynaecological priority. It occurs when fertilized ovum implants outside the uterine cavity. Ectopic pregnancy is estimated to be 1-2% of all-natural conception. This study aims to evaluate the role of the placental growth factor in the diagnosis of ectopic pregnancy. A case-control study was conducted in (Baghdad) teaching hospital in (Baghdad, Iraq) over one year. The study includes 240 women: 120 women with first trimester (5-10) weeks viable intrauterine pregnancy, and 120 women with ectopic pregnancy. There is a significant association observed in the placental growth factor mean (PLGF), which is lower in ectopic pregnancy than in intrauterine pregnancy. The range of PLGF was less than 50pg/mL in ectopic pregnancy, while it was up to 800pg/mL in intrauterine pregnancy. In an ectopic pregnancy with a cut-off PLGF level of ≤ 15.5pg/mL, the PLGF had a sensitivity of (92.5%), a specificity of (82.5%), a positive predictive value of (91.8%), a negative predictive value of (83.5%), and an accuracy of (90%). Different factors can affect PLGF, like the parity and body mass index. The serum level of the placental growth factor seems to be a promising biomarker for diagnosing ectopic pregnancy because a highly significant difference was found between healthy and ectopic pregnancy.

MRI of complete hydatidiform mole with normal hCG and viable intrauterine pregnancy

MRI of complete hydatidiform mole with normal hCG and viable intrauterine pregnancy

Developing a core outcome set for future infertility research: an international consensus development study† ‡.

STUDY QUESTIONCan a core outcome set to standardize outcome selection, collection and reporting across future infertility research be developed?SUMMARY ANSWERA minimum data set, known as a core outcome set, has been developed for randomized controlled trials (RCTs) and systematic reviews evaluating potential treatments for infertility.WHAT IS KNOWN ALREADYComplex issues, including a failure to consider the perspectives of people with fertility problems when selecting outcomes, variations in outcome definitions and the selective reporting of outcomes on the basis of statistical analysis, make the results of infertility research difficult to interpret.STUDY DESIGN, SIZE, DURATIONA three-round Delphi survey (372 participants from 41 countries) and consensus development workshop (30 participants from 27 countries).PARTICIPANTS/MATERIALS, SETTING, METHODSHealthcare professionals, researchers and people with fertility problems were brought together in an open and transparent process using formal consensus science methods.MAIN RESULTS AND THE ROLE OF CHANCEThe core outcome set consists of: viable intrauterine pregnancy confirmed by ultrasound (accounting for singleton, twin and higher multiple pregnancy); pregnancy loss (accounting for ectopic pregnancy, miscarriage, stillbirth and termination of pregnancy); live birth; gestational age at delivery; birthweight; neonatal mortality; and major congenital anomaly. Time to pregnancy leading to live birth should be reported when applicable.LIMITATIONS, REASONS FOR CAUTIONWe used consensus development methods which have inherent limitations, including the representativeness of the participant sample, Delphi survey attrition and an arbitrary consensus threshold.WIDER IMPLICATIONS OF THE FINDINGSEmbedding the core outcome set within RCTs and systematic reviews should ensure the comprehensive selection, collection and reporting of core outcomes. Research funding bodies, the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) statement, and over 80 specialty journals, including the Cochrane Gynaecology and Fertility Group, Fertility and Sterility and Human Reproduction, have committed to implementing this core outcome set.STUDY FUNDING/COMPETING INTEREST(S)This research was funded by the Catalyst Fund, Royal Society of New Zealand, Auckland Medical Research Fund and Maurice and Phyllis Paykel Trust. The funder had no role in the design and conduct of the study, the collection, management, analysis or interpretation of data, or manuscript preparation. B.W.J.M. is supported by a National Health and Medical Research Council Practitioner Fellowship (GNT1082548). S.B. was supported by University of Auckland Foundation Seelye Travelling Fellowship. S.B. reports being the Editor-in-Chief of Human Reproduction Open and an editor of the Cochrane Gynaecology and Fertility group. J.L.H.E. reports being the Editor Emeritus of Human Reproduction. J.M.L.K. reports research sponsorship from Ferring and Theramex. R.S.L. reports consultancy fees from Abbvie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. B.W.J.M. reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. C.N. reports being the Co Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring, and retains a financial interest in NexHand. A.S. reports consultancy fees from Guerbet. E.H.Y.N. reports research sponsorship from Merck. N.L.V. reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the work presented. All authors have completed the disclosure form.TRIAL REGISTRATION NUMBERCore Outcome Measures in Effectiveness Trials Initiative: 1023.

Laparoscopic surgery for endometriosis.

Background Endometriosis is the presence in inappropriate sites of tissue that normally lines the uterus. It can cause pain and subfertility. Different treatments for endometriosis are available, one of which is laparoscopic ('key hole') surgery, performed to remove visible areas of endometriosis. Cochrane review authors assessed the evidence on the use of laparoscopic surgery to treat pain and fertility problems in women with endometriosis. Laparoscopic surgical techniques include ablation, which means destruction of a lesion (for example by burning), and excision, which means cutting a lesion out. Study characteristics We included 10 randomised controlled trials (involving 973 participants). They were conducted in Australia, Canada, Egypt, Iran and the United Kingdom. Most compared laparoscopic ablation or excision versus diagnostic laparoscopy only. Four of the 10 studies reported their source of funding. The evidence was current to July 2013. Key results We found that laparoscopic surgery may be of benefit in treating overall pain and subfertility associated with mild to moderate endometriosis. Laparoscopic excision and ablation were similarly effective in relieving pain, although this result came from a single study. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety

Heterotopic pregnancy: a case report

BackgroundHeterotopic pregnancy describes the occurrence of two pregnancies in different implantation sites simultaneously, which is rare, yet it is a challenge to diagnose such a problem due to complex clinical and laboratory findings. In the current study, we present a case of first trimester heterotopic pregnancy diagnosed by ultrasound (US) and magnetic resonance imaging (MRI) and was managed successfully.Case presentationA 22-year-old primigravida lady with spontaneous pregnancy was presented by increasing lower abdominal pain for 5 days with brownish vaginal discharge, nausea, and vomiting episodes. Trans-abdominal and endovaginal ultrasound was performed and revealed a viable intrauterine pregnancy of 8 weeks and 1 day, associated with a heterogeneous complex right adnexal mass. MR imaging revealed a right adnexal mass intimately anterior to the normal right ovary. Laparascopy was done; it revealed a distended right fallopian tube with pregnancy while the right ovary was not seen (impeded in the pouch of Douglas), and right salpingectomy was done. The specimen was sent for histopathology. The patient tolerated the procedure well and was then taken to the recovery room in stable condition. The histopathological report confirmed the diagnosis of ectopic pregnancy.ConclusionHowever, heterotopic is a rare condition, any pregnant woman presenting with alarming abdominal pain and adnexal abnormality; heterotopic pregnancy should be among the differential diagnosis possibilities. The patient should be thoroughly investigated using ultrasound and MRI if needed, to exclude this rare diagnosis and allow on-time proper management.

Double trouble? Clinic-specific risk factors for monozygotic twinning

To investigate clinic-specific risk factors for monozygotic twinning (MZT) using a large, electronic database. Retrospective case-control study. Infertility clinics. Using an electronic medical record system, viable clinical pregnancy (confirmation of a gestational sac(s) and presence of at least one fetal pole with a heartbeat on first trimester ultrasound), data were obtained from homologous invitro fertilization (IVF) cycles after single ET from June 1, 2004, to December 31, 2016. Monozygotic twinning was defined as a pregnancy with two fetal heartbeats on ultrasound with sex concordance at birth. None. Risk factors for MZT including cycle type, method of insemination, and method of cryopreservation. Of the 28,265 IVF cycles that met inclusion criteria over the study period, 8,749 (31.0%) resulted in a viable intrauterine clinical pregnancy. There were 102 (2.7%) MZT in the fresh cycle cohort and 133 (2.7%) in the frozen cycle cohort. Neither cryopreservation nor the method of cryopreservation was a significant risk factor for MZT. However, the use of sequential media was an independent risk factor for MZT in fresh, but not frozen, ETs (odds ratio = 1.72, 95% confidence interval, 1.10-2.68). Significant differences were seen in the incidence of MZT between clinics, and this difference persisted after controlling for known risk factors (clinic 0, reference; clinic 2, odds ratio = 2.22; 95% confidence interval, 1.48-3.32; clinic 3, odds ratio = 1.93; 95% confidence interval, 1.30-2.87). Differences in MZT rates exist between individual IVF clinics, suggesting that variations in practice patterns may contribute to this event. The present study noted the use of sequential media was an independent risk factor for fresh but not frozen cycles.

Exosomal MicroRNAs in Serum as Potential Biomarkers for Ectopic Pregnancy.

Design From July 2016 to June 2018, 36 women with symptomatic early pregnancy around 4-8 weeks of gestation were recruited into the study. Among them, there were 16 women with viable intrauterine pregnancy (VIP), 9 women with spontaneous abortion (SA), and 11 women of EP. Serum exosomal miRNAs were extracted and measured at the first prenatal visit. Statistical analysis was performed to determine the clinical utility of these biomarkers as single markers and as multimarker panels for EP. Results Concentrations of miR-378d in serum exosomes were significantly higher in EP than in VIP and also SA group. As a single marker, miR-378d had the highest specificity of 64% at the sensitivity of 89.1%. Comparatively, both combined panels of hCG, progesterone, miR-100-5p and hCG, progesterone, and miR-215-5P yielded the specificity of 96%. Panels for all markers achieved the highest specificity of 80% at the sensitivity of 91%. Conclusions Although further validation in large-scale prospective studies is necessary, our results suggest that serum exosomal miR-378d, miR-100-5p, and miR-215-5P are promising biomarkers for early EP.

Treatment of tubal heterotopic pregnancy with viable intrauterine pregnancy: Analysis of 81 cases from one tertiary care center

ObjectivesThe aim of our study was to analyze the treatment and pregnancy outcome of tubal heterotopic pregnancy (HP) patients with a viable intrauterine pregnancy (IUP) in our center. Study designThis was a retrospective analysis of 81 patients with tubal HP and a viable IUP. Patients were divided into either an expectant treatment group (29 patients) or a surgical treatment group (52 patients, 36 laparoscopy and 16 laparotomy). Data related to the basal clinical characteristic of all patients, rescue treatment and ectopic pregnancy (EP) rupture rate in the expectant treatment group, operation details in the surgical treatment group and pregnancy outcomes were collected and analyzed. Subgroup analyses were also performed. ResultsIn the expectant treatment group, the abortion rate, EP rupture rate and rescue treatment rate were 10.34 % (3/29), 21.14 % (7/29) and 34.48 % (10/29), respectively; subgroup analysis revealed that the rescue treatment rate in patients with EP mass enlargement ≥50 % was 71.43 % (5/7), which was significantly higher than that in patients with EP mass enlargement <50 % (15.00 %, 3/20), with P = 0.011. In the surgical treatment group, the abortion rate of all patients was 15.38 % (8/52); the abortion rate was 22.22 % (8/36) in the laparoscopy subgroup, which was significantly higher than that in the laparotomy subgroup (0.00 %, 0/16), with P = 0.038. ConclusionsSurgical treatment is a safe treatment option for tubal HP with a viable IUP, and laparoscopic surgery may be a potential risk factor for abortion. A high risk of failure exists for expectant management of tubal HP with a viable IUP, and EP mass enlargement ≥50 % may be a potential predictor of rescue treatment.

Sonographic detection of fetal abnormalities before 11 weeks of gestation.

Sonographic detection of fetal abnormalities before 11 weeks of gestation.

A Case of Heterotopic Pregnancy- Right Cornual Ruptured Ectopic with Non Viable Intrauterine Pregnancy

A Case of Heterotopic Pregnancy- Right Cornual Ruptured Ectopic with Non Viable Intrauterine Pregnancy

A core outcome set for future endometriosis research: an international consensus development study.

To develop a core outcome set for endometriosis. Consensus development study. International. One hundred and sixteen healthcare professionals, 31 researchers and 206 patient representatives. Modified Delphi method and modified nominal group technique. The final core outcome set includes three core outcomes for trials evaluating potential treatments for pain and other symptoms associated with endometriosis: overall pain; improvement in the most troublesome symptom; and quality of life. In addition, eight core outcomes for trials evaluating potential treatments for infertility associated with endometriosis were identified: viable intrauterine pregnancy confirmed by ultrasound; pregnancy loss, including ectopic pregnancy, miscarriage, stillbirth and termination of pregnancy; live birth; time to pregnancy leading to live birth; gestational age at delivery; birthweight; neonatal mortality; and major congenital abnormalities. Two core outcomes applicable to all trials were also identified: adverse events and patient satisfaction with treatment. Using robust consensus science methods, healthcare professionals, researchers and women with endometriosis have developed a core outcome set to standardise outcome selection, collection and reporting across future randomised controlled trials and systematic reviews evaluating potential treatments for endometriosis. TWEETABLE ABSTRACT: @coreoutcomes for future #endometriosis research have been developed @jamesmnduffy.

THE ROLE OF ACTIVIN A AND FOLLISTATIN IN THE DIFFERENTIATION BETWEEN VIABLE INTRAUTERINE PREGNANCY FROM MISSED MISCARRIAGE AND ECTOPIC PREGNANCY

Objective: The objective of the study was to investigate the role of activin A and follistatin (FS) in the differentiation between viable intrauterine pregnancy from missed miscarriage and ectopic pregnancy (EP).&#x0D; Study Design: This was a case–control study.&#x0D; Setting: This study was conducted at the Department of Obstetrics and Gynecology at Al-Yarmouk Teaching Hospital, from February 2017 to October 2017.&#x0D; Patients and Methods: The study included 90 pregnant women, aged from 21 to 40 years old in their the first trimester attending the outpatient and inpatient clinic with single fetal pregnancy with a gestational age range between 6th and 8th weeks, they were divided into three groups; Group A: Includes 30 cases with uncomplicated pregnancies in their first trimester, Group B: Includes 30 cases diagnosed as missed miscarriages, and Group C: Includes 30 cases diagnosed as EPs.&#x0D; Results: There was no significant difference in the maternal age and body mass index between the three groups, β-human chorionic gonadotropin, activin A, FS, and their ratio were significantly higher in the healthy intrauterine pregnancy compared to missed miscarriage and EP. Activin A and activin A/FS ratio had an excellent ability to discriminate EP from healthy intrauterine pregnancy, while FS alone had good ability to discriminate between EP and intrauterine pregnancy. Activin A had fair ability to discriminate missed miscarriage from intra healthy uterine pregnancy, while both FS and activin A/FS ratio had poor ability to differentiate missed miscarriage and intrauterine pregnancy.&#x0D; Conclusion: Activin A can be used with high accuracy as a biomarker for EP and missed miscarriage, FS alone, and activin A/FS ratio is a possible biomarker, but it offers lower accuracy compared to activin A alone.

Acute pelvic pain following miscarriage heterotopic pregnancy must be excluded: case report

BackgroundHeterotopic pregnancies are increasing in prevalence and this case highlights the importance of excluding the diagnosis in patients with pelvic pain following miscarriage. A known pre-existing intrauterine pregnancy can be falsely reassuring and delay the diagnosis of a potentially life-threatening concurrent ectopic pregnancy.Case presentationIn this report, we describe a case of spontaneous heterotopic pregnancy in a woman who had initially presented with pelvic pain and vaginal bleeding, and was diagnosed on pelvic ultrasound with a missed miscarriage; a non-viable intrauterine pregnancy. She re-presented 7 days later with worsening pelvic pain and bleeding, and a repeat pelvic ultrasound identified a ruptured tubal ectopic pregnancy in addition to an incomplete miscarriage of the previously identified intrauterine pregnancy. She underwent an emergency laparoscopy where a ruptured tubal ectopic pregnancy was confirmed.ConclusionBeing a time critical diagnosis with the potential for an adverse outcome, it is important that the emergency physician considers heterotopic pregnancy as a differential diagnosis in patients presenting with pelvic pain following a recent miscarriage. The same principle should apply to pelvic pain in the context of a known viable intrauterine pregnancy or recent termination of pregnancy. A combination of clinical assessment, beta human chorionic gonadotropin levels, point of care ultrasound and formal transvaginal ultrasound must be utilized together in these situations to explicitly exclude heterotopic pregnancy.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) enables operative management of the peripartum trauma patient in hemorrhagic shock

Trauma related injury is the leading cause of non-obstetric maternal death. The gravid uterus is at risk for injury, particularly during motor vehicle accidents. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a means of controlling pelvic hemorrhage in the setting of trauma. We report the use of REBOA in a hemodynamically unstable, multiply-injured young woman with viable intrauterine pregnancy.