Spontaneous conception and intrauterine pregnancy in a symptomatic missed abortion of ectopic pregnancy conceived in the previous cycle

Tubal superfetation following frozen-thawed single-embryo transfers in two separate cycles: Case report and literature review

Superfetation is a very rare occurrence. In the context of assisted reproduction, it has been reported only as an intrauterine pregnancy after ovarian stimulation and/or embryo transfer in the presence of an undiagnosed ectopic pregnancy. Here we report a case of a 27-year-old anovulatory patient, gravida 1 para 1, who underwent two frozen-thawed single-blastocyst transfers in separate cycles. The patient reported that 12 days after the first transfer, she had menstrual bleeding and stopped her estradiol and progesterone supplementation without undergoing a blood human chorionic gonadotropin (βhCG) test. At her request, a second cycle was immediately initiated, with endometrial thickness measuring 4 mm. Eleven days after the second transfer, the βhCG value was inappropriately high. A right tubal pregnancy corresponding to 8 gestational weeks was diagnosed. Laparoscopy revealed a prominent right tubal pregnancy in addition to a significantly smaller left tubal pregnancy. The discordant tubal pregnancies were confirmed histologically. To our knowledge, superfetation involving a second ectopic pregnancy coexistent with a first, contralateral ectopic pregnancy consequent to consecutive in vitro fertilization procedures has not previously been described in the medical literature. This case emphasizes the importance of routine βhCG testing after every IVF cycle, even if apparently unsuccessful.

A review of the mechanisms and evidence for typical and atypical twinning

The mechanisms responsible for twinning and disorders of twin gestations have been the subject of considerable interest by physicians and scientists, and cases of atypical twinning have called for a reexamination of the fundamental theories invoked to explain twin gestations. This article presents a review of the literature focusing on twinning and atypical twinning with an emphasis on the phenomena of chimeric twins, phenotypically discordant monozygotic twins, mirror-image twins, polar body twins, complete hydatidiform mole with a coexistent twin, vanishing twins, fetus papyraceus, fetus in fetu, superfetation, and superfecundation. The traditional models attributing monozygotic twinning to a fission event, and more recent models describing monozygotic twinning as a fusion event, are critically reviewed. Ethical restrictions on scientific experimentation with human embryos and the rarity of cases of atypical twinning have limited opportunities to elucidate the exact mechanisms by which these phenomena occur. Refinements in the modeling of early embryonic development in twin pregnancies may have significant clinical implications. The article includes a series of figures to illustrate the phenomena described.

Simultaneous fallopian tube and duodenal serosal ectopic pregnancies from a spontaneous conception: a case report

OBJECTIVE

To present a case report of two concurrent ectopic pregnancies (EP), in a disparate distal location within abdominal cavity with potential life-threatening consequences.

DESIGN

Case report.

SETTING

In-patient acute hospital admission.

PATIENT(S)

A multiparous woman with two children and a previous right tubal pregnancy treated with laparoscopic salpingectomy, who initially presented with an acute abdominal pain and vaginal bleeding suspicious of an EP. Having had the EP confirmed and treated with laparoscopic salpingectomy, she presented again 3 weeks later with acute abdominal pain, whereupon further evaluation an EP was found on the serosal surface of the second part of the duodenum.

INTERVENTION(S)

Laparoscopy and laparotomy followed by excision of the duodenal EP.

MAIN OUTCOME MEASURE(S)

Recovery to health and discharge from hospital.

RESULT(S)

Tissue histologic confirmation of left fallopian tubal EP, duodenal (second part) serosal EP, and return of β-hCG level <1 IU/L.

CONCLUSION(S)

Maternal deaths from failure to manage EPs appropriately remain prominent. This case report underscores the importance of vigilance at initial laparoscopic surgery and the need to reconsider the presence of another EP in any subsequent acute presentation within a short time of discharge. A mandatory, postoperative β-hCG level monitoring following treatment of all EPs would have alerted to an unusual clinical situation.

Fast MR imaging in obstetrics

Ultrasonography (US) is the initial imaging modality of choice for evaluation of patients in obstetrics. However, the results of US are not always sufficient. Magnetic resonance (MR) imaging, which uses no ionizing radiation, may be an ideal method for further evaluation. Although MR imaging is not recommended during the first trimester and use of contrast material is not recommended in pregnant patients, fast MR imaging is useful in various obstetric settings and can provide more specific information with excellent tissue contrast and multiplanar views. In pregnant patients with acute conditions, various diseases (eg, red degeneration of a uterine leiomyoma) may be diagnosed. MR imaging allows characterization of pelvic masses discovered during pregnancy and diagnosis of postpartum complications (eg, abscess, hematoma, ovarian vein thrombosis). In pregnant patients with hydronephrosis, MR urography can demonstrate the site of obstruction and the cause (eg, a ureteral stone). MR pelvimetry may be beneficial in cases of breech presentation. Contrast material-enhanced dynamic MR imaging allows one to evaluate the vascularity of a placental polyp, detect the viable component of a gestational trophoblastic tumor, and diagnose a uterine arteriovenous malformation. MR imaging enables diagnosis of rare forms of ectopic pregnancy and early diagnosis of ectopic pregnancy.