Heterotopic Pregnancy after In Vitro Fertilisation and Embryo Transfer Post-unilateral Salpingectomy: A Case Report and Literature Review

Heterotopic pregnancy (HP) is the simultaneous occurrence of intrauterine and ectopic pregnancies (EP). The incidence of HPs occurring spontaneously ranges from 1 in 10,000 to 1 in 30,000. However, this incidence is reported to be 1 in 100 pregnancies following artificial reproductive techniques. HP is a potentially life-threatening condition that is frequently misdiagnosed, as most diagnoses for HPs are delayed, and are only made after rupture of the EP. A high index of suspicion is, therefore, required for an accurate and timely diagnosis in order to reduce maternal morbidity and mortality, which currently stands at 1 in 200,000 live births. The most common risk factors include pelvic inflammatory disease, previous EP, assisted reproduction techniques, and ovarian hyperstimulation syndrome. Transvaginal ultrasound is the gold standard for diagnosis. As detection of an intrauterine pregnancy often leads to the mistaken exclusion of a concomitant EP, a careful transvaginal scanning of the uterus and appendages should be performed in all females of reproductive age with a positive pregnancy test and red flags in anamnesis, and/or with clinical symptoms. Routine transvaginal ultrasound at Day 27 after embryo transfer could facilitate the diagnosis of HP; however, symptoms onset before or after Day 27 are clues to early diagnosis. MRI can be very helpful in diagnosing atypical cases.

The Use of Frozen Embryo Transfer and the Development of Pregnancy-Induced Hypertension: A Literature Review

The use of assisted reproduction techniques has been associated with obstetric complications. An understanding about which methods and treatment protocols produce better outcomes would provide greater opportunities for a successful pregnancy. The aim of this literature review was to identify whether frozen embryo transfer (FET) leads to a greater incidence of pregnancy-induced hypertension (PIH) compared to fresh embryo transfer. Fifteen studies were identified and subsequently reviewed. Eleven studies suggested FET increased the incidence of PIH–gestational hypertension and pre-eclampsia. The evidence suggests a correlation between FET and PIH. Exploration into why this is the case should be the focus of future studies. Implications for clinical practice involve extensive preconception counselling and potentially advising prophylactic low-dose aspirin with the aim of lower the incidence of PIH.

Uterine Incision at the Fundus,Transitory Devascularisation, and Myometrial Resection for Uterine Preservation in Anterior Accretism: A Case Report

Placenta accreta spectrum is a serious obstetric condition related to abnormal adherence of placental tissue to the myometrium and high maternal and fetal morbidity. In order to achieve the best outcome, the management of this condition must be carried out by an experienced multidisciplinary team and the individual characteristics of the patient must be taken into consideration, such as comorbidities and desire for reproductive preservation. This case report presents the conservative surgical management of placenta accreta spectrum in a 23-year-old patient who underwent an elective caesarean section with uterine preservation because of anterior placenta increta. The authors performed a transverse uterine incision at the fundus with transitory uterine devascularisation of the lower uterine segment with partial myometrial removal. This technique was successful for controlling the haemorrhage and preserving the uterus, with no complications.

Conservative Management After a Single Fetal Death in a Dichorionic Diamniotic Twin Pregnancy and Fetus Papyraceus: A Case Report

Multifetal pregnancies are estimated to represent 3.2% of all pregnancies (80% are dichorionic and 20% monochorionic) and are associated with a higher risk of perinatal morbidity and mortality relative to single pregnancies. The authors report a successful case of conservative management of a dichorionic diamniotic twin pregnancy after a single fetal death in the second trimester of pregnancy. The diagnosis was made in the 22nd week of pregnancy and the pregnancy was followed up until delivery in the 39th week. A healthy (2.855 kg) female infant was born and a dead fetus, approximately 20 cm in length and connected by the rudimentary umbilical cord to the small calcified placenta, was seen. The occurrence of a single fetal death is a relatively common event, which has implications for maternal and fetal outcomes. This diagnosis is relevant due to its potential effect on the survival of the other fetus and on possible maternal complications. In order to avoid complications and achieve the optimal maternal and neonatal outcomes, conservative prenatal follow-up should focus on careful monitoring and serial assessment of both fetal and maternal wellbeing. In gestational losses where the fetus is retained intrauterine for at least 10 weeks, there is the possibility of finding fetus papyraceus at the time of delivery. This is a rare event that results from incomplete reabsorption of the dead fetus, which is then compressed between the membranes and the uterine wall.

Examining Diagnostic Options and Classification Systems Available for Endometriosis

Introduction: Endometriosis is characterised by the presence of endometrium-like tissue outside the uterus, and is often associated with chronic pelvic pain, infertility, and compromised quality of life. Development of reliable methods of early diagnosis, staging, and classification of endometriosis would allow for restriction of disease progression by its early detection and strategising towards its early treatment and management. Diagnostic options: Typically, diagnosis and staging of endometriosis include a history and physical examination followed by clinical, imaging, and laparoscopic findings. Surgical inspection of lesions at laparoscopy with histological confirmation remains the most reliable procedure towards the detection of endometriosis and its classification. Although there are many putative peripheral biomarkers having potential diagnostic values for endometriosis, further studies are necessary for their validation. Classification systems: Based on anatomical, clinical, imaging, and several pathophysiological findings, various classifications and staging systems of endometriosis, e.g., revised American Society for Reproductive Medicine (rASRM), ENZIAN, Endometriosis Fertility Index (EFI) and Foci–Ovarian endometrioma–Adhesion–Tubal endometriosis–Inflammation (FOATI) scoring systems, have so far been postulated. However, there is no fool-proof diagnostic and classification approach available for the disease due to the general failure of current systems to reflect reproducible correlation with the major symptoms of endometriosis. Conclusion: A ‘toolbox approach’, using all the available diagnostic and classification systems maximising the information available to healthcare providers and females, is a recent recommendation. Development of collaborative research networks for the harmonisation of patient information, biological sample collection, and its storage, and that of methodological and analytical tools in a wider patient base is necessary to discover reliable leads for future diagnostic options and a classification system for endometriosis.

Diagnostic Criteria and Treatment Modalities of Ectopic Pregnancies: A Literature Review

Background: Ruptured ectopic or extrauterine pregnancy (EP) is responsible for 6% of maternal deaths in the first trimester. This review was designed to summarise the diagnostic criteria and treatment modalities of EPs. Methods: Recent guidelines of the international societies of obstetrics and gynaecology, including the Royal College of Obstetricians and Gynaecologists (RCOG), the American College of Obstetricians and Gynecologists (ACOG), and the European Society of Human Reproduction and Embryology (ESHRE), were reviewed to summarise the diagnostic criteria and treatment modalities of EPs. Results: A minimum β-human chorionic gonadotropin (β-hCG) rise of ≥35% in 48 hours was suggested to diagnose intrauterine pregnancy. A β-hCG rise <35% in 48 hours has 96.2% positive predictive value, 69.7% negative predictive value, and 80.2% overall accuracy in predicting EPs. The blob sign has >90% positive predictive value in diagnosing EPs in symptomatic females with positive β-hCG and no definite intrauterine gestational sac by transvaginal sonography. The interstitial ectopic pregnancy and cornual pregnancy are two separate entities of EPs. Interstitial line sign has 80% sensitivity and 98% specificity in diagnosing interstitial ectopic pregnancy. A meta-analysis reported 89% overall success rate for methotrexate in treatment of EPs; the multi-dose regimen was significantly more successful than the single-dose regimen. Conclusion: Institutes and healthcare providers should follow clear guidelines and/or protocols for the management of EPs. Institutes should implement competency-directed training programmes to increase healthcare providers’ skills to diagnose and treat EP variants using different modalities.

D-chiro-inositol, Vitamin D, and Epigallocatechin Gallate Avoid Surgery in Females with Uterine Fibroids: Two Case Reports

Uterine fibroids (UF) represent the most common benign tumours in females of reproductive age, and can negatively affect fertility. Patients with UFs need to reduce the tumour size with pharmacological treatments or surgically remove the fibroid before using assisted reproductive technology (ART). On the other hand, surgery implies long waiting times before ART to avoid the risk of rupture of the uterus. Long waiting periods are often unacceptable for older individuals who want to undergo ART procedures. Unfortunately, no specific and safe treatment for UFs is currently available. Here the author reports two cases of patients with UFs and associated heavy menstrual bleeding who seek pregnancy through ART. Both underwent a daily treatment with epigallocatechin gallate, vitamin D, vitamin B6, and D-chiro-inositol for 3 months. The patients showed a volume reduction of 73.8% and 68.4%, respectively. This was associated with decreased blood loss (42.1% and 48.7%, respectively). After 3 months from the end of the treatment, both patients underwent ART procedure without the need for surgical intervention.

Physiotherapy in Urinary Dysfunction Post-Surgery for Endometriosis: Case Report

Endometriosis is characterised by the presence of endometrial tissue outside the uterine cavity that responds to oestrogen and stimulates local inflammatory processes, adhesions, pelvic pain, and infertility. The treatment of endometriosis includes the use of medications and videolaparoscopy for excision of adhesions or lesions. Some complications are associated with the videolaparoscopy, such as vascular, intestinal, urinary, neurological, and more rarely, vulvar oedema, which makes the rehabilitation difficult in the immediate postoperative period. In relation to the urinary dysfunction and to the vulvar oedema, physiotherapy has resources with demonstrated efficacy in the treatment of such complications after videolaparoscopy; they can rehabilitate the patient and improve their quality of life in a short time. In this study, the authors report the case of a patient treated by the Physical Therapy Service of the Santa Casa de Misericórdia Hospital of São Paulo, São Paulo, Brazil, with urinary retention and vulvar oedema after videolaparoscopy for endometriosis, which showed improvement in vulvar oedema with the application of physiotherapy.

Sore Throat Treatment Guidelines are Fanning the Flames of Antimicrobial Resistance

Sore throat represents a significant yet under-recognised battle in the war against antimicrobial resistance (AMR). It is one of the most common reasons people visit a doctor and approximately 60% walk away with a prescription for antibiotics.1 However, studies have indicated that 70–95% of all cases are viral2 and most patients would be better served with symptom relief. A systematic review of global sore throat management guidelines by members of the Global Respiratory Infection Partnership (GRIP) suggested the problem could be rooted in a focus on serious, yet increasingly rare, conditions, such as quinsy and acute rheumatic fever (ARF). While ARF can be a dangerous complication of Group A streptococci (GAS), which are identified in 15–30% of sore throat cases, the incidence of ARF is exceedingly rare in most parts of the world.3 All but one of the 36 identified guideline documents discussed antibiotic therapy and less than two-thirds advocated the use of laboratory tests to confirm GAS. Just 50% gave advice on symptom relief, which evidence suggests is the most appropriate approach in most cases.4 Dr Martin Duerden, lecturer in therapeutics and prescribing at Cardiff University, Cardiff, UK, member of the GRIP, recently retired general practitioner, and co-author of the review, believes countries should re-evaluate their guidelines. In this interview, Dr Duerden talks about the role of fit-for-purpose sore throat guidelines in antimicrobial stewardship, the importance of appropriate symptom relief, and how coronavirus disease (COVID-19) could represent an opportunity for change.