Two Gestational Sacs, Two Locations - Heterotopic Pregnancy - Case Report

Introduction: Heterotopic pregnancy (HP) is defined as two gestational sacs simultaneously present in two different locations, being the uterus and the fallopian tubes the more common. Sporadic HP is a very rare condition (1:30,000 pregnancies). With the use of medically assisted reproduction the prevalence is significantly higher(1:7,000). Considering spontaneous pregnancy, HP is associated with risk factors, being prior inflammatory pelvic disease the most common. The clinical presentation is similar to that of ectopic pregnancy or spontaneous miscarriage although it is usually a more late diagnosis. Case report: 25 year-old pregnant woman, OI 0000, previously healthy; admitted at the Emergency Department (ED) with acute pelvic pain mainly at the right iliac fossa and moderate vaginal bleeding confirmed by speculum examination. She was hemodynamically stable and the bimanual palpation was painful; no prior medically assisted reproduction technique had been performed. The haemoglobin value was within normal range and the serum β-hCG was 2,763mUI/mL. The ultrasonography at the ED showed an in uterus gestational sac and another one inside the right fallopian tube; in both gestational sacs cardiac activity was absent. HP diagnosis was then established and the patient was admitted at the Obstetrics Ward for surveillance and ultrasonographic/laboratorial reassessment; complete miscarriage of the uterine pregnancy occurred but methotrexate was necessary for the treatment of persistent tubarian pregnancy. Conclusion: When evaluating a pregnant woman with pelvic pain and vaginal bleeding one should always be aware of several differential diagnosis amongst which HP should be considered. If the patient has in uterus viable pregnancy the treatment of the ectopic concomitant gestational sac should be as conservative as possible; methotrexate should not be used in that situation as it leads to uterine pregnancy miscarriage in about one third of the patients.

Early Sac Shrinkage Predicts a Low Risk of Late Complications After Endovascular Aortic Aneurysm Repair

BACKGROUND: Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. METHODS: Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. RESULTS: Some 597 EVARs (71.1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47.6 per cent), moderate shrinkage (5-9 mm) in 142 (23.8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28.6 per cent). Four years after the index imaging, the rate of freedom from complications was 84.3 (95 per cent confidence interval 78.7 to 89.8), 88.1 (80.6 to 95.5) and 94.4 (90.1 to 98.7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3.11; P < 0.001). Moderate compared with major shrinkage (HR 2.10; P = 0.022), early postoperative complications (HR 3.34; P < 0.001) and increasing abdominal aortic aneurysm baseline diameter (HR 1.02; P = 0.001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. CONCLUSION: Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.