Spontaneous heterotopic triplet pregnancy with a two viable intrauterine embryos and an ectopic one with right tubal rupture / Gravidez heterópica tripla espontânea com dois embriões intrauterinos viáveis e um ectópico com ruptura da tuba uterina direita

Abstract Heterotopic pregnancy (HP) is defined as the simultaneous development of an intra- and an extra uterine gestation. The occurrence of a spontaneous triplet HP is an exceptionally rare medical condition. We report the case of a young woman with spontaneous heterotopic triplets at 8weeks of gestation, with amisdiagnosis of topic twins and acute appendicitis. The ectopic tubal pregnancy was ruptured and a salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed uneventfully. The two healthy babies were delivery by cesarean section at 36 ± 2 weeks of gestation. Heterotopic triplets with ruptured tubal ectopic pregnancy represent a special diagnostic and therapeutic challenge for the obstetrician. A high rate of clinical suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Resumo A gravidez heterotópica é definida como o desenvolvimento simultâneo de uma gestação intra- e extra-uterina. A ocorrência de gravidez tripla heterotópica espontânea é uma condição médica excepcionalmente rara. Relatamos o caso de uma jovem com gravidez tripla espontânea, às 8 semanas de gestação, com um diagnóstico errôneo de gêmeos tópicos e apendicite aguda. A gravidez tubária ectópica estava rota e uma salpingectomia foi realizada por laparotomia. A gravidez intrauterina progrediu sem intercorrências. Os bebês nasceramsaudáveis por cesariana realizada às 36 semanas de gestação.Agravidez de heterotópicos comectopia e rotura tubária é umdesafio diagnóstico e terapêutico.Umalto índice de suspeita e tratamento oportuno por laparotomia ou laparoscopia podem preservar a gestação intrauterina com um resultado bem sucedido da gravidez tópica.

Role of Emergency Hysterectomy in Modern Obstetrics.

A retrospective study was done to estimate prevlance, indications and complications of emergency hysterectomy done for various obstetric indications over two years was carried out. There were 37549 confinements during study period from April 2006 to Aug 2008. Out of this 27213 (72.4%) delivered vaginally and 10336 (27.5%) by Cesarean section. 80 emergency hysterectomies were done, incidence being 2.13 /1000 births. Mean age was 30.5 years. Majority (75%) were from rural areas. Maximum cases were para 2-4. Most common indication for emergency hysterectomy was uterine rupture (40%) followed by atonic PPH (28.75%). Placenta previa (9%). Secondary PPH (6.25%), broad ligament hematoma (6.2%) placenta accreta &increta (2%).fibroid with bleeding (3.7%). Couvelaire uterus (2.1%) and obstructed labour with septicemia (1.2%). Majority of uterine rupture cases were late referrals from rural areas. Out of 32 cases of rupture uterus 20 were with previous LSCS and 12 were multipara. Maternal mortality was 2.5% and the cause of death was related to irreversible shock and DIC. Identification of high risk cases, early referral and procedures like internal illiac artery ligation can reduce the incidence of Emergency Hysterectomy.