Search

Introduction. A significantly increased frequency of multiple pregnancies including more than two fetuses is a consequence of using assisted reproductive technologies and ovulation stimulations. However, such pregnancies remain poorly investigated. Aim: to study the course and perinatal outcomes of quadruplet pregnancies.Materials and Methods. 7 pregnant women with quadruplets were examined. A comprehensive examination, including fetometry, monitoring of the cervical length, Doppler examination, and treatment of all complications were performed for all pregnant women. Results. Quadruplet pregnancy belongs to the peak risk group for the frequency of multiple gestational complications: cervical incompetence (85.7 %), anemia (71.4 %), preeclampsia (57.1 %), fetal growth retardation (71.4 %), premature birth (100.0 %), massive bleeding during delivery (33.3 %), extremely low birth weight newborns (30.8 %), respiratory disorders (100.0 %), intraventricular hemorrhages (38.5 %).Conclusion. Women with quadruplet pregnancies should be monitored and give a birth in level 3 perinatal centers. Delivery should be preferentially performed by caesarean section. The data obtained additionally underline that as few as a single embryo should solely transferred.

First trimester transvaginal embryo reduction is an effective alternative for the management of multifetal pregnancy in assisted reproduction and is done by performing an intracardiac embryo puncture until a systole is verified. A 32-year-old G2 A1 conceived through in vitro fertilization (IVF) at 10 weeks of gestation. Ultrasonography confirmed quadruplet pregnancy with viability of all four fetuses with minimal sub chorionic hemorrhage. The couple was counselled about all potential complications and were counselled to undergo fetal reduction of quadruplets to twins. She underwent fetal reduction and pregnancy was uneventful in first and second trimesters with regular antenatal check-ups. In third trimester the woman with 35 weeks of gestation with twin breech presented with premature preterm rupture of membranes (PPROM), delivered by emergency lower section caesarean section (LSCS) with first twin as breech and second twin as vertex. First twin was delivered with birth weight 1.75 kg and second twin with birth weight 1.75 kg. Keywords: Total reduction, Multifetal pregnancy, IVF, Transvaginal embryo reduction, PPROM.

Quadruplets are set of four off springs born at one birth. Quadruplets occurring more frequently as assisted reproduction technique but spontaneous conception and delivery of 4 male live fetuses are something rare case to be reported. Improved MCH care in high risk obstetric cases with team work and Obstetric ICU/HDU and NICU. We report a case of 28 year old multiparous woman presented at around 10 week of amenorrhea with positive pregnancy test. After evaluation she was found to carry 4 live fetuses. She was managed conservatively till 34 week of gestation with regular ANC monitoring. Caesarean section was performed when labour pain was started for obstetrical complications and successful delivery of 4 healthy live male children of 1.75, 1.5, 1.5, 1.2 kg. Entire delivery was possible in Obstetric HDU set up and level 3 NICU setup. This case is unique due to SPONTANEOUS conception of quadruplet pregnancy with regular ANC checkups and delivery at centre with obstetric ICU back up & team work. We followed this case for entire post natal period and infant age of all Children. Keywords: Multiple gestation, Quadruplets, Dizygotic.

Objective: To assess the effectiveness and safety of non-surgical management for six heterotopic interstitial pregnancies.Material and methods: We retrospectively analyzed the data of six women diagnosed with heterotopic interstitial pregnancies who underwent non-surgical treatment at the CHA Bundang Medical Center between January 2007 and December 2017. Three heterotopic interstitial pregnancies were treated with sono-guided potassium chloride (KCl) injections. Two cases were managed expectantly. One heterotopic quadruplet pregnancy with twin, left interstitial, and tubal pregnancy was treated by sono-guided KCl injection and laparoscopic left salpingectomy. Complications and outcomes were measured.Results: Three cases were treated with sono-guided KCl injection and the intrauterine pregnancy continued to term. Intrauterine pregnancies were vaginally delivered without complications. One case that was treated expectantly was delivered at full term, while the other case resulted in spontaneous abortion. Quadruplet heterotopic pregnancy was successfully managed with sono-guided KCl injection and laparoscopic salpingectomy. Intrauterine twin pregnancy was successfully delivered by elective cesarean section at 37 + 0 weeks of gestation with healthy babies. Conclusions: KCl injection under ultrasonographic guidance could be a safer and more effective treatment option than surgical treatment in hemodynamically stable patients with fetal cardiac activity in interstitial pregnancy. Expectant management could be an option for patients with no fetal cardiac activity.

Heterotopic pregnancy is the condition where both intrauterine and ectopic pregnancy are present. It rarely occurs after natural conception, but is more common with assisted reproductive techniques, when more than one embryo is transferred. Quadruplet heterotopic pregnancy is exceedingly rare. Methods: A literature review was conducted aiming to highlight the diagnosis difficulties and the management options in heterotopic quadruplet pregnancies. Results: Nine relevant studies were identified by researching PubMed up to 2021 for “heterotopic quadruplet pregnancy”, “quadruplet intrauterine and ectopic pregnancy”, “synchronous intrauterine and ectopic pregnancy”. Conclusions: In this paper, we present a case of heterotopic quadruplet pregnancy and address the difficulty in diagnosing this condition and make formal recommendations.

Background We discuss the challenges of multiple pregnancy at very advanced reproductive age. Case presentation We present the case of a quadruplet pregnancy at the maternal age of 65 following in-vitro fertilization (IVF) with donor eggs and sperm, involving cross-border reproductive care. All children born were at 25 weeks’ gestation and survived; however, poor neurodevelopmental outcome remains a major concern in one child. Conclusions The use of reproductive technology to achieve a multiple pregnancy at such an advanced post-menopausal age generated a debate on ethical, psychosocial and medical questions. We share this debate and highlight the need to reconsider international guidelines for women of advanced reproductive age.

Quadruplet pregnancy is a pregnancy state where four fetuses grow simultaneously inside a mother's womb. Four fetuses developing in a womb is a challenge not only to the mother but to the obstetrician who has to calculate every risk associated with such pregnancy. High order pregnancy is considered a high risk pregnancy due to increase in maternal, fetal and neonatal morbidity and mortality. So a multidisciplinary approach with early involvement of neonatologists and anesthesiologists for the assessment of such case is essential for a successful obstetric outcome. Here we present a case report of 27 years G3P1L1A1 at 33 weeks 2 days of gestation with quadruplet pregnancy with previous lower segment Cesarian section with history of ovulation induction, delivered successfully via cesarean section with successful outcome of all 1 female and 3 male babies. Keywords: case report; cesarean section; fertility agent; multiple pregnancy; pregnancy; quadruplets.

Spontaneous higher order multiple gestation is rare with an incidence of 0.01–0.07% (Nnadi 2013). Moreover, the occurrence of spontaneous quadruplet pregnancy is exceedingly rare with an incidence ...

Objective: Triplet or higher-order multiple pregnancies are often caused due to ovulation induction. Spontaneous quadruplet pregnancy is a rare phenomenon which is associated with maternal and fetal complications. Here in, we report a spontaneous quadruplet pregnancy with no family history and as a result of an unwanted pregnancy. Case report: The patient was a 34-year-old, G4 L2 Ab1. She noticed being pregnant during breastfeeding, a spontaneous quadruplet pregnancy. There was no case of multiple pregnancies in her or her husband's family. In week 29 she was hospitalized due to the diagnosis of preterm labour. At 32 weeks and 4 days of gestation, because of the restart of labour contractions and dilatation development, she underwent a cesarean section. The outcome was the birth of 4 healthy neonates weighing between 1800 to 2100 gram and normal Apgar score. Conclusion: Quadruplet pregnancy can rarely occur spontaneously even unintentionally, and can reach the third trimester without prophylactic cerclage.

Multiple pregnancy is a known complication of in‑vitro fertilization and embryo transfer (IVF‑ET). It is usually associated with serious perinatal morbidity and/or mortality as well as significant maternal morbidity and efforts to reduce these has led to the concept of elective single embryo transfer (ESET) in developed countries, this concept has not been entrenched in the practice in Nigeria. We report a case of quadruplet pregnancy following the transfer of three embryos following IVF and reviewed the relevant literature.Key words: Complications; in‑vitro fertilization; pregnancy; quadruplets.

BACKGROUND: Heterotopic pregnancy (HP) is a condition characterized by the coexistence of multiple fetuses at two or more implantation sites. It occurs in 1% of pregnancies after assisted reproductive techniques (ART). Presence of triplet intrauterine pregnancy with ectopic gestational sac is one of the rarest forms of HP. Ectopic pregnancy is implanted in the ampullary segment of the fallopian tube in 80% of cases. Most of the patients present with acute abdominal symptoms due to rupture of the tube. CASE PRESENTATION: This article reports a case of quadruplet heterotopic pregnancy after intracytoplasmic sperm injection (ICSI) with an ampullary ectopic pregnancy and intrauterine triplet pregnancies. The ruptured ampullary pregnancy was emergently managed by right salpingectomy. This was followed by embryo reduction at 12 + 6 weeks and successful outcome of intrauterine twin pregnancy.

The aim of the report was to present a method of zygosity determination in multiple pregnancy. The study wascarried out on same-sex neonates born as a result of spontaneous quadruplet pregnancy. Zygosity was determinedby DNA profiling. The pregnancy was confirmed to be polyzygotic. DNA profiling may be used as a method ofzygosity determination in multiple pregnancy.

Introduction : When more than two fetuses simultaneously develop in the uterus, it is called higher order multiple pregnancy. The incidence of such pregnancies ranges from 0.01% to 0.07%. Case report: We report a case of 26-year-old G 2 P 1 L 0 D 2 with previous history of preterm vaginal twin delivery, diagnosed to have quadruplet pregnancy. She was admitted at 28 weeks of gestation for safe confinement. At 33 weeks of gestation, emergency cesarean section was conducted with outcome of two female and two male babies with quadriamniotic and quadrichorionic placenta, without any intra and post-operative complications. Conclusion: A multidisciplinary approach with good neonatal care facilities is warranted for a better outcome in higher order multiple pregnancies. DOI: https://doi.org/10.22502/jlmc.v4i1.88 Journal of Lumbini Medical College. 2016;4(1):46-9

Higher order (triplet or more) multiple pregnancies occur when more than two fetuses are present in the uterus at the same time. Quadruplets are a set of four offspring born at one birth which can be fraternal (multizygotic), identical (monozygotic) or a combination of both. Multizygotic quadruplets occur from fertilisation of four different sets of ovum and sperm. Monozygotic multiples are the result of a fertilized egg that splits into two or more embryos. Multizygotic quadruplets can be all male, all female, or a combination of both while monozygotic quadruplets will always be of the same gender. Here we present a case of 26-year-old G2A1L0 with previous history of one spontaneous abortion at 8 wk of gestation. After evaluation, she was found to carry three live foetuses with an IUFD. She was managed conservatively till 35 wk of gestation with regular monitoring of coagulation parameters. Elective caesarean section was done at 35 wk; two male, one female live babies and one IUFD male baby were delivered. This case is unique due to the fact that our patient conceived a multizygotic quadruplet pregnancy spontaneously after an abortion. One fetus died in utero and the pregnancy continued successfully resulting in 3 live born healthy babies.

BACKGROUND: Most patients with preterm labour have higher levels of psychosocial stress. Hypnosis can play an important role in reducing preterm labour. METHOD: A literature review of 13 856 articles on preterm labour was carried out; only 7 reports on preterm labour and hypnosis could be identified (Evidence level 3 and 4 a). RESULTS: Schwarz (1963) and Logan (1963) each described three case reports in which preterm labour was stopped using hypnosis. Brown and Massarelli (2002) used hypnosis in a quadruplet pregnancy. Goldman (1992) showed that with the use of hypnosis preterm labour can be influenced on different levels, including controlling psychosocial stress and the cognitive awareness of the preterm level, as well as inducing relaxation to reduce the side effects of medication, directly relaxing the uterine muscles and reducing the chance of preterm delivery. Omer (1987) compared a hypnosis group with a control group which only received standard therapy. The hypnosis group showed a significant prolongation of pregnancy and an increased birth weight compared with the standard therapy (prolongation of pregnancy; t [111] = 3.09; p < 0.002; weight 2917 g vs. 2692 g; t [111] = 1.64; p = 0.05). With regard to the prevention of preterm labour, Cheek (1995) described a special effect through the processing of conscious and unconscious anxieties of pregnant women using psychotherapy and hypnosis. Many studies have shown a correlation between stress and preterm labour. Brown et al. (2007) described a reduction in the rate of preterm labour (6.8 to 2.6%) through the introduction of hypnosis and the use of ideomotor signals. CONCLUSION: Hypnosis seems to be a new, effective therapy with no side effects and can prolong pregnancy in cases with preterm labour. Further multi-centre randomised controlled studies are needed.

International audience; We report a 12-year-old boy who presented with abdominal pain and who was found to have an aneurysm of the abdominal aorta (AAA). The patient was born from a quadruplet pregnancy induced by in vitro fertilization. Postnatal transient respiratory distress required assisted ventilation that had been monitored by two consecutive umbilical arterial catheters (UAC). AAA is a rare condition in childhood. Infection and/or trauma are known to be the most frequent causes. Most of the reported cases have occurred in children in whom a UAC had been placed during the neonatal period. In this patient the delay between UAC placement and diagnosis was considerable. At the time of this report the patient had remained well during a follow-up of 8 years after treatment.

Heterotrophic pregnancy is defined as the coexistence of intrauterine and extra-uterine gestations. Although spontaneous heterotrophic pregnancy is very rare event with incidence change to 1/30.000, common use of ovulation induction and assisted reproductive techniques (ART) increase the incidence of heterotrophic pregnancy to 1/100 [1]. Treatment of heterotrophic pregnancy should be made safely without risking both mother and intrauterine pregnancy. We report in this article an extremely rare case of a quadruplet heterotrophic pregnancy after an intrauterine insemination with an ovulation induction.

Monochorionic triplet pregnancies are very rare. Here we report 2 cases of multiple pregnancies with monochorionic triplets following intracytoplasmic sperm injection (ICSI) and day 3 embryo transfer. The 2 women concomitantly underwent controlled ovarian hyperstimulation due to male factor infertility. Following oocyte retrieval, ICSI and assisted hatching (AH) were performed, and the 2 women conceived consecutively. One patient had a quadruplet pregnancy, which included monochorionic triplets, while the other had monochorionic triplets. Selective embryo reduction by intracardiac KCl injection targeted at 2 of the triplets was performed on the patient with the quadruplet pregnancy, but the third triplet also died. The gestation continued as a singleton pregnancy, and the patient gave birth to a healthy female baby at 38 weeks. The other patient gave birth to 3 healthy female babies at 34 weeks. Possible etiologic factors for the formation of monozygotic splitting among women undergoing assisted reproduction treatment are discussed. Copyright © 2004 S. Karger AG, Basel.

Blastocyst transfer is advocated to reduce the risk of multiple gestations in pregnancies by assisted reproduction. Nevertheless, there remains the rare inherit possibility of embryo splitting that can result in monozygotic twins leading to high-order multiples. Also, when a patient is found to have a higher gestation than the number of embryos transferred it calls into question the IVF facility’s competency and credibility. The case report presented such a rare phenomenon of embryo splitting and the clinical consequences precipitated from it. In the patient, two blastocysts were transferred 5 days after transvaginal oocyte retrieval. The pregnancy confirming hCG test did not predict high-order multiples in this case. Early ultrasonography documented trichorionic-quadramnionic gestation. Selective reduction of the monochorionic twins was done at 11 weeks. Dichorionic twin gestation continued uneventful until 22 weeks at which point the patient experienced preterm premature rupture of membranes with subsequent delivery. The pathology report confirmed trichorionic-quadramnionic gestation. The mode of splitting was different for the two embryos one leading to monozygotic dichorionic and the other to monozygotic monochorionic. Furthermore, the implantation was also apparently asynchronous with one implanted considerable later than the other. The first β-hCG value seemingly did not represent the entire initial implementation events otherwise the value would be higher carrying the early signal of high-order multiple.

Quadruplets are a set of four offspring born at one birth which can be fraternal (multizygotic), identical (monozygotic) or a combination of both. Multizygotic quadruplets occur from fertilisation of four different sets of ovum and sperm. Monozygotic multiples are the result of a fertilized egg that splits into two or more embryos. Multizygotic quadruplets can be all male, all female, or a combination of both while monozygotic quadruplets will always be of the same gender. Here we present a case of 32-year-old G4P3L0 with previous history of three term intrauterine foetal death (IUFD) at 27 wk of gestation. After evaluation, she was found to carry three live foetuses with an IUFD. She was managed conservatively till 35 wk of gestation with regular monitoring of coagulation parameters. Elective caesarean section was done at 35 wk and three live female babies and one male still born were delivered. This case is unique due to the fact that our patient conceived a multizygotic quadruplet pregnancy spontaneously following a bad obstetric history (3 previous term intrauterine fetal deaths). One fetus died in utero and the pregnancy continued successfully resulting in 3 live born healthy babies.

This case report presents a new association reaction and a new treatment for quadruplet pregnancies. The hypnotic interventions can increase clinical management of quadruplet pregnancy. It illustrates new insights into the treatment of quadruplet pregnancies, and it suggests useful future research.

We report the prenatal diagnosis of twin-to-twin transfusion syndrome (TTS) at 11 weeks’ gestation. The diagnosis was made in a trichorionic quadruplet pregnancy which was conceived after in vitro fertilization and intracytoplasmic sperm injection for male subfertility and transfer of 3 embryos. Growth discordance, oligo/polyhydramnios and abnormal arterial and venous Doppler flows were demonstrated in 2 monochorionic fetuses, while the remaining 2 dichorionic fetuses were unremarkable. Selective fetocide of the donor by intracardiac injection of potassium chloride was followed by the spontaneous demise of the recipient. The pregnancy course remained uneventful until 32 weeks of gestation when the patient developed preterm labor. Two healthy preterm babies were delivered by cesarean section. The diagnostic problems of this early manifestation of TTS are discussed.

Objetivo: reportar un caso de embarazo cuádru­ple y revisar la literatura disponible con respecto disponible con respecto a la edad gestacional en la que se identifica el tipo de placenta (mono o policoriónica) en la que finaliza el embarazo, el peso del recién nacido y la frecuencia del cuidado prenatal de este tipo de gestaciones.Materiales y métodos: se presenta del caso de una mujer con embarazo cuádruple secundario a técnica de reproducción asistida, atendida en una institución de cuarto nivel de complejidad, ubicada en la ciudad de Bucaramanga, Colombia. Se realizó una revisión de la literatura publicada en las bases de datos Medline vía PubMed, Embase, SciELO y UptoDate® con los términos de búsqueda: “em­barazo múltiple”, “cuádruples”, “atención prenatal” y “resultado perinatal”. La búsqueda se limitó por idioma (artículos en inglés y español).Resultados: se recuperaron 19 referencias que cumplían con los criterios de in­clusión y de exclusión. No hay información sobre la frecuencia con la que se debe hacer el control prenatal. El tipo de placenta se pudo establecer entre las semanas 9 y 25; la edad gestacional varió entre 26 y 34 semanas. El peso varió entre 1.076 y 1.770 g. Los embarazos multigestación se acompañan frecuentemente de complicaciones maternas y perinatales.Conclusiones: el diagnóstico del embarazo cuádruple puede hacerse temprano en la gestación. Frecuentemente se acompaña de prematuridad y bajo peso al nacer. Se requieren estudios que evalúen el manejo más seguro y efectivo de esta condición.

Quadruplet surrogate pregnancy is a rare pregnancy but, has become common due to assisted reproductive technology (ART). Its management is a big challenge to obstetricians and co-clinicians worldwide. This was a pregnancy managed at the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria in a 33 year old hypertensive surrogate mother with turbulent first trimester medical disorders that called for termination of the pregnancy by other co-managing clinicians. However, the pregnancy became stable in late 2nd trimester with emergency caesarean section at 33 weeks following preterm premature rupture of membranes (PPROM). Its management was a big challenge that necessitated multidisciplinary approach with successful outcome of four healthy live babies (three males and one female) and the controversial practice of surrogacy

A 28-year-old Taiwanese woman who had received ovulation induction by clomiphene citrate (CC), follicular-stimulating hormone (FSH), and human chorionic gonadotrophin (hCG) treatment was diagnosed with a quadruplet pregnancy containing a hydatidiform mole and three fetuses at nine weeks' gestation. Expectant management failed to achieve any viable neonate due to massive antepartum haemorrhage and preterm delivery at 25 weeks' gestation. Five other cases previously reported involving quadruplets or triplets with a complete hydatidiform mole and two or three fetuses are reviewed. All cases ended as premature non-viable fetuses. Analysis of the clinical features, management, and outcome both in our patient and these reports suggest that more efficacious treatment planning, such as selective feticide, should be considered in order to improve the likelihood of attaining an advanced gestational age for a single fetus.

Due to a surge in the availability of assisted reproductive techniques (ART), the incidence of multiple pregnancies is increasing. Preterm labor is a major complication in such pregnancies. Preterm delivery of the first fetus is often followed by delivery of the remaining fetuses. However, conservative management and delayed interval delivery in the remaining fetuses might allow for fetal lung maturity and would reduce perinatal morbidities. A 32-year-old female had a quadruplet pregnancy after receiving ART. Fetal reduction to triplet pregnancy was performed at 11 weeks of gestation. The remaining triplet pregnancy was stable until 29 weeks of gestation, when the first triplet was delivered after spontaneous rupture of membranes. Under intensive monitoring, the remaining 2 fetuses were delivered by cesarean section at 31 weeks of gestation. Only the first fetus had retinopathy after discharge. In conclusion, delayed interval delivery of the remaining fetuses should be attempted after preterm delivery of the first fetus.

BACKGROUND Uterine rupture of an unscarred uterus is a rare complication in a quadruplet pregnancy. CASE A 30-year-old woman, gravida 4 para 0030, with a quadruplet pregnancy and no previous uterine surgeries presented with moderate vaginal bleeding at 32 4/7 weeks of gestation. Fetal testing was reassuring, and the cervix showed no signs of preterm labor. A decision was made to proceed with cesarean delivery because of the amount of vaginal bleeding, with surgical findings of uterine rupture superior to the lower uterine segment. CONCLUSION High-order gestations may be an independent risk factor for uterine rupture.

OBJECTIVE: The purpose of this investigation was to determine the value of biophysical profile testing in preventing intrapartum death in patients with high-order multiple gestations (triplets or quadruplets). STUDY DESING: A retrospective review was performed of patients with triplets and quadruplets cared for by Phoenix Perinatal Associates from October 1988 to December 1991. Biophysical profile testing was used as the primar method of fetal surveillance in thes pregnancies. Fetal heart rate monitoring on an external monitor wasused as back-up and in cases sent to labor and delivery for problems. The ultrasonographic parameters of the biophysical profile score were used without the nonstress test component because of technical difficulty with that test in high-order multiple pregnancies. A score of 6 to 8 8 was therefore considered reassuring. 4 8 equivocal, and 0 or 2 8 possibly abnormal. Testing was done twice per week. RESULTS: Eighteen patients with triplets and six patients with quadruplets constituted the study group. The last biophysical profile before delivery was examined to evaluate the value of the test. There was no antepartum deaths in these 78 babies. The last biophysical profile score was 2 8 in nine fetuses of five triplet pregnancies and two fetuses of one quadruplet pregnancy. These six pregnancies (25%) were delivered on the basis of biophysical profile results and clinical circumstances. There was no morbidity or mortality in the 19 babies delivered because of abnormal biophysical profile testing. Four pregnancies had poor outcome at delivery in spite of 8 8 biophysical profile scores on all babies within 4 days of delivery. Of these four, two patients had worsening pregnancy-induced hypertension, one had abruptio placentae, and one had a severely growth-retarded infant. CONCLUSION: There were no stillbirths in this series. Twenty-five percent of these pregnancies eventually were delivered for nonreassuring biophysical profile testing, with good outcome. Four pregnancies had poor neonatal outcome in spite of normal biophysical profile testing. All of these pregnancies had active changes in physiologic features leading to delivery (two worsening pregnancy-induced hypertension, one abruptio placentae, one spontaneous rupture of membranes and labor). The biophysical profile appears to be a reliable antepartum test of fetal well-being in triplets and quadruplets.

Following a long period of secondary unexplained infertility, a couple had assisted conception treatment with IVF and transfer of two embryos 2 days later. The woman conceived and was found to have a quadruplet pregnancy. Following spontaneous labour onset at 34 weeks gestation, she was delivered by immediate Caesarean section. All four babies (three boys, one girl) were eventually discharged home with the mother. All the boys were found to be of differing zygosity. The quadruplet pregnancy was attributed to natural conception following intercourse and fertilization of oocytes not collected at the time of IVF. The wisdom of intercourse during a cycle of IVF is discussed.

Case of heterotopic quadruplet pregnancy with coexistence of tubal and intrauterine twins. Objective (s): To present the case heterotopic quadruplet pregnancy with coexistence of tubal and intrauterine twins and its successful surgical management with brief literature review. Design: A case report supplemented with brief literature review and discussion. Setting: City clinical university hospital. Patient (s): Heterotopic quadruplet pregnancy with tubal and intrauterine twins in a 31-year-old woman after natural conception. Intervention (s): Laparoscopy, adhesiolisys, aspiration of tubal embryos through tubotomy and cervical dilatation and vacuum aspiration of intrauterine embryos as well as vaginal and intraoperative laparoscopic ultrasound examination. Main outcome measure (s): Physical examination, laparoscopy and postsurgical hCG serum assay, as well as preintra- and postoperative vaginal ultrasound and intraoperative laparoscopic sonography. Result (s): Successful diagnosis and treatment of a case of heterotopic quadruplet pregnancy with coexistence of tubal and intrauterine twins in a 31-year-old woman with 6 artificial abortions, pelvic inflammatory diseases and periadnexal adhesions, after natural conception was described. An intraoperative laparoscopic sonography was applied to complete diagnosis of heterotopic pregnancy with coexistence of tubal and intrauterine twins after control of bleeding and stabilization of patient condition due to necessity to perform an emergency surgery. The case was supplemented with a brief review of literature and discussion. Conclusion (s): A unique case of heterotopic quadruplet pregnancy with coexistence of tubal and intrauterine twins after natural conception was presented in the first time.

Blastocyst transfer of just one or two embryos has been used to help limit the number of high-order gestations. In this case report we describe the occurrence of a quadruplet pregnancy after the transfer of only two blastocysts during IVF. Sonographic examination showed four fetuses and what appeared to be quadriamniotic/quadrichorionic sacs, suggesting that a concomitant spontaneous conception had occurred. Definite confirmation of zygosity was obtained by genetic testing using DNA microsatellite polymorphism determinations after the birth of one boy and three girls at 32 weeks gestation. Although this event has not been reported previously, the possibility of its occurrence should be kept in mind. IVF patients with patent Fallopian tubes should be cautioned against intercourse late in their controlled ovarian stimulation, especially if they would decline multifetal reduction.

A case of dichorionic twin pregnancy was diagnosed in a 29-year-old, on routine ultrasound at 12 weeks. Subsequent ultrasounds for persistent vaginal bleeding at 16 weeks revealed molar placenta with viable fetus in both gestational sacs. The patient declined any invasive prenatal testing to confirm the karyotype of the fetus. The pregnancy was managed expectantly until 21 weeks, when she had a spontaneous abortion of twin fetuses and separate placentae with attached molar tissue. A final karyotype on cord blood samples confirmed 46XY and 46XX for both fetuses. Histopathology of molar tissue reported complete mole, with diploid chromosomal pattern on subsequent DNA flow cytometry. The clinical, ultrasound and chromosomal examination suggest that there has been a quadruplet pregnancy where two embryos developed into normal fetuses and other two degenerated to complete moles.