Spontaneous heterotopic pregnancy is a rare clinical condition in which intrauterine and extra uterine pregnancies occur at the same time. It can be a life threatening condition and can be easily missed with the diagnosis being overlooked. We present the case of a 40 year old patient who was treated for a heterotopic pregnancy. She had a transvaginal ultrasound because of a previous ectopic pregnancy and an intrauterine gestational sac was seen with false reassurances. The patient presented acutely with a ruptured tubal pregnancy and this was managed laparoscopically. The ectopic pregnancy was not suspected at her initial presentation. A high index of suspicion is needed in women with risk factors for an ectopic pregnancy and in low risk women who have free fluid with or without an adnexal mass with an intrauterine gestation.

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Introduction Southampton University Hospital (SUHT) has maintained a relatively low Caesarean section (CS) rate over the past 6 years, despite being a tertiary referral centre. However an increase in forceps delivery has been observed raising concerns over perineal trauma risks. Design A review of computerised obstetric data from 2003 to 2009 in a large university hospital and comparison with maternity statistics for England. Results Our CS rate has remained consistently lower (21-22%) and instrumental deliveries higher than England. The lower CS rate is mainly due to elective cases which have shown a decline to 6.7%, in contrast to a gradually rising national rate for both elective (9-10%) and emergency CS (15%). The rates of normal births are comparable, decreasing nationally

Leiomyomas (fibroid) arise from the smooth muscle of the myometrium and are benign in nature. Intavascular leiomyomatosis is an unusual and rare condition where the fibroid grows into the pelvic veins and inferior vena cava and sometimes extends into the heart chambers. We present a case where a woman presented to us with multiple fibroids and underwent an abdominal hysterectomy. The diagnosis was not suspected before the surgery but diagnosed on histopathology. The patient underwent further surgery to remove the fibroids from the pelvic veins and the inferior vena cava. This condition has been reported in only few case reports around the world. In view of the rarity of this condition, the diagnosis can be easily missed. We suggest an increased vigilance in women who have large fibroids with unusual features in symptoms or during surgery. Pre-surgical imaging will help to make diagnosis, and good surgical outcomes can be achieved by a multidisciplinary surgical approach.