The high prevalence of abnormal cervical cytology in the context of immunosuppression has been recognized for many years. In response to repeated observations of cervical cancers in HIV-infected women, moderate and severe cervical dysplasia were designated as early symptomatic HIV infection (Category B) by the Centers for Disease Control and Prevention (CDC) in 1993, and invasive cervical cancer as an AIDS-defining condition (Category C). HIV-infected women, therefore, differ from the general population not only with a greater risk for more, but also potentially more severe cervical disease. In the era of highly active antiretroviral therapy, with HIV-infected women living for longer, there is a clear need to address this increased risk with appropriate management guidelines which this review attempts to provide.

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The recent increase in heterotopic pregnancies has been largely attributed to the increased use of assisted reproduction technologies. We report the rare case of a multiparous woman with a spontaneous conception resulting in a triplet heterotopic pregnancy: a twin intrauterine pregnancy and a single right tubal ectopic pregnancy. Heterotopic pregnancy is a rare and potentially life-threatening condition in which simultaneous gestations occur at 2 or more implantation sites. It is infrequent in natural conception cycles, occurring in 1:30 000 pregnancies. However, the prevalence is rising with the increased use of assisted reproduction techniques to that of 1:100 to 1:500 in these patient subgroups, highlighting the need to incorporate it into a clinician’s diagnostic algorithm.

A 27 year old para 1, whose only previous baby had been delivered uneventfully at term, five years earlier, booked at 13 weeks of gestation. Her antenatal course was uneventful until 26 weeks when she presented with sudden onset right iliac fossa pain of 24 hours duration with clinical features suggestive of acute appendicitis. An ultrasound scan of her ovaries was normal.Appendicectomy was performed by the general surgeons via a Lanz incision. Inadvertently, the uterine wall was incised to 3 cm in length on the right anterolateral aspect leading to bleeding and leakage of amniotic fluid from the incision site. While pressure was applied to the site of leakage, we performed an ultrasound scan to determine the presence of a fetal heart rate and to get an impression of residual amniotic fluid volume. With a live fetus and continued leakage of liquor came the dilemma of either delivering the baby by caesarean section to face potential problems associated with prematurity, or managing conservatively.We opted for conservative management. The Lanz incision was extended and the uterine incision was oversewn with 3/0 vicryl suture. A single dose of 1.2 g co-amoxiclav was given to the mother to reduce the risk of infection. The appendicectomy was completed, and there was no further leakage of amniotic fluid. The abdomen was closed. A Redivac drain (serial number: 5022506, HVS 600 mL, manufactured by Van Straten-Medinorm, Germany) was left intraperitoneally. Indomethacin, 1 at a dose of 100 mg, was given per rectum for its potential tocolytic effect.Post-operatively, the patient received an oral course of cephalexin and metronidazole at a dose of 500 mg tds and 400 mg tds, respectively. Indomethacin at an oral dose of 50 mg was given every 6 hours for 24 hours. Oral dexamethasone 2 at a dose of 12 mg 12 hours apart was given for the first 24 hours to aid fetal lung maturation. Daily cardiotocography and twice weekly C-reactive protein and white cell count were performed. These remained normal. The drain was removed on the second post-operative day.The patient was discharged on the fifth post-operative day with a normal amniotic fluid volume on scan.The patient was managed with regular scans for amniotic fluid volume and fetal growth, both of which were normal, and was delivered, electively, at 38 weeks by caesarean section, of a 3.55 kg female baby with normal Apgar scores. The mother was discharged on the fifth post-operative day. DiscussionA literature search revealed no previous report of perforation of the gravid uterus at the limits of viability at appendicectomy. However, there have been several published reports of uterine stabbings 3,4 and even gunshot wounds 5,6 in pregnant women with generally a high degree of morbidity and mortality for both the woman and her fetus. -7The decision to attempt to prolong gestation was based primarily on the fact that the appendectomy stump did not overlie the hysterotomy. If that were the case, the risk of infection, preterm delivery under adverse conditions, and possible loss of...

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