Caesarean scar ectopic pregnancy of 12 weeks: a rare and unexpected long-term complication of caesarean section

Caesarean scar ectopic pregnancy (CSEP) is one of the rarest of all ectopic pregnancies. CSEP is a life-threatening condition and should be timely diagnosed and managed because if left untreated, it may lead to serious complications like uterine rupture, hemorrhage, hypovolemic shock and even maternal death. A 29-year-old female with history of amenorrhea 3 months, was referred from remote rural area with severe abdominal pain and vaginal bleeding for 15 days. Her previous childbirth was by caesarean section (CS), 4 years back. Trans abdominal ultrasonography (USG) revealed gestational sac in lower uterine segment and attached to anterior wall. Upper uterine segment was empty, crown lump length was 5.86 cm corresponding to 12 weeks and 3 days. As the pregnancy was 12 weeks with very thin myometrium covering it and placenta fully covering internal orifice of the cervix uteri (internal OS), took decision for laparotomy. Vaginal bleeding and abdominal pain are the most common presenting symptoms of CSEP. Severe acute abdominal pain or heavy vaginal bleeding may indicate impending rupture while hemodynamic instability may indicate rupture of CSEP. Laparoscopy or laparotomy can be done in such cases to remove pregnancy. Chose laparotomy as it would give quick, better access and control of hemorrhage in this case. The risk of CSEP and placenta accrete should be specially emphasized when counselling women requesting CS for nonmedical reasons. Prompt and accurate diagnosis using transvaginal ultrasonography (TVUS) followed by individualized treatment will significantly help to reduce morbidity related to CSEP

Prevention of vault prolapse in cases of procedentia using combined vaginal and laparoscopic approach for vault suspension: Agrawal’s technique

Background: The objective of the current study was to assess the need of vault suspension after completion of hysterectomy in all cases of procedentia to prevent vault prolapse and to reduce the operating time for sacrocolpopexy using combined vaginal and laparoscopic approach by two surgeons.Methods: A total of 25 women undergoing surgery for procedentia were included. After completion of hysterectomy the need for vault suspension was assessed intraoperatively. In all cases polypropelene mesh was fixed vaginally to the uterosacral and cardinal ligaments. Vaginal vault was closed vaginally. Laparoscopic surgeon did laparoscopic sacrocolpopexy (LSC). Intraoperative and post-operative complications were then evaluated.Results: Our average operating time was 35 minutes for vaginal hysterectomy and 15 minutes for LSC. The shorter duration of surgery was because mesh was fixed vaginally and trackers were used to fix the mesh to sacral promontory. Intraoperative complications like bladder, ureteric, bowel injuries and hemorrhage were nil in our series. Postoperative stay in hospital was uneventful and all cases were discharged on second postoperative day. Conversion rate to laparotomy was nil. All cases have completed follow up for 5 years with 100% subjective and objective improvement.Conclusions: Restoration of vagina to its normal anatomic position remains the most important fact to prevent vault prolapse. Our technique is very easy, less time taking with negligible complication rates

A case of large cervical lipoleiomyoma simulating malignancy: an intraoperative dilemma

Primary lipomatous tumors of the uterus are very unusual benign neoplasms with an incidence of 0.03% to 0.2%. Most commonly described in the uterine corpus, lipoleiomyomas (LLM) have been reported in cervix, broad ligament and retro peritoneum. Here we report a case of perimenopausal women with cervical LLM which was highly friable simulating cervical malignancy, creating an intraoperative dilemma. A 45 year old perimenopausal woman presented with severe abdominal pain with difficulty in passing urine and motion, excessive bleeding per vaginum with increased frequency of menses, since 6 months. Ultrasonography revealed a well-defined rounded to oval heterogeneous hyperechoic lesion with minimal vascularity measuring 10.4×11.0×7.7 cm, volume-469 cc, probably arising from anterior lip of cervix. Patient was taken for laparotomy. Intraoperative friability and vascularity of the mass was suggestive of malignancy. LLM, if asymptomatic, requires no treatment. But symptomatic cases require surgical management

Uterine torsion in a case of previous two caesarean section mimicking uterine rupture: a case report

Uterine torsion (UT) is defines as a rotation of the uterus of more than 45 degree on its long axis. The predisposing factors for UT can be uterine asymmetry due to fibroids or mullerian anomalies, foetal malpresentation, pelvic adhesions and abdominal or ligamentous laxity other possible causes include external cephalic version, maternal trauma and abdominal massage. The clinical presentation of UT is non-specific. We report a case of previous 2 CS where we suspected rupture uterus but intraoperatively it was UT with unruptured fibrosed scar of previous CS. A 31 years old, G3P2 presented in emergency department with history of amenorrhea 9 months and severe abdominal pain for 5-6 hours. She had previous 2 CS done for contracted pelvis. We immediately suspected rupture of previous CS scar. On laparotomy dense intra-abdominal adhesions were found. After adhesiolysis we could find any sign of previous scar on the visible uterine wall. Entire uterine wall seemed as if we were doing CS in a primiparous patient. This made us suspicious of UT. UT is considered rare and has been referred to as an ‘obstetrician’s once in a lifetime diagnosis’. Recently cases have been reported with no associated pelvic factors although a common feature in all these cases had been previous CS. UT is a potentially dangerous complication of pregnancy both to the mother and to the foetus. Maternal mortality in modern era highly unexpected event but maternal morbidity can occur because of complications like uterine rupture, uterine abruptio, sepsis, pulmonary embolism and iatrogenic complications like injury to blood vessels, urinary tract and rectum. During laparotomy where correction of UT is not possible, a deliberate posterior hysterotomy can be done for delivery of foetus. Bilateral plication of the round ligaments can be done to prevent immediate postpartum recurrence of UT. UT though rare should be kept in mind while performing CS in cases of previous CS, associated myomas, ovarian tumour, malpresentations of foetus. Clinical symptoms may be absent or nonspecific and the diagnosis may be intraoperative

Assessment of the pregnancy rates using sequential day 3 and day 5 embryo transfer in IVF/ ICSI patients

Background: To assess the pregnancy rates using sequential day 3 and day 5 embryo transfer in IVF/ ICSI patients.Methods: This prospective study was conducted in Aarogya Hospital and test tube baby Centre, Raipur from 1st January 2013 to 30th November 2019. Total 100 patients undergoing IVF/ICSI in the study period were offered sequential transfer.Results: Our fertilization rates were 80% with 85.7% grade I embryos on day 3. Blastocyst formation rate was 71.42%. Cycle cancellation rates were nil. Clinical pregnancy rates per retrieval cycle were 50% and implantation rates were 24% with acceptable multiple pregnancy rates of 12%.Conclusions: We advocate that this technique is useful in all patients having good quality embryos in adequate number for double transfer as this optimizes the chance of selection of the most viable embryo for transfer which is probably the key for a successful IVF program.

Thanatophoric dysplasia- a rare cause of stillbirth and perinatal mortality: a case report

Lethal skeletal dysplasia is estimated to occur in 0.95 per 10,000 deliveries. Thanatophoric dysplasia affects about 1in 25000 to 50000 births. The term thanatophoric is Greek word for “death bearing”. Children with this condition are usually stillborn or die shortly after birth from respiratory failure. We report a case of LSD (Thanatophoric dysplasia), in an unbooked patient where previous two children and couple were absolutely normal.  Our patient, 31 years old, unbooked case presented with history of amenorrhea 8 months and unable to perceive fetal movements. Her husband’s age was 33 years. This was her third pregnancy. She had previous 2 deliveries by LSCS. Ultrasonography revealed single intrauterine live fetus in breech presentation with multiple fetal anomalies. There was shortening and deformity of all four limbs (micromelia) with poor mineralization of all bones. Thorax was pear shaped with short horizontal ribs and abnormal cardiothoracic ratio. LSCS was done in emergency for impending rupture of previous LSCS scar. Post-delivery examination and X-ray of the fetus revealed decreased skull mineralization, frontal bossing, hypoplastic nasal bone, midface hypoplasia, mandibular hypoplasia, pear shaped chest, protuberant abdomen, micromelia, dumbbell shaped appearance of all long bones. TD is caused due to mutation of the fibroblast growth factor receptor 3 gene (FGFR3), which is located on the short arm of chromosome 4. Type I TD is characterized by marked underdeveloped skeleton and short-curved long bones. Conventional radiographic examination remains the most useful means of studying the dysplastic skeleton. Bony evaluation is best done on X-rays or ultrasonography. The diagnosis of TD can be established with ultrasound and molecular confirmation in the second trimester can help in genetic counselling and termination of such lethal pregnancies. LSD’s are rare event. If our patient had undergone anomaly scan in second trimester of pregnancy, this defect could have been detected earlier. The outcome of fetus is lethal but maternal morbidity can be reduced if diagnosed early

Large sporadic abdominal wall desmoid tumor due to repeated caesarean sections, a rare and long-term unexpected morbidity

We present a case of large abdominal wall desmoid tumor (DT) arising due to repeated caesarean sections (CS) in a young woman of reproductive age group and managed with wide resection of tumor and abdominal wall reconstruction (AWR). Our patient was a 30-year-old female, came with complaints of persistent abdominal pain associated with mass on abdominal wall and difficulty in walking for 2 years. Patient had 3 living children, all were delivered by CS. Ultrasonography and CT scan of abdomen with contrast revealed a large solid abdominal wall mass and FNAC was suggestive of benign spindle cell neoplasm. We performed a wide surgical excision of tumor. Abdominal wall reconstruction done with prolene mesh. Post-operative period was uneventful with satisfactory wound healing. DTs are rare tumors that occur anywhere in the body and have quite variable clinical behavior. In our patient this tumor had occurred sporadically about 4-5 years of last child birth. Repeated trauma of surgeries on the abdominal wall led to the catastrophic destruction of the musculature in our patient. In this case CT scan revealed solid lump on abdominal wall without any evidence of incisional or inguinal hernia and associated intraabdominal pathology. Our specimen tested positive for β catenin confirming DT. Surgery remains the main stay of treatment in all patients. In female patients presenting with lower abdominal wall tumor with history of previous CS or gynecological surgeries, DT should be considered.

Reducing operative morbidity among female patients combining laparoscopic hysterectomy and laparoscopic ventral hernia mesh repair procedures: a single centre 14 years experiences

Background: During laparoscopic ventral hernia repair (LVHR) mesh is used and so this procedure is not combined with any other major surgery, due to the risk of mesh infection. We did laparoscopic hysterectomy (LH) with LVHR in our study group and found it to be safe procedure with excellent patient recovery and satisfaction rates. Aims and objectives of the study was to assess the short- and long-term clinical outcomes of doing LH and LVHR simultaneously. The primary objectives were to evaluate the intraoperative and post-operative complications, mesh infection rates, hernia recurrence rates and patient satisfaction rates for at least 4 years.Methods: This prospective study was conducted at Aarogya Hospital and test tube centre from 1st January 2007 to 31st December 2016 and follow up completed by 31st December 2020. Total 100 women were included, willing for LH and LVHR simultaneously irrespective of the size of uterus and hernia defect size up to 7cms.Results: Maximum number of patients 65% were in the age group of 45-55 years. 70% patients had previous surgeries commonest being LSCS in 46% cases. Hernia defect size was between 3-5 cm in length and width in 70% cases, requiring dual mesh fixation in 68% cases of size 15x15cms. Our recurrence rate for hernia was nil, 98% cases were highly satisfied with the surgical outcomes by the end of 4 years follow-up.Conclusions: We emphasize that LH can be easily done with LVHR in combination reducing operative morbidity

Making caesarean myomectomy safe and feasible: a 12 year single center experience

Background: To standardize our protocol of caesarean myomectomy to make it safe and feasible for all patients.Methods: This prospective study was conducted in Aarogya Hospital and test tube baby Centre, Raipur from 1st January 2008 to 1st August 2020. Total 45 patients who had documented fibroid in index pregnancy and consented for the procedure were included. B- Lynch sutures were prophylactically applied in all cases to prevent PPH.Results: Our maximum patients were between the age of 20-30 years (66.67%) and 75.56% were primigravida. 44.45% cases were of intramural fibroids and in 53.34% cases the size of myoma was >5 cm. Malpresentation was seen in 15.56% cases. 62.22% myomas were removed through single incision. 33.33% patients had uneventful second CS with us with excellent scar healing in 93.33% cases. 20% cases had secondary infertility and are advised further evaluation to find cause of infertility.Conclusions: The decision to proceed with elective myomectomy at time of CS should be approached with proper pre-operative evaluation of the patient, thorough counseling for hysterectomy if required, expert team, arrangement of blood and adequate correction of medical factors like anemia, hypertension, and diabetes mellitus. Prophylactic application of B -Lynch sutures in all the cases made a dramatic improvement in tone of uterus which we observed intra operatively

Postmenopausal endometrial carcinoma presenting as urinary incontinence: a case report

Endometrial carcinoma (EC) most commonly presents with postmenopausal bleeding (PMB) or blood tinged vaginal discharge. Watery vaginal discharge is usually reported in fallopian tube malignancy. We reported a case of EC where she had profuse watery discharge from private part mimicking urine and so patient visited urologist for urinary incontinence and was later diagnosed as endometroid adenocarcinoma. A 73 year old female presented with history of passing urine involuntarily for last 3 months. Endometrial biopsy revealed endometrial endometroid adenocarcinoma-FIGO grade-2. FDG PET-CT scan revealed primary neoplastic pathology of uterus or endometrium with no lymphadenopathy. PMB or vaginal discharge in women with high risk factors like obesity, diabetes mellitus, unopposed oestrogen exposure needs prompt evaluation. PMB is highly suspicious of malignancy arising from cervix or uterus but copious watery discharge should also be evaluated thoroughly with ultrasound and confirmation of underlying malignancy with hysteroscopic guided endometrial sampling should be done