A case report on ACUM: a rare mullerian anomaly

Accessory and cavitated uterine mass (ACUM) is a rare, newly recognized mullerian anomaly. It is an accessory cavity lined by functional endometrium within an otherwise normal uterine cavity, in contrast to the other mullerian anomalies in which the uterus is malformed. It is often misdiagnosed as myoma, adenomyosis or adenomyoma. The entity needs expertise to diagnose as it is a rare but treatable cause of severe dysmenorrhea and chronic pelvic pain in young females with a wide range of differential diagnosis. A 30 years old female with history of one abortion 2 years back, came to infertility OPD with complaints of lower abdominal pain with severe dysmenorrhea, dyspareunia and inability to conceive since 2 years. Her menstrual cycle was regular with normal flow. USG pelvis showed subserosal fibroid of 4×3 cm in fundus region of uterus. On HSG, bilateral fallopian tubes were patent. MRI-pelvis revealed normal uterus with thick walled cavitatory lesion of size 4.1×3.6 cm with thick T2W hypointense wall similar to myometrium in continuation with right fundal wall of uterus containing blood products suggestive of ACUM. Both ovaries were normal, no obvious adnexal lesion/collection/free fluid noted in peritoneal cavity. Laparoscopy followed by laparotomy with excision of ACUM was performed. The MRI findings of an accessory cavitated uterine mass located below the attachment of round ligament with haemorrhagic contents, normal shaped uterus with normal bilateral tubes and ovaries should suggest the diagnosis of ACUM pre-operatively

Urinary bladder agenesis with bilateral single system vaginal ectopic ureters in adult

Agenesis of urinary bladder is an extremely rare condition with only 60 cases and 22 live births being reported previously. Ureteric ectopia is a must for survival. We present a unique case of bladder agenesis detected in adulthood where bilateral single system ureters were draining ectopically in a grossly dilated vagina in normally developed female genital tract

Ruptured ovarian artery aneurysm in puerperium: a rare occurrence

We present a rare case of Ovarian Artery Aneurysm in a puerperium. It was managed by endocopic banding of the ovarian artery following failed attempts at endovascular embolisation. The patient remained stable on three months follow up. The pathogenesis of this rare condition is also discussed.

Successful outcome of pregnancy in uncorrected tetralogy of fallot

Tetralogy Of Fallot (TOF) is the most common cyanotic congenital heart disease. Most commonly, it is detected in the first year of life and it is rare for patients with the disease to reach adulthood without corrective surgery. Pregnancy in patients with uncorrected TOF is rare and is associated with high morbidity and mortality rates. This is due to increased maternal hypoxemia and cyanosis because of fall in systemic vascular resistance and rise in cardiac output which exacerbates the right to left shunt. Its management poses a challenge to the clinician because of the rarity of its occurrence and the paucity of literature. 22 year old woman, G3A2 with uncorrected TOF presented at 36 weeks gestation to the emergency room with breathlessness on routine daily activities (NYHA III) and severe fetal growth restriction. The patient had higher hemoglobin and hematocrit levels and lower platelet count. Oxygen saturation was low. Pregnancy was terminated by caesarean section under spinal anesthesia. Post caesarean patient had a febrile course and falling oxygen saturation (nadir 45.4%) which was intensively managed in consultation with cardiologist and physicians. She was discharged along with her baby in satisfactory condition on post-operative day twelve. Uncorrected TOF in pregnancy poses a therapeutic dilemma to the obstetrician, cardiologist and anesthetist.  Intensive multidisciplinary management is essential to optimize the fetomaternal prognosis. With adequate care, good outcome can be achieved

Hysteroscopic salpingosonography: a novel technique for infertile patients

Background: Infertility is akin to curse in our country. Patients of infertility run from pillar to post to get relief. Government Hospitals in India lie at the tail end of window-shopping of infertility centres by the patients having exhausted all their resources. Patients report without any detailed records, lost reports, coming after long hiatus of having stopped treatment in desperation, making one wonder how to proceed. At the other end are patients who have undergone laparotomy for various reasons like intestinal obstruction, tubercular abdomen, adnexal masses and their tubal status is not very clear on HSG. So, repeat laparoscopy in the former group and performing ab initio in the latter, involves putting the patients to the risk of general anesthesia, injury to internal organs due to anticipated adhesions. Although Hassan’s technique of open trocar entry is well accepted the first port entry, whatever be the mode, is an entry open to risks.Methods: In a selected group of infertile women, a baseline TVS was done on 2/3 day of menses and on the 7/8 day of menstrual cycle hysteroscopy was done which was immediately followed by another transvaginal ultrasound. The descriptive statistics is presented in the form of percentages and appropriate graphs.Results: Among the 54 patients who underwent this procedure, 65% had normal uterine cavity. 18% were referred for IVF. 9.2% conceived post procedure.Conclusions: Successive use of transvaginal ultrasound after hysteroscopy i.e Hysteroscopic sonosalpingography is a useful procedure in a select group of infertile patients. 

A ‘never before’ presentation of a common Mullerian abnormality

Transvaginal septum is one of uncommon Mullerian anomalies which may lead to infertility. We all depend so often on HSG and MRI for investigating these infecund patients. Here we bring out how a distended vaginal cavity with contrast mimicked the uterine cavity on HSG misleading the clinician. The septum was missed on MRI too initially. A simple surgical correction and the patient was able to conceive in her very first cycle

Is scar tenderness a reliable sign of scar complications in labor?

Background: Cesarean section has come a long way from being a risky & restrictive surgery to one that is safe and quick. Due to a rise in the rates of primary caesarean section globally, repeat cesarean section has also become very common. The chief concern during labor with scarred uteri is that of scar rupture which can have devastating fetal and maternal consequences, including mortality. Several studies monitoring for the features of scar rupture like abnormal cardiotocography (CTG), severe abdominal pain persisting between contractions, acute onset scar tenderness, hematuria or abnormal vaginal bleeding, maternal tachycardia or shock, cessation of uterine activity and loss of station of the presenting part exist with the exception of scar tenderness which has not been evaluated separately in any study. The present prospective observational study was undertaken in a tertiary care hospital to evaluate the sensitivity and specificity of scar tenderness as a sign of scar complications in labor. Methods: 78 women with one previous cesarean delivery in spontaneous labor at term undergoing trial of scar were monitored for progress of labor and observed for vaginal bleeding, scar tenderness, maternal pulse and blood pressure every 30 minutes. Scar tenderness was elicited by pressing below and behind the pubic symphysis in between uterine contractions while engaging the woman in conversation and noting for a visible wince. Fetal heart rate auscultation was done as per protocol. Trial of scar was terminated for scar tenderness, unexplained maternal tachycardia, fresh vaginal bleeding, fetal heart rate abnormalities and non-progress of labor.Results: The sensitivity and specificity of scar tenderness as a predictor of scar complications was 92.3% and 3.8%, while accuracy was 33.3%. The likelihood ratio of a positive sign of scar tenderness being associated with scar complications in labour is 1.48. Maternal tachycardia was not a significant predictor of scar complications in labour (p value=0.2). Past history of D&E has relative risk of 2.85 for scar complications.Conclusions: Scar tenderness is a sensitive sign of scar complications and should continue to be elicited for all women undergoing trial of labor after previous caesarean

Correlation of lipid profile of infertile men with abnormal semen parameters

Background: Male’s inability to impregnate a fertile female is referred as male factor infertility. It accounts for 40-50% of infertile couples and affects almost 7% of all men. Male comorbidities and conditions, which negatively affect men’s health, have been repeatedly associated with impaired reproductive functioning. Cholesterol is the main substrate for steroid synthesis and it plays crucial role in formation of sperm plasma membrane and thus in spermatogenesis, highlighting the role of serum lipids in male fecundity. Purpose of the study is to evaluate correlation lipid profile of male partners with abnormal semen parameters in infertile couples. Methods: A cross sectional study was carried out in the infertility clinic of a tertiary care hospital for over 18 months and 151 infertile men with abnormal semen parameters (as per WHO 2010 criteria) were enrolled. Evaluation of lipid profile was done and its relationship with abnormal semen parameters was analyzed. Results: Significant positive correlation was seen between LDL and Triglyceride with sperm concentration and total sperm count. However, significant negative correlation was seen between Triglyceride and sperm motility and TMSC. Total and progressive motility was found to be significantly associated with total cholesterol (p<0.05). Infertile men having higher total cholesterol were found to have better total and progressive motility compared to men with less total cholesterol. Conclusions: Our findings demonstrated that lipid profile has significant correlation with semen parameters, specifically sperm concentration, count and motility

A rare case of paraneoplastic neurological syndrome with ovarian teratoma

Paraneoplastic neurological syndrome (PNS) is a neuropathological disorder of central nervous system, in this the patient presents with a tumor anywhere in the body with diverse neuropsychiatric symptoms. The clinical manifestation of the tumor may be preceded by PNS. We are reporting a case of a 23-year-old married nulliparous female who came to the gynaecology outpatient department (OPD) with the history of mass per abdomen for the past four months and also undergoing treatment for acute psychosis, memory loss and cognitive impairment for the past five months. Her symptoms were not relieved on treatment. After clinical, laboratory and radiological evaluation possibility of paraneoplastic neurological syndrome associated with ovarian teratoma was made. Patient was taken up for staging laparotomy with U/L salpingoophrectomy. After surgical treatment her psychiatric symptoms rapidly improved and her psychiatric medications doses was reduced. PNS should be suspected in female patients presenting with an acute history of neuropsychiatric symptoms. Tumor resection should be performed at the earliest to improve patient outcomes

Urinary bladder agenesis with bilateral single system vaginal ectopic ureters in adult

Agenesis of urinary bladder is an extremely rare condition with only 60 cases and 22 live births being reported previously. Ureteric ectopia is a must for survival. We present a unique case of bladder agenesis detected in adulthood where bilateral single system ureters were draining ectopically in a grossly dilated vagina in normally developed female genital tract