Factors and outcome analysis of emergency peripartum hysterectomy in a tertiary care center catering to hilly terrain for a five-year period: a retrospective study

Background: Emergency peripartum hysterectomy (EPH) is a life-saving surgery associated with significant morbidity and mortality. In the state of Uttarakhand, due to the hilly terrain and poor ante-natal awareness, type 1 and 2 delay is expected in seeking health care. Thus, the present study was conducted in a tertiary care hospital to evaluate the incidence, risk factors, indications, and outcomes of EPH.Methods: Medical records of 63 patients who underwent EPH from January 2015 to December 2019 were retrospectively analyzed for the patient characteristics, high risk factors, indications and type of hysterectomy and outcome.Results: The incidence of EPH at our institute was 2.78 per 1000 deliveries. Most patients (89.89%) were referred cases. There were 4 home deliveries and 4 patients referred for obstructed labour.  The average parity was 2.71±1.13. Thirty-four patients (53.97%) presented in the emergency department in shock. The leading indication was uterine atony (46.03%) followed by rupture uterus (26.98%) and placenta accreta spectrum (23.81%). All patients needed blood transfusion. Intensive care unit admission was required in 88.89%. The maternal mortality was 15.87%.  All the three levels delays contributing to poor outcome were identified. Conclusions: Uterine atony and rupture of non-scarred uterus due to obstructed labour were the prominent indications of EPH. Strengthening of referral system and timely referral of high-risk patients to a setup with facilities for management of high risk obstetric cases can play an important role in decreasing the incidence and morbidity and mortality of EPH

Urogenital myiasis – An atypical presentation

The infestation of the human body by maggots has been reported worldwide and occurs most commonly in people of lower socioeconomic status and poor personal hygiene. Urogenital is the rarest site of myiasis presentations. Here we report the case of a 20-year-old, sexually inactive female student who presented with a necrotic growth in the paraurethral region infested with numerous maggots. The lesion involved the urethra and the bladder base. She was treated with debridement and bladder irrigation. The cystoscopy and local examination performed 2 weeks after admission, confirmed the complete healing of the urogenital lesion. Managing this patient’s unique challenge was to assess the extent of the involvement and removal of all maggots from the deepest wound portion. The female internal and external urogenital myiasis is a very occasional and under-reported health hazard. Reporting such cases increases the public and physician awareness about the mode of presentation, right diagnosis, and available treatment options

Evaluation of risk of malignancy index as a diagnostic tool in cases with adnexal mass

Background: Ovarian tumour usually presents as adnexal mass but often it is difficult to differentiate between benign and malignant tumour. Several diagnostic modalities such as sonography and tumours markers have been evaluated in the past, but none have been established as an ultimate diagnostic tool individually. The development of a mathematical formula using a logistic model, incorporating menopausal status, the serum level of a glycoprotein called CA-125 and USG score has been described in the form of different malignancy indices. The purpose of this study was to evaluate the various risks of malignancy indices (RMI 1, 2, 3, and 4) in the pre-operative evaluation of adnexal masses especially to differentiate between benign and malignant masses. Another objective of the present study was to compare the four RMI with each other in terms of various statistical parameters like specificity and sensitivity.Methods: Women with adnexal masses who underwent surgical treatment were included in this study as histopathological examination was taken as gold standard to calculate the accuracy of RMI. The sensitivity, specificity and positive predictive value and negative predictive value of all the four RMI were calculated and data analyzed.Results: A total of 65 patients were included in the study. RMI 1,2,3,4 was calculated according to their formula. Sensitivity of RMI- 1, 2, 3 and 4 was calculated to be 63.63%, 77.27%, 63.63% and 77.27% respectively. Specificity of RMI- 1, 2, 3 and 4 was calculated to be 69.04%, 64.28%, 64.28% and 62.79% respectively.Conclusions: Risk of malignancy index is a good diagnostic tool to differentiate between benign and malignant pelvic masses. RMI- 2 and RMI-4 had maximum sensitivity while RMI-1 had maximum specificity. Overall RMI-2 appears to be the most accurate of all the four RMI

Conservative management of Cesarean Scar Ectopic Pregnancy

Caesarean scar pregnancy (CSP) refers to a gestational sac that has implanted in the scar of a previous caesarean delivery due to incomplete healing of the caesarean scar, as may be seen in CSP occurring few months of caesarean delivery. It is the rarest kind of ectopic pregnancy which is usually misdiagnosed leading to life threatening complications, like rupture with haemorrhage and hemodynamic collapse. Therefore, a high index of suspicion is required to diagnose CSP. Here, we present two case reports of CSP presenting at 6 and 7 months after cesarean delivery, respectively. The first one presented to us as a case of incomplete abortion following medical abortion, and the second patient was referred to us as a case of cervical pregnancy. A decrease in the primary caesarean rate and prolongation of the inter-pregnancy interval is essential to avoid CSP

Ectopic pregnancy in a case of congenital mullerian anomaly: a diagnostic dilemma

Ectopic or extrauterine pregnancy occurring in a case with mullerian defect is very rare and poses diagnostic challenges. Undescended and non-communicating fallopian tubes are extremely rare mullerian anomalies. Here authors present a case of ectopic pregnancy occurring in an undescended non-communicating fallopian tube in a patient with unicornuate uterus with absent horn, which was managed laparoscopically. A 32-year-old lady, diagnosed case of left unicornuate uterus with absent right horn, was referred to us with the suspicion of ruptured ectopic pregnancy. The abdominopelvic ultrasound showed a soft tissue lesion of size 32×24 mm, towards the right lateral pelvic wall near the iliac vessels, with increased vascularity on colour flow doppler.  The patient underwent laparoscopy which showed left sided unicornuate uterus with normal left tube and ovary. The right uterine horn was absent.  An undescended right ovary and tube were found attached to the peritoneum at the level of pelvic brim along the right lateral pelvic wall.  Right sided tubal ectopic pregnancy with rupture was present along with 300-350 cc of hemoperitoneum. The patient was treated with laparoscopic right sided total salpingectomy. In patients with unicornuate uterus and atypical presentation, ectopic pregnancy should be ruled out in an undescended non-communicating fallopian tube. Salpingectomy of incidentally diagnosed non-communicating fallopian tubes is recommended to prevent future ectopic pregnancy

Evaluation of risk of malignancy index as a diagnostic tool in cases with adnexal mass

Background: Ovarian tumour usually presents as adnexal mass but often it is difficult to differentiate between benign and malignant tumour. Several diagnostic modalities such as sonography and tumours markers have been evaluated in the past, but none have been established as an ultimate diagnostic tool individually. The development of a mathematical formula using a logistic model, incorporating menopausal status, the serum level of a glycoprotein called CA-125 and USG score has been described in the form of different malignancy indices. The purpose of this study was to evaluate the various risks of malignancy indices (RMI 1, 2, 3, and 4) in the pre-operative evaluation of adnexal masses especially to differentiate between benign and malignant masses. Another objective of the present study was to compare the four RMI with each other in terms of various statistical parameters like specificity and sensitivity.Methods: Women with adnexal masses who underwent surgical treatment were included in this study as histopathological examination was taken as gold standard to calculate the accuracy of RMI. The sensitivity, specificity and positive predictive value and negative predictive value of all the four RMI were calculated and data analyzed.Results: A total of 65 patients were included in the study. RMI 1,2,3,4 was calculated according to their formula. Sensitivity of RMI- 1, 2, 3 and 4 was calculated to be 63.63%, 77.27%, 63.63% and 77.27% respectively. Specificity of RMI- 1, 2, 3 and 4 was calculated to be 69.04%, 64.28%, 64.28% and 62.79% respectively.Conclusions: Risk of malignancy index is a good diagnostic tool to differentiate between benign and malignant pelvic masses. RMI- 2 and RMI-4 had maximum sensitivity while RMI-1 had maximum specificity. Overall RMI-2 appears to be the most accurate of all the four RMI