Parulekar SV
Valvi
D, Parulekar SV.
Parulekar SV
Editorial
Parulekar SV
Editor-in-chief
We are happy to present the March 2014 issue of the journal.
In this issue we have eight unusual case reports - an even mix of obstetrics, gynecology,
oncology, and imaging. Mullerian anomalies continue to make their mark at our
center, and there are three of them in this issue. There is an unusual
Mullerian anomaly of complete uterine septum, with duplicated cervix and
longitudinal vaginal septum in a patient who presented with primary
infertility. There is another one with a large leiomyoma in one horn of a
bicornuate uterus. There is also a new operative technique for excision of a
hemihematometra. With early antenatal registration and good antenatal care,
obstetric mishaps have become rare. But a few patients do continue to present
with complications like obstructed labor and uterine rupture. There is a case
of insuperable pelvic obstruction due to a giant fecolith, and another one of
spontaneous rupture in a primigravida, which was followed by a rupture in the
next pregnancy. There are two other interesting cases - one is of a term gravid
uterus in a complicated ventral hernia and the other of an endometrial stromal
sarcoma. There is also a first of its kind - removal of a broad ligament lipoma
vaginally during a vaginal hysterectomy. I hope the articles prove useful and
enjoyable to our readers.
Leiomyoma in a Bicornuate Uterus
Author
information
Valvi
Durga*, Parulekar SV**
(*Assistant Professor,
** Professor and Head. Department of Obstetrics
and Gynecology, Seth G.S. Medical College and K.E.M Hospital,
Mumbai, India.)
Abstract
A 36 years unmarried female
was presented with distension and chronic pain in abdomen which was more acute during menses. CT scan showed left sided
broad ligament fibroid with right fused ectopic kidney, absent left kidney and
both ureters on the same side. On exploration there was evidence of bicornuate
uterus with fibroid in the left horn.
Removal of left horn of bicornuate uterus was done.
Introduction
Abnormalities in the formation or fusion of the mullerian
duct results in a variety of anomalies of the uterus and vagina. Mullerian
anomalies are commonly associated with renal, spinal, cloacal anomalies.[1]
There is particular association of
unilateral renal agenesis or ectopia, uterine duplication or unicornis, and
vaginal agenesis.[2] The incidence of mullerian duct anomalies
ranges from 0.5 to 5%. Bicornuate uterus results from incomplete fusion of
uterovaginal horns at the level of the fundus and are thought to represent 25%
( range 10-39% ) of mullerian duct anomalies.[5,6] According to
American Fertility Society, bicornuate uterus is class 4 mullerian anomaly.[2]
The renal anomalies are always ipsilateral to rudimentary horn. Cytogenetic
abnormalities in the form of spontaneous chromosomal rearrangements are known
to occur in uterine leiomyomas. These chromosomal arrangements may be
responsible for the initiation and progressive growth of the leiomyomas.[3]
The possible reason for this uncommon occurrence could be a decreased
concentration or sensitivity of the estrogen receptors or a lesser genetic
predisposition for the clonal chromosomal abnormalities that are observed in
women with normal uterus with leiomyomas.[3] Hysterosalpingography,
hysteroscopy, laparoscopy, pelvic ultrasonography (USG) using the convex
abdominal and transvaginal probes, computerized tomography and magnetic
resonance imaging of the pelvic organs are increasingly being used as
diagnostic modalities. MRI is the standard method for imaging uterine
anomalies. It provides high-resolution images of the uterine body, fundus, and
internal structure. In addition, it can help evaluate the urinary tract for
concomitant anomalies.[4]
Case Report
A 36 years unmarried was
woman presented with distension and pain in abdomen for 7-8 months. It was
continuous, mild, in both lumbar region and iliac fossae, aggravated during
menses. Her menses were regular. She had a history of kyphoscoliosis and right
hip arthropathy. On examination she had a normal female body contour and normal
secondary sexual characteristics. General and systemic examination showed no abnormality.
On abdominal examination there was a nontender, and relatively fixed lump of
the size of approximately 24 weeks of gestation. External genitalia were
normal. Speculum vaginal examination showed no abnormality. Bimanual pelvic
examination showed the cervix to be continuous with the abdominal mass. Her
hemogram, blood sugar levels, renal and liver function tests were normal. CT scan report was suggestive of left sided
broad ligament leiomyoma, right ectopic fused kidney, and both ureter on the right
side. Both ureters were catheterized prior to an exploratory laparotomy, so as
to localize and safeguard them during surgery. The ureters were found to be on
the right side that of the malrotated kidney crossing over the normal one as
shown in figure 1.
Figure 1. Plain
radiograph of the abdomen and pelvis, anteroposterior view. Two ureters are
seen on the right side, the lower ureter belonging to the malrotated left
kidney crossing the right ureter from lateral to medial side.
A bicornuate uterus with
a leiomyoma in the left horn was found during laparotomy (figure 2). The
leiomyoma measured about 18 cm in diameter and was wedged in the pelvis.
However it could be lifted out of the pelvis. Left hemi-hysterectomy was done.
A myomectomy was not performed because the right horn was well developed, and
was more likely to carry a pregnancy to term or near term than a reconstructed
but scarred left horn. The ureteric
catheters were removed after the operation.
She made an uneventful recovery. Histopathological examination showed leiomyoma
with myxoid degeneration.
Figure 2. Leiomyoma in
the left horn of a bicornuate uterus.
Discussion
There are few cases of
leiomyoma in mullerian anomalies reported in the literature. Most of theses
presented with increasing dysmenorrhea, unilateral mass, and pain in abdomen,
as did our patient. Usually the diagnosis is not made clinically, because of
its low incidence. Cases of leiomyoma in bicornuate uterus has been reported
previously.[7,8] Occurrence
of a leiomyoma in mullerian anomalies is rare, the possible reason for this
uncommon occurrence could be a decreased concentration or sensitivity of the
estrogen receptors or a lesser genetic predisposition for the clonal
chromosomal abnormalities that are observed in women with normal uterus with
leiomyomas.[3] If the degree of separation of the two horns is
large, the leiomyoma can be relatively mobile. When mobile, the leiomyoma is
mistaken for a subserous pedunculated leiomyoma, and when fixed, a broad
ligament leiomyoma. If the horns are not widely separated, a leiomyoma in one
of the horns may be mistaken for one in the lateral wall of a normal uterus. If
it is lower in position in such a situation, it may be mistaken for a broad
ligament leiomyoma. If it is in one of two widely separated horns of a
bicornuate uterus, but is very large, it may be impacted in the pelvis and may
be mistaken for a broad ligament leiomyoma. In the case described, the leiomyoma
was of this last type. It may be missed on USG, but is usually diagnosed on CT
or MRI. The diagnosis was missed in our patient on USG, because the endometrial
cavity of the affected horn was not visualized. It was missed even on CT scan.
It is important to make the diagnosis of mullerian anomalies accurately in view
of the high risk of associated anomalies like spinal, renal and cloacal
anomalies.[1] However it is not practical to perform a CT or MRI in
every case of leiomyomas, because that would not be cost effective as a large
number of such scans would have to be performed in order to pick up one case.
Furthermore, a laparotomy would be required irrespective of the diagnosis, and
surgical approach to the removal of the leiomyoma could be decided based on the
findings without any deficiency in the results. Hence we do not recommend CT or
MRI for patients with uterine leiomyomas. Leiomyoma usually undergo hyaline
degeneration but our patient had myxoid degeneration.
References
1.
John A Rock,Howard W Johns,et al. Telinde of
operative gynaecology, Mullerian abnormalities,vol 12, 2010; 540-544.
2.
Jaya Singhe Y, Rane A, Stalewki H, et al. The Presentation
and Early Diagnosis of the Rudimentary Uterine Horn. Obstet Gynecol June 1,
2005; 105(6) : 1456-1467.
3.
Rein MS, Friedman
AJ, Barbieri RL et al. Cytogenetic abnormalities in uterine leiomyomata. Obstet Gynecol 199; 77:923-6.
4.
Ibrahim Syed, Hero K Hussain, et al. Imaging in
mullerian duct abnormalities. Mar 8,2013.
5.
Troiano RN, Mccarthy SM. Mullerian duct
anomalies: imaging and clinical issues. Radiology. 2004; 233 (1):19-34.
6.
Nahum GG. Uterine anomalies. How common are
they, and what is their distribution among subtypes? J Reprod Med. 1998;43
(10): 877-87.
7. Ly JQ. Rare bicornuate uterus with fibroid
tumours: Hysterosalpingography- MR imaging correlation. Am. J. Roentgenol,
2002; 179:537-8.
8. O Ayoola, O Alao,
B Ibitoye, S Ma’aji. Bicornuate Uterus With Associated Bilateral Tubal Blockage
And Fibroid Tumors: A Rare Combination Causing Infertility. The Internal
Journal of Radiology. 2006; Vol 6; Number 1.
Citation
Valvi D, Parulekar SV. Leiomyoma in a Bicornuate Uterus. JPGO Volume 1 Issue 3,
March 2014, available at: http://www.jpgo.org/2014/03/leiomyoma-in-bicornuate-uterus.html
Obstructed Labour Due to a Giant Fecolith
Author information
Yadav Pramila*, Warke HS**, Gupta
AS***
(* Fourth Year Resident,
**Associate Professor, *** Professor)
Abstract
Obstructed
labour due to a fecolith in the rectum and colon is very rare. Fecoliths cause
many complications in pregnancy like dystocia, rupture uterus and
malpresentation. It may also compress the bowel and cause bowel perforation. We
are presenting a case of obstructed labour and malpresentation caused by a huge
fecolith.
Introduction
Fecolith
is fecal impaction in the rectum and colon. It causes significant patient
morbidity.[1] Patient commonly complaints of constipation.
It is
frequently secondary to poor bowel or dietary habits.[2] Bladder
stone and rectal fecoliths have been implicated as cause of soft tissue
dystocia.[3,4]
Case
report
A 22 years
old married woman, G4P3L1 IUFD2 with 26.5/7 weeks with IUFD with previous LSCS was referred to our hospital with
complaints of leaking per vaginum and decreased fetal movements since 12 hours.
She had not passed stool since 5-6 days. There was no history of bleeding per vaginum or pain in
abdomen. On presentation her general and systemic examination were normal.
Abdominal examination revealed a pfannensteil scar of previous LSCS, uterus was
26 weeks in size, deviated to right side, subserosal fibroid measuring 3x4 cm
was felt in the suprapubic region and FHS was absent. Vaginal speculum could
not be introduced due to a mass impacted in the vagina. On vaginal (PV)
examination a 10x9 cm mass impacted in the vagina was felt. Cervix could not be
felt. Provisional diagnosis of a 26 weeks pregnancy with IUFD with a large
cervical fibroid or rectal mass was made.
On
ultrasonography (USG) a dead fetus in transverse lie with extensive flexion of
its body with spalding sign was seen. There was no free fluid in abdominal
cavity and uterine rupture was ruled out. Uterine part of cervix could not be
assessed on ultrasonography. CT scan was done. It showed a grossly distended
rectum,
descending and transeverse colon. Rectum and sigmoid colon were extensively
loaded with faeces which appeared to be compressing the lower part of the
uterus, cervix and vagina.
Figure 1
CT Image in Transverse Section. Showing the bladder stone (B.S.), fetal skeleton (F.S.) and fecolith (FL)
Figure 2
CT Image in Longitudinal Section: Showing the dilated bowel loops (D.B.L.), rectum (R), fetal head (F.H.) and fecolith (FL)
A 4.7 x
3.1 cm sized calculus was noted in the urinary bladder. Right kidney was 12.3 x
5.7cm and left kidney was 5.6 x 3.2 cm. There was bilateral hydronephrosis and
hydroureter.
Final
diagnosis on CT scan was IUFD with transverse lie, fecal impaction, urinary bladder
calculus, bilateral hydronephrosis and hydroureter .
Her Hb was
11.1gm%, WBC, platelet counts and DIC profile were
within normal limits. Enema
was given. There was incomplete evacuation of the bowel. Cervical
Os could now be reached with difficulty. On PV she was 2-3cm dilated,
60% effaced, station was high up, pelvis was adequate and an
indentable fecolith
was felt through the posterior vaginal wall.
We watched
for progress of labour. After 4 hours she developed signs of obstructed labour
with scar tenderness and impacted shoulder with hand prolapse.
Patient
was taken for emergency hysterotomy and anal dilation with manual removal of the
fecolith with suprapubic
cystolithotomy. A multidisciplinary team approach involving gynaecologist,
surgeons, and anesthesiologists was undertaken.
Abdomen was opened through an infra-umbilical midline incision. Intraoperatively bladder
was advanced and distended with a calculus of
5x4cm size. Sigmoid and transverse colon were loaded and
markedly distended with
stools. Lower uterine segment was thinned out. Female baby of
780 g was
delivered by breech extraction. Liquor was scanty and placenta
was foul
smelling. The uterus was sutured in a single layer.
Lithotomy
position was given and surgeons noted a fissure in ano at 7
o’clock position, stricture 2-3cm from anal verge and grossly dilated sigmoid
colon loaded with hard stools. Anal dilatation and manual removal of feces was
done. Colon was milked from descending colon up to rectum and feces were
evacuated
till colon completely collapsed. Bowel was inspected and there was
no evidence of any stricture, serosal tear or perforation.
The vesical
calculus of 5x4 cm was removed by a cystotomy. Midline suprapubic
catheter was placed and bladder was closed in two layers. Abdomen
was closed in layers. One
unit blood transfusion was given. Postoperatively patient was given
antibiotics, analgesics. Postoperative course was uneventful. Suprapubic
catheter was removed after three weeks.
Discussion
Prolonged
stasis of fecal matter causes impaction and a giant fecolith
forms. This
obstructs the colon necessitating surgery.
[1] Direct abdominal x-rays, ultrasosnography and CT
scans are the imaging modalities to diagnose intestinal obstruction
caused by fecal impaction. Emergent surgical intervention
and removal of fecolith is life saving.[5] Urolith causing
dystocia requires caesarean section with cystolithotomy .[3] In this case, fecolith
caused the malpresentation (transverse lie) and obstructed labor.
As the
urolith was not in the pelvis but suprapubically it did not
contribute to the obstructed labor. A timely emergency hysterotomy
with anal dilation, manual removal of feces, milking of descending,
sigmoid
colon and suprapubic cystolithotomy prevented a neglected
obstructed labor and its consequences.[1,2,3,4,5] In this case the
giant fecolith
leading to obstructed labour was not diagnosed by the
referral secondary care center. It was erroneously diagnosed as a large posterior
cervical fibroid. In
cases with obstructed labour with a mass felt per vaginum, large fecoliths
should be considered in the differential diagnosis. Multidisciplinary team
approach is essential for management of such cases.
Acknowledgements
We
acknowledge Mantri Nilima, Tiruke Raviraj and Chaturvedi Pritali for performing
emergency hysterotomy; Jadhav Sudhir and Patel Maitri for removal of fecolith;
and Gajingi Ajay and Sharma Anand for performing suprapubic cystolithotomy on
this patient
References
1.
Farshid AM.
Fecal Impaction. Clinics in colon and rectal surgery.
2005;18(2):116-119.
2.
Colapinto MN,
Vowinckel EAM, Colapinto ND.
Complete Currarino syndrome in an adult, presenting as a fecolith obstruction:
report of a case. Can J Surg. 2003 Aug; 46(4):303-306.
3.
Ait Benkaddour Y, Aboulfalah A, Abbassi H. Bladder stone:
uncommon cause of mechanical dystocia. Gynecol Obstet. 2006 Aug; 274(5): 323-4.
4.
Holt WA,
Hendricks CH.
Dysfunctional labour due to fecal impation: report of a case. Gynecol
Obstet. 1969; 68: 502-504.
5.
Atahan
K, Cokmez A, Durak E, Gur S,
Tarcan E. Colonic Obstruction
Secondary to Giant Fecolith. J Colon Rectum disease. 2010; 20: 84-86.
Citation
Yadav P, Warke HS, Gupta AS. Obstructed labour due to a Giant
fecolith. JPGO Volume 1 Issue 3, March 2014, available at:http://www.jpgo.org/2014/03/obstructed-labour-due-to-giant-fecolith.html
Epulis of Pregnancy
Author
Information
Ranjana Desai*, Nalini Jangid**, Rashmi
Sharma***, Kiran Mirdha****
(*Professor, **3rd year P.G. Resident, Department
of Obstetrics and Gynaecology; ***Assistant Professor, Department of Pathology;
****Medical Officer, Department of Obstetrics and Gynaecology; Dr. Sampoornanand
Medical College, Jodhpur)
Abstract
Epulis
of pregnancy is a benign growth of the gingiva with a rare occurrence during
pregnancy. This is a report of a case of epulis during pregnancy which showed
spontaneous regression after delivery.
Introduction
Epulis
fissuratum or Granuloma fissuratum is an oral pathologic hyperplastic condition
that appears in the mouth as an overgrowth of fibrous connective tissue mainly
from gingivial tissues.[1] When it is associated with the edges of
an ill fitting denture it is referred to as Inflammatory fibrous hyperplasia, Denture
epulis or Denture induced fibrous hyperplasia. Epulis in a patient without
dentures can also be diagnostic of Crohn's disease.[2]
Its occurrence in a pregnant woman is termed
Epulis of Pregnancy or Granuloma gravidarum. Since it is rare during pregnancy
and because its prevalence in pregnancy has not been well documented, the
present case merits attention.
Case Report
A 24 year old third gravida with two full
term normal deliveries presented to our antenatal clinic with amenorrhea of 7
months duration. While taking her history it was noted that she had an
irregular fleshy growth over her teeth. On everting her upper lip and examining
the gums of the upper jaw, a 2 centimeters long irregular fleshy mass was
detected arising from the gums and growing over and between her incisor teeth (figure
1). On examining the oral cavity the lesion extended 3 centimeters posteriorly
on the soft palate (figure 2). The lesion was firm to touch, non-tender.
History revealed that the growth had slowly evolved from a small size to the
present one over a period of 2 months. The lesion was asymptomatic and the
patient refused a biopsy. A clinical diagnosis of epulis of pregnancy was made.
No surgical intervention was advised and only oral hygiene in the form of mouth
wash with a commercially available over-the-counter mouth wash consisting of an aqueous solution
containing bezoic acid, poloxamer 407, eucalyptol, thymol, sodium benzoate, and
menthol mixed in alcohol twice a day and regular brushing of teeth twice daily
was recommended. One month after delivery the mass had spontaneously regressed
to half its size. And two months after delivery the lesion was one fourth its
former size. After this the patient was lost to follow up.
Figure
1 : Anterior view of the epulis. Note the irregular fleshy growth emerging from
between the incisors.
Figure
2 : Buccal view of the epulis. Note the dumbbell shape of the tumor displacing
the incisors.
Discussion
Epulis
of pregnancy (synonyms: pregnancy tumor, granulaoma gravidarum, pyogenic
Granuloma) is described as a gingival lesion that looks like a small, dome
shaped hemangioma, often with a peripheral collarette of scales. The excess
tissue is firm and fibrous; ulcerations may be present. It is usually
pedunculated but may be sessile. It appears in gums around the alveolar
vestibule, in either the mandible or maxilla (upper jaw) but is more commonly
found in the frontal part of the maxilla during the third trimester. Often it
has been referred to as pyogenic granulaoma in medical literature but the term
is a misnomer, for this is not an infectious or pustular process.
The
lesion is usually asymptomatic but appears cosmetically unsightly. It may
interfere with mastication, closure of the oral cavity, brushing or flossing. The
teeth adjacent to the epulis may loosen due to the pressure effect or may show
migration.[3] Sometimes there may be recurrent bleeding from the
lesion resulting in life threatening hemorrhage requiring blood transfusion.[4]
Etiologic
factors responsible for epulis of pregnancy are improper maintenance of oral
hygiene which leads to chronic gingivitis and the influence of hormones by a
complex and partly understood mechanism on the gingival vasculature.[5,6]
Epulis
has several histologic types. Granulomatous type is the prevalent type during
pregnancy. It presents an inflammatory component characterized by lymphocytes, plasma
cells and neutrophiles, an abundant vascular component with newly formed
capillaries and a great proliferation of fibroblasts.[7]
The
lesion usually resolves partially or completely post partum within 1 to 4 months[3]
as it did in this case reported. Persistent lesion requires treatment by
firstly removal of irritating factors and secondly surgical excision of the
lesion, curettage, chemical or electric cauterization, cryo therapy or laser
ablation.[5]
References
1. Niville BW, Damm DD, Allen CM, Bouqout JE. Oral and maxillofacial Pathology,
2nd edition, Philadelphia, W B saunders, 2002, 437- 495.
2. Budtz-Jorgensen E. Oral mucosal lesions associated with wearing of
removable dentures. J oral pathol 1981;10:65-80.
3. Orosz M, Szende B, Gábris K. The clinical and pathological symptoms of
pregnancy epulis. Fogorv Sz. 2007 Oct; 100(5):237-41, 233-6.
4. Adeyemo WL, Ladeinde AL, Ajayi OF, Umeizudike K, et al. Pregnancy
epulis associated with life threatening haemorrhage in a Nigerian woman. Nig Q
J Hosp Med. 2010 Jan-Mar; 20(1):10-2.
5. Saravanum T, Shakila KR, Shanthini K. Pregnancy Epulis, Ind J of Multidiscp Dentistry. 2012;2(3):514-17.
6. Rabinerson D, Kaplan B, Dicker D, Dekel A. Epulis during pregnancy. Harefuah. 2002 Sep;
141(9):824-6.
7. Tumini V, Di Placido G,
D'Archivio D, et al. Hyperplastic
gingival lesions in pregnancy. I. Epidemiology, pathology and clinical aspects.
Minerva Stomatol. 1998 Apr; 47(4):159-67.
Citation
Desai R, Jangid N, Sharma R, Mirdha K. Epulis of Pregnancy. JPGO Volume 1 Issue 3, March 2014, available at: http://www.jpgo.org/2014/03/epulis-of-pregnancy.html
Broad Ligament Lipoma
Author Information
Parulekar SV.
(Professor and head of Department of Obstetrics and
Gynecology, Seth GS Medical College and KEM
Hospital, Mumbai, India.)
Abstract
Broad ligament lipoma is a very rare tumor. There are only
11 cases reported in the English world literature.[1,2,3,4,5] This is the first
case reported in which the lipoma was removed vaginally.
Introduction
Primary retroperitoneal tumors account for 0.2% of all
neoplasms, of which about 80% are malignant neoplasms.[6] Retroperitoneal
benign lipomas are extremely rare, being 2.9% of all primary retroperitoneal
tumors.[7] We present a case of a broad ligament lipoma diagnosed and removed
during vaginal hysterectomy.
Case Report
A 58 year old postmenopausal woman presented with complaint
of something coming out per vaginum for 6 months. She was found to have a third
degree uterine prolapse, moderate cystocele and moderate rectocele. The uterus
was small and the fornices were free. She was subjected to vaginal hysterectomy
and repair of vaginal wall prolapse. During the operation, the right borad
ligament was found to be bulging out after the uterosacral and uterine pedicles
were clamped, cut, and ligated. The cornual structures of both sides were
clamped, cut and ligated with No. 1 polyglactin, the clamp on the right side
being applied medial to the broad ligament mass. Then the two leaves of the
right broad ligament were separated. A well defined tumor measuring 7X4X3 cm
was found in it, having the appearance of a lipoma (figure 1). It was dissected
out of the broad ligament, taking care not to injure the ureter. There was no
active bleeding from the bed of the tumoe after its removal. The pelvic
peritoneal opening was closed with a purse-string suture of No. 1-0 polyglactin,
leaving the right broad ligament partially open towards the vagina. The angles
of the vagina were anchored to the pedicles of the uterosacral ligaments with
No. 1 polyglactin sutures. The vagina was closed with No. 1-0 polyglactin
sutures, leaving space for vaginal drainage of right broad ligament. The
patient had no vaginal bleeding postoperatively. She made an uneventful
recovery. Histopathological examination of the tumor showed it was lipoma.
Figure 1. Right broad ligament lipoma (L). The uterine corpus
(Ut), cervix (Cx), and right ovary (black arrow) are shown.
Figure 2. The broad ligament has been opened and the lipoma
is seen being enucleated out.
Figure 3. The lipoma.
Figure 4. The uterine corpus (Ut), cervix (Cx), and right
broad ligament (black arrow) are shown after removal of the lipoma.
Discussion
Pelvic lipomas are exceedingly rare. They can arise from the
iliac vessels and paravaginal tissues.[8] A lipoma is a soft tumor, and it may
be missed clinically in broad ligament location when it is small to medium in
size. In the case presented, it was not palpable on bimanual examination. No
imaging of the pelvis was done because no indication was perceived. Otherwise
the tumor can be diagnosed by ultrasonography, computed tomography (CT), or
magnetic resonance imaging (MRI). As there are no significant optical
differences between a lipoma and a well-differentiated liposarcoma on CT or
MRI, observed prior to surgery between lipomas and well-differentiated
liposarcomas, one has to be prepared to deal with the latter when undertaking
removal of a lipoma in this location. If the tumor is coincidentally diagnosed
at the time of a laparotomy or a vaginal hysterectomy for a different
indication, prior awareness of the possibility of a sarcomatous nature should
help in better surgical management of the tumor. Vaginal dissection of the lipoma can be
difficult, and should be undertaken only if the tumor is diagnosed during a
vaginal hysterectomy, and that too in presence of pelvic tissue relaxation, as
in this case. Otherwise it is a lot safer to abandon the vaginal approach and
remove the tumor abdominally by the extraperitoneal route. The ureter has to be
isolated prior to any dissection and safeguarded during the dissection. As
these lipomas are known to recur and undergo malignant transformation, these
patients require a close follow-up.
Acknowledgement
I thank Dr Anil Mirchandani for the operative photographs.
References
1.
Eltabbakh GH. Broad ligament lipoma
presenting as a pelvic mass: a case report. J Reprod Med. 2007 Jun;52(6):543-4.
2.
Cantin PFR. Lipoma of the Broad Ligament
Br Med J 1959;1:1242.
3.
Pai MR, Naik R, Raughuveer CV. Primary retroperitoneal tumors: a
25 year study. Indian J Med Sci 1995;49:139-41.
4.
Gardner GH, Greene RR, Peckham B. Tumors
of the broad ligament. Am J Obstet Gynecol 1957;73:536-8.
5.
Hull WB, Blumenfeld ML, Jacques D. Large
paravaginal pelvic lipoma: A case report. J Reprod Med 1999;44:636-8.
6.
Armstrong JR, Cohen I. Primary malignant
retroperitoneal tumors. Am J Surg 1965; 110:937-43.
7.
Pai MR, Naik R, Raughuveer CV. Primary retroperitoneal tumors: a
25 year study. Indian J Med Sci 1995;49:139-41.
8.
Genadry R, Parmley T, Woodruff JD. The
origin and clinical behavior of parovarian tumor. Am J Obstet Gynecol
1977;129:873-6.
Citation
Parulekar SV. Broad Ligament Lipoma. JPGO Volume 1 Issue 3, March 2014, available at: http://www.jpgo.org/2014/03/broad-ligament-lipoma.html
Term Uterus in Complicated Ventral Hernia
Author Information
Nidhi Rathi*, Alka
Gupta**
(* Second Year
Resident, ** Professor; Department of Obstetrics and Gynecology, Seth G. S. Medical College & K.E.M. Hospital,
Mumbai, India.)
Abstract
Herniation of the gravid uterus in anterior wall abdominal
hernia is rare. About 15-20 cases have been reported so far. There is no
guideline to manage such cases. Management has to be individualized according
to the patient’s presentation. We report a case of incisional hernia containing
the gravid uterus with repeated excoriation of the overlying abdominal skin.
Introduction
Incisional hernia is an abdominal wall defect that occurs at
the site of previous surgical incision following breakdown in the continuity of
the fascia closure.[1] Incidence of incision hernia is about 11% in
abdominal laparotomies [2-3] and with wound infection incidence goes
up to 26%.[4] Gravid uterus though a rare content of the hernia sac
predisposes to serious complications like burst abdomen, preterm labor,
spontaneous abortion, accidental hemorrhage, intrauterine growth restriction,
dysfunctional labor, obstructed labor,uterine rupture and intrauterine fetal
death.[5-6] Initially these
hernias are reducible however as pregnancy advances or diagnosis is delayed the
gravid uterus is at a risk for incarceration and subsequent strangulation. [7,
8]
Case report
A 34-year-old second gravida para-1 (G2P1) presented at 24
weeks of gestation in emergency with omentum protruding through a thin shiny,
excoriated and discolored overlying skin on an anterior abdominal wall hernia.
She had a previous normal delivery 4 years back. On day 4 of that delivery she
developed sub acute intestinal obstruction due to ileo caecal tuberculosis
resulting in an ileal stricture. Exploratory laprotomy and ileo-ileal resection
anastomosis was done. Her post operative course was uneventful. She completed 9
months anti tubercular chemotherapy under direct observation. Six Months
following surgery she noted a swelling in her abdomen that would increase on
standing and decreases on lying down. She again consulted the surgeon for the
same and was diagnosed to have incisional hernia and was advised to continue
conservative management in form of abdominal binder and to undergo elective
mesh repair of the hernia after completion of her family. She conceived.
Examination revealed a midline vertical infraumbilical scar extending 3-4 cms
above umbilicus with a large hernial sac containing a 24-week-size gravid
uterus, which was drooping down up to her waist.
Figure 1 Gravid uterus in the incisional hernia
The fascial defect measured 15cm x 15 cm. Skin was
stretched, thin, shiny, discoloured with overlying ulceration and omentum
protruding through it.
Figure 2 Excoriation of the overlying skin. Arrow indicates
the site of the excoriation and the visible omentum
Figure 3 Excised prolapsed omentum
Figure 4 Sutures seen on the skin after surgical repair.
Uterus and the fetal parts were felt superficially. Uterus
was reducible. There was no evidence of strangulation. Surgeons evaluated her.
Ultrasonography (USG) of the abdomen was done. It showed a midline anterior
abdominal wall defect of size 10 cms suggestive of anterior abdominal wall
hernia with bowel, omentum and the gravid uterus as its content. All her blood
investigations were normal. Surgeons excised the prolapsed part of the omentum
and closed the skin defect under local anesthesia. The patient was discharged
next post operative day. She was advised to wear the abdominal binder regularly
and follow up weekly in the antenatal OPD. Again now at 33 weeks of gestation
the skin overlying the hernia underwent necrosis and through a defect of 7 mm
the omentum presented at the skin defect (Figure 2). Surgeons repeated the same
conservative surgical procedure. She is scheduled for elective cesarean section
with herniorraphy (mesh plasty) at 38 weeks of gestation.
Discussion
The usual contents of the abdominal wall hernia sac are
omentum and loops of small intestine. Herniation of gravid uterus through
abdominal wall is an uncommon but grave condition. Incarceration of the gravid
uterus with or without strangulation along with ulceration and excoriation of
the overlying skin and bleeding from the ulcerated area can lead to shock. [7,
8, 9] However, ulceration of overlying skin of the hernia sac without
incarceration or strangulation has also been reported. [10] Our case
presented similarly as her pregnancy advanced. Diagnosis of the above condition
is clinical and it can be confirmed on USG. In cases of doubt of strangulation
an MRI can be diagnostic. [10]
Management of incisional hernia in pregnancy in mainly
conservative, including manual reduction of hernia and use of abdominal binder
during antenatal period and labor. [1, 5, 9, 11] Elective cesarean
section is considered to be safest as the integrity of the weak anterior
abdominal wall and or the scarred uterus during vaginal birth is uncertain. [11]
Hernia repair can be done at the time of cesarean section or can be done at an
interval of 6-8 weeks. Post partum elective herniorrhaphy allows an optimal
repair as the overstretched abdominal wall skin can be fashioned to correct
dimension. Further the repaired abdominal wall is not subjected to mechanical
stresses of labor and there is no associated risk of wound disruption and
infections.[11] However, incarceration, burst abdomen or
strangulation will necessitate an immediate repair even in the antenatal
period. The pregnancy then grows to term. [12,13] Elective antenatal
hernia repair have been reported during
the 2nd and 3rd trimester of pregnancy with an outcome of
normal term vaginal delivery. [7,13]
However such approach is associated with significant risk of anesthesia
and surgical intervention during pregnancy. Moreover, the enlarged uterus
itself may hinder optimal herniorrhaphy, and further enlargement with advancing
gestation may disrupt the hernia repair. [6] In patients with very
large defect or in remote areas an alternative, intermediate method of
aggressive physiotherapy of abdominal wall muscles along with abdominal binder
can be offered.
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