Volume 1 Issue 11, November 2014


Gupta AS

Incidence of twins, triplets or multiple gestations has increased in present times due to the increased use of assisted reproductive technologies. However, the incidence of uniovular twining has remained unchanged. Plural pregnancies are high risk as the mother is at an increased risk of obstetric hemorrhages, preterm premature rupture of membranes, anemia, preeclampsia and operative interventions. Maternal factors increase the risk to the growth restricted and premature fetuses.  Permutation and combinations of abnormal presentations increases the chances of cesarean sections or intrauterine manipulations for the last fetus. Besides these common problems uniovular twins, either monochorionic diamniotic or monochorionic monoamniotic, face unique peril. In monoamniotic twins almost 70% twins will have chronic cord entanglement. Twin to twin transfusion (TTTS) and the other rare (incidence of about 1 in 100,000) but dramatic jeopardy is the conjoined twin.
Twin to twin transfusion syndrome occurs in about 15% of all monochorionic twins wherein the shared placenta has usually an arterial to venous communication. This is usually unidirectional. Rarely bidirectional arterial to arterial anastomoses may be present.  The artery to vein anastomosis results in discordant growth as the donor becomes anaemic, oliguric, growth retarded and may die in utero due to exsanguination and the recipient becomes macrososmic, polycythemic, polyuric leading to polyhydramnios, and may die due to circulatory overload. Death of one twin usually results in a better outcome for the survivor. Chorionicity and TTTS are best diagnosed by ultrasonography (USG) before 14 weeks of gestation. The presence of the Lambda sign or the “T” image at the interface between the amniotic membrane and the placenta differentiates the dichorionic placenta from the monochorionic placenta respectively. TTTS can be diagnosed by the presence of growth discordance, same gender of the fetuses and presence of oligohydramnios  (< 2 cm maximum vertical liquor pocket) in one amniotic sac and polyhydramnios (> 8 cm maximum vertical liquor pocket) in the other sac. Circulatory overload features may also be seen in severe cases of TTTS. The management of TTTS can be expectant or interceptive. Expectant management includes fortnightly serial USG for discordance in abdominal and head circumferences and amniotic fluid depth in each sac. Severity of the TTTS is assessed by Quintero’s criteria and fetal 2D echo. Severe TTTS requires either fetoscopic guided laser ablation of vascular anastomoses, septostomy and amnioreduction or umbilical cord clamping.  Umbilical cord clamping of one twin is done to deliberately save one of the twins when the survival chances for both twins are dismal.  Laser ablation of the anastomosis is the best treatment option for severe TTTS.
Conjoined twins are extremely rare. They should be prenatally diagnosed by the sonologist when a monochorionic, monoamniotic placenta is detected. Once diagnosed pregnancy may be terminated, or delivery should be planned by cesarean section to prevent dystocia, obstructed labor and catastrophic uterine rupture. Vaginal birth of undiagnosed conjoined twins has been reported not only in the past but also recently.
We bring one such case of conjoined twins in this issue and one case of TTTS. We hope our readers would gain experience from the cases presented in this November issue of our journal.

Conjoined Twin Delivered Vaginally

Author Information

Desai R, Goel S, Desai D.
(* Professor, ** Third Year Resident, *** Final Year MBBS Student, Department of Obstetrics and Gynaecology, Dr S.N. Medical College, Umed Hospital, Jodhpur, India.)


An extremely rare case of vaginal birth of term conjoined thoraco-omphalopagus twins diagnosed after delivery.


Conjoined twins are identical twins whose bodies are joined in utero.[1]  It’s a rare phenomenon with an incidence of 1 in 50,000-100,000 births. The incidence is somewhat higher incidence in Africa and Southwest Asia.[2] The overall survival rate for conjoined twins is approximately 25%[3] and the condition is more frequent among females,[2] with a ratio of 3:1. It is rare to see a conjoined twin reaching up to term. The present case merits attention because it is an unusual case of a patient who presented with an undiagnosed conjoined twin reaching full term and subsequently delivered vaginally.

Case Report

Figure 1. One twin has delivered up to the thorax.

Figure 2. Thoraco-omphalopagus 

A 28 years old gravida four and para three presented with amenorrhea of 9 months and labor pains since 6 hours. A traditional birth attendant (TBA), called dai in the vernacular in India, had tried to deliver the baby at home, but in spite of applying traction, had only succeeded in delivering the head and the patient was referred to our hospital for management. On presentation at our hospital, the baby’s head and both arms were found to have delivered (figure 1).
The patient’s vital parameters were normal but she was exhausted. Her per abdomen examination showed that her uterus was term sized with full bladder reaching up to umbilicus and absent fetal heart sounds suggesting fetal death. After catheterization and emptying the bladder, local examination revealed that the baby’s head was cyanosed and both arms were delivered and the umbilical cord without pulsation was entangled in right shoulder (figure 1). After lifting the head another fetal arm was seen. A vaginal examination was performed which showed the presence of a second conjoined fetus in the uterus. With all preparation for surgery, a gentle traction was given to the delivered fetal head with the hope to deliver the dead twins vaginally. The patient delivered the trunk and the limbs of the first twin, followed by the head, trunk and limbs of the second twin in that order. The twins were female. Figure 2 shows the still born female conjoined thoraco-omphalopagus twins weighing 5.2 kilograms with single placenta soon after normal vaginal delivery and catheterized patient with the umbilical cord still within the uterus in the background.


Thoraco-omphalopagus twins develop from a single ovum, when the embryo divides more than 13 days after fertilization, when the division is incomplete. The placenta tends to be monoamniotic monochorionic type.[6,7] Various types of conjoined twins are as shown in the following table, of which only 60% are born alive.[8,9]

Thoraco omphalopagus
parasitic twins

Attention should be focused on training TBA to recognize complicated pregnancy and to make them understand when to refer such cases to medical centers instead of attempting home delivery. Antenatal visits ensure that complications of pregnancy are picked up easily and rare events like conjoined twins can be easily diagnosed on fetal ultrasonography. It should be suspected whenever there is a diagnosis of monochorionic monoamniotic twin, fetal bodies never seen separately on regular USG, presence of  multiple vessels in umbilical cords and detection of other anomalies.[10] Conjoint twin can be ruled out once distinct placenta or no intervening membranes are seen. Two dimensional ultrasound with color Doppler has emerged as an important prenatal diagnostic tool for diagnosis of conjoined twin at 11 to 14 weeks.[11,12]

The delivery of conjoined twins is the next important decision to make. Vaginal delivery is virtually impossible in conjoined twins as obstruction is inevitable, unless the fetuses are macerated or when labor occurs prematurely.[6,7] If the fetuses are viable, they require delivery by cesarean section and when they are not viable they still require cesarean delivery because of the dystocia presented, unless they are very small and then vaginal delivery may succeed.[5] The present case stands out because the patient was an unbooked case that presented as an emergency due to obstructed labor. There was no time to perform any tests like radiography or ultrasonography. The diagnosis of conjoined twins was made in the course of managing the emergency and large conjoined twins weighing 5.2 kilograms were delivered vaginally which is a rare event and which proved to be quite fortuitous in this case.


Conjoined twins are an uncommon phenomenon and their vaginal birth is a rare event. Antenatal visit and proper care would ascertain that unexpected encounters like the one cited in this report are avoided.

  1. Conjoined Twins: Facts About the twins. University of Maryland Medical Center. Available from: http://umm.edu/programs/conjoined-twins/facts-about-the-twins.
  2. Carnevale FC1, Borges MV, Affonso BB, Pinto RA, Tannuri U, Maksoud JG. Importance of angiographic study in preoperative planning of conjoined twins: case report. Clinics (Sao Paulo). 2006 Apr;61(2):167-70.
  3. The craniopagus malformation: classification and implications for surgical separation. James L. Stone and James T. Goodrih. Brain 2006 129(5):1084-1095.
  4. Le Tao; Bhushan, Vikas; Vasan, Neil (2010). First Aid for the USMLE Step 1: 2010 20th Anniversary Edition. USA: The McGraw-Hill Companies, Inc.2010. p. 121.
  5. Van Den brand SFJJ, Nijhuis J G, Van Dongen PWJ. Prenatal ultrasound diagnosis of Conjoint Twins. Obstet Gynecol Survey 1994;49;656-62.
  6. Osmanağaoğlu MA, Aran T, Güven S, Kart C, Özdemir Ö, Bozkaya H. Thoracopagus Conjoined Twins: A Case Report. Obstet Gynecol Nov 28, 2010. doi:  10.5402/2011/238360
  7. Kamalian N, Shirani S, Soleymanzadeh M Thoraco- Omphalo- Ischiopagus Tripus Conjoined Twins: Report of a Case. J Forensic Res 2011;2:117. doi:10.4172/2157-7145.1000117
  8. Edmonds LD, Layde PM. Conjoined twins in the United States, 1970- 1977. Teratology 1982;25:301-308.
  9. Rudolph AJ, Michaels JP, Nichol BL. Obstetric management of conjoined twins. Birth Defects 1967;3:1-28.
  10. Koontz WL, Herbert WN, Seeds JW, Cephalo RC. Ultrasonography in the antepartum diagnosis of conjoined twins: A report of two cases. J Reprod Med 1983;28: 627-630.
  11. Pajkrt E, Jauniaux E (2005) First-trimester diagnosis of conjoined twins. Prenat Diagn 25: 820-826.
  12. Vural F, Vural B (2005) First trimester diagnosis of dicephalic parapagus conjoined twins via transvaginal ultrasonography. J Clin Ultrasound 33: 364- 366.

Desai R, Goel S, Desai D. Conjoined Twin Delivered Vaginally. JPGO 2014; Volume 1 Issue 11. Available from: http://www.jpgo.org/2014/11/conjoined-twin-delivered-vaginally.html

Endometrial Stromal Nodule

Author Information

Chaudhari J*, Patil D**, Shende A***, Chauhan AR****.
(* Assistant Professor, Pathology; ** Third Year Resident, Obstetrics Gynecology; *** Third Year Resident, Pathology; **** Additional Professor, Obstetrics Gynecology. Seth GS Medical College & KEM Hospital, Mumbai, India.)


Endometrial stromal tumors are rare, and can be benign or malignant. Benign endometrial stromal tumors are also known as stromal nodules; endometrial sarcomas are malignant stromal tumors, which can be the more common low-grade sarcomas or high grade sarcomas.  Endometrial stromal nodules are well- circumscribed, expansile, and do not invade the myometrium. Conversely, endometrial sarcomas infiltrate the myometrium, invade vascular spaces, and have the capability to invade adjacent tissues and metastasize. Extensive sampling of the interphase between tumor and myometrium is of utmost importance to distinguish between stromal nodule and sarcoma. We present a case of endometrial stromal nodule (ESN) in a patient of rheumatic heart disease.


Tumors of endometrial stroma are very rare mesenchymal tumors of the uterus with architectural and cytological features suggestive of endometrial stromal cells.[1] The World Health Organization classification of tumors of the breast and female genital organs divides uterine stromal neoplasms into three groups: benign endometrial stromal nodule (ESN), low-grade endometrial stromal sarcoma (LGESS), and undifferentiated endometrial sarcoma (UES).[2] ESN, though cytologically similar to low-grade stromal sarcoma, has a well-circumscribed, expansile margin and is benign. On the other hand, UES is a rare but highly malignant sarcoma which lacks overt endometrial stromal differentiation.[1, 2]

Case History

A 38 year old female, known case of rheumatic heart disease with mitral stenosis since 20 years, presented with dull pain and discomfort in the lower abdomen since 5 months. Abdominal and pelvic examination revealed a painless pelvic mass of approximately 14 weeks’ size, with a palpable 8 x 8 cm mass on right posterior-lateral uterine wall. Pelvic ultrasound showed bulky uterus of 11.5 x 6.1 x 8.7 cm size, with 8.2 x 7.6 x 7.1 cm right postero-lateral wall fibroid with multiple cystic areas within, suggestive of cystic degeneration of fibroid. Both ovaries were visualized; presence of a left ovarian simple cyst of 3.7 x 2.9 cm size without septations or solid component within it were noted. Laboratory investigations were normal. Total abdominal hysterectomy was done which was uneventful. Intra operative findings were suggestive of uterine enlargement, bilateral normal ovaries and bilateral paraovarian cysts, approximately 4 x 5 cm size. The uterus was enlarged and on opening a large well circumscribed mass measuring 8 x 7x 4 cm was seen in myometrium which was bulging above the surface, yellow white with few cystic areas, as seen in Figure 1. 

Figure 1. A well circumscribed mass in the uterus with yellow white cut surface and few cystic areas

On microscopy, it showed a non-encapsulated circumscribed mass showing small cells with oval nuclei, granular chromatin, scanty clear to eosinophilic cytoplasm arranged in sheets with arteriole sized blood vessels. Only three tiny tongue- like projections were seen invading less than 3 mm depth in the myometrium. There were no areas of necrosis, mitosis or nuclear atypia, nor was there definite vascular invasion. The histological features were typical of endometrial stromal nodule (Figure 2).

Figure 2. Circumscribed mass showing small oval cells and arteriole sized blood vessels. (HE 400X) 


Endometrial stromal tumours are one of the least common neoplasms of the uterus, with a reported incidence of about 2 per million women annually. [3] The clinical presentation is nonspecific; the patients may be asymptomatic or may present with significant vaginal bleeding, pelvic or abdominal pain or discomfort. [4] There is no reliable preoperative diagnostic procedure to identify this tumour; hysterectomy is the treatment of choice and diagnosis is based on microscopic examination. ESNs are grossly well circumscribed and lack permeative infiltration of an ESS. But some of them have a little irregularity of the margin and may even be minimally invasive i.e. less than 3 mm invasion and less than 3 foci [1, 4] Although the presence of an EST is sometimes established by curettage, a definitive diagnosis of LGESS can be made if myometrial and/or vascular invasion is identified in the tissue fragments. A hysterectomy is usually required to permit thorough evaluation of the tumor margin; this is necessary to distinguish a stromal sarcoma from a benign stromal nodule. [4]Although ESS resembles non-neoplastic proliferative endometrial stroma, they are morphologically heterogeneous. Fibroblastic and smooth-muscle differentiation may be seen and may erroneously suggest myometrial infiltration. [4] ESNs like other uterine neoplasms of stromal origin occur primarily in older postmenopausal women, in whom hysterectomy is usually done. [2, 3, 4] In women of reproductive age who desire fertility conservation, diagnostic sonography and hysteroscopy may be used to follow up tumor growth. In some cases, progesterone therapy with local excision may be successful. [4] The prognosis is excellent once the diagnosis is confirmed.

  1. Baker Patricia, Oliva Esther. Endometrial stromal tumours of the uterus: a practical approach using conventional morphology and ancillary techniques. J Clin Pathol 2007; 60 (3): 235–243
  2. Tavassoli FA, Devilee P. World Health Organization Classification of Tumors: Pathology and genetics of the breast and female genital organs, IARC Press; Lyon; 2003: 230-50
  3. Zaloudek C, Hendrickson MR. Mesenchymal tumors of the uterus. In: Kurman RJ. Blaustein’s Pathology of the Female Genital Tract. 5th ed. Springer, Springer–Verlag, New York, Berlin, Heidelberg 2001: 561-615.
  4. Sahande Elagoz, Fügen Kıvanc, Handan Aker, Sema Arici, Hatice Ozer, Tevfik Güvenal et al. Endometrial stromal tumors – a report of 5 cases. Aegean Pathology Journal 2005; 2: 140–45.

Chaudhari J, Patil D, Shende A, Chauhan AR. Endometrial Stromal Nodule. JPGO Volume 1 Issue 11. Available from: http://www.jpgo.org/2014/11/endometrial-stromal-nodule.html

Chronic Ectopic Pregnancy Masquerading as a Pyosalpinx

Author Information

Pandey N*, Gupta AS**.
(* Third Year Resident, ** Professor. Department of Obstetrics and Gynecology, Seth GS Medical College & KEM Hospital, Mumbai, India.


A 22 year old nulligravida presented with pelvic pain for 2 months. There was no menstrual irregularity. There was a left adnexal mass on pelvic examination. Provisional diagnosis of pelvic inflammatory disease with probability of genital tuberculosis was made. The patient was started on antibiotics. Ultrasonography (USG) was suggestive of pyosalphinx. Serum β-hCG was negative. Laparoscopy showed dense pelvic adhesions. Laproscopic adhesiolysis was done. A friable looking mass of 3 cm x 3 cm was seen on the left fallopian tube and was excised. Histopathology confirmed the diagnosis of a chronic ectopic. This case highlights that the differential diagnosis of a chronic ectopic should always be kept in mind while treating a patient with an adnexal mass.


The entity of a chronic ectopic gestation has not been properly defined in the gynecological textbooks [1,2] . It is formed due to repeated hemorrhages in the gestational sac leading to disintegration and formation of a pelvic mass.[3, 4, 5] A chronic ectopic pregnancy is often mild symptomatically and has a protracted course.[5,6] Its clinical presentation can often be confused for pelvic inflammatory disease, endometriosis or uterine leiomyoma.[3]

Case Report

A 22 year old patient, nulligravida, presented with complaints of pelvic pain for the past 2 months. She did not complain of any fever, menstrual irregularity or vaginal discharge. There was no other major medical or surgical illness in the past except for a history of hypersensitivity to ciprofloxacin. On examination, her general condition was fair and vital parameters were stable, with a pulse rate of 84/min and blood pressure of 110/70 mm Hg. There was no pallor or icterus. Cardiovascular system and respiratory system were within normal limits. The abdomen was soft with tenderness in the left iliac fossa. On per speculum examination, cervix and vagina were healthy. There was no vaginal discharge. On bimanual examination uterus was normal in size, anteverted and mobile. There was a left sided tense, cystic and tender adnexal mass of around 4 cm in size. Right sided adnexa was free.

Figure 1. Ultrasound Image of the adnexal mass. The cursor defines the adnexal mass which was suspected to be a pyosalpinx.

In her investigations, Hb was 13.2 gm%. White cell count was 8,700/mm3 and her liver and renal function tests were within normal limits. Serum β-hCG level was <1.2 mIU/ml. Pelvic USG was suggestive of a heterogeneous mass visualized above the left ovary of 4.4 x 3.1 cm with cystic changes, suggestive of a pyosalphinx. Endometrial thickness was normal. The patient was started on parenteral broad spectrum antibiotics and posted for a diagnostic and operative laparoscopy. On laparoscopy pelvis was obliterated with a thick curtain of omentum. After Adhesiolysis the uterus was visualized. It was normal in size. Right fallopian tube and ovary were normal. Multiple adhesions between the tube and the cul-de-sac were released to visualize the left adnexa. On the left side one 3x3 cm friable looking mass was seen at the end of the tube The left ovary was normal. An intra operative diagnosis of chronic ectopic pregnancy was made. Left sided salphingectomy was done. Histopathology showed presence of non-viable villi which was consistent with the diagnosis of a chronic ectopic pregnancy of the left Fallopian tube.


A chronic ectopic pregnancy is not a very rare entity and hence should be kept in the differential diagnosis of any complex adnexal mass.[1] It classically has very mild symptoms and a protracted course.[5,6] USG can be useful in diagnosing a chronic ectopic pregnancy but is not specific. USG picture can mimic that of pelvic inflammatory disease, endometriosis or uterine leiomyoma.[3] Serum β-hCG levels also tend to be negative. A clinical suspicion is all that can help in obtaining a pre-operative diagnosis.
In this case, the serum β-hCG levels were negative and the USG was suggestive of a pyosalphinx. The main complaint of the patient was pain in abdomen. This can be correlated to her intraoperative finding of multiple adhesions. It remains a matter of debate whether the treatment of this patient should have been limited to adhesiolysis, since it would take care of her chief complaint. Whether a salphingectomy is actually required for a chronic ectopic pregnancy or the mass can be treated expectantly, like that of an unruptured ectopic mass on medical management, requires further study.[5] An unruptured ectopic mass on medical management is monitored solely with the fall in serum β-hCG levels, and left alone once the β-hCG levels are normal. Since the β-hCG levels are normal for most of the chronic ectopic pregnancy, applying the same principal is not possible. It can be argued that a surgical intervention should remain restricted to solving the chief complaint and may not involve salpingectomy in all the cases, especially in the younger women who are desirous of childbearing. Twin possibilities of spontaneous recanalisation of the tube and restoration of its function or persistence of the pathology causing the ectopic implantation  persists. When operative laparoscopy is done in symptomatic patients it makes for good clinical practice to excise the lesion and obtain a tissue diagnosis as occasionally neoplastic or inflammatory lesions like tuberculosis may be diagnosed.


We can conclude that the differential diagnosis of chronic ectopic pregnancy should be kept in mind while dealing with a case of adnexal mass.

  1. Turan C, Ugur M, Dogan M, Ekici E, Vicdan K, Gokmen O. Transvaginal Ultrasonographic findings of Chronic Ectopic Pregnancy. European Journal of Obstetrics & Gynecology and Reproductive Biology.1996 Aug; 67(2):115-119.
  2. Uğur M, Turan C, Vicdan K, Ekici E, Oğuz O, Gökmen O. Chronic ectopic pregnancy: a clinical analysis of 62 cases. Aust N Z J Obstet Gynaecol. 1996; 36(2): 186–189.
  3. Bedi DG, Fagan CJ, Nocera RM. Chronic ectopic pregnancy. J Ultrasound Med. 1984 Aug; 3(8):347-52.
  4. Harada, M., Hiroi, H., Fujiwara, T., Fujimoto, A., Kikuchi, A., Osuga, Y., Momoeda, M., Kugu, K., Yano, T. and Taketani, Y. Case of chronic ectopic pregnancy diagnosed in which the complete shape of the fetus was visible by ultrasonography. Journal of Obstetrics and Gynaecology Research. 2010; 36: 462–465.
  5. Nacharaju  M, Vellanki V S, Gillellamudi S B, Kotha VK and Alluri A. A Rare Case of Chronic Ectopic Pregnancy Presenting as Large Hematosalpinx. Clinical Medicine Insights Reproductive Health 2014; 8: 1–4.
  6. Manson F. Ectopic pregnancy with negative serum hCG level. http://sonoworld. com/fetus/page.aspx?id=1712. Updated March 28, 2006. Accessed date: 27/08/2014.


Pandey N, Gupta AS. Chronic Ectopic Pregnancy Masquerading as a Pyosalphinx. JPGO Volume 1 Issue 11. Available from: http://www.jpgo.org/2014/11/chronic-ectopic-pregnancy-masquerading.html

Endometrial Microscopic Foreign Body

Author Information

Gewndolyn Fernandes*, Parulekar SV**
(* Associate Professor, Department of Pathology, ** Professor and Head, department of Gynecology and Obstetrics; Seth GS Medical College & KEM Hospital, Mumbai, India)


Endometrium can develop a number of chronic granulomatous as well as nongranulomatous inflammatory lesions. We present a case of an endometrial microscopic foreign body of plant origin. This is the first case of its type in the world literature.

The endometrium can be affected by a number of inflammatory agents, infectious as well as noninfectious. Infections include tuberculosis, atypical  mycobacterial infection, actinomycosis, endemic mycosis, and parasitic infestation. Noninfectious  conditions  include foreign  body  reaction, sarcoidosis, lymphoma and other neoplastic conditions, Crohn  disease, and operative trauma. We present a case of an endometrial foreign body reaction that was focal and microscopic, the foreign body being of plant origin. This is the first case of a microscopic foreign body in the endometrium with chronic inflammation in the world literature.
Case Report

A 54 year old woman presented with a second degree uterine prolapse, moderate cystocele and moderate rectocele. She had been married for 30 years. She had a normal delivery 27 years ago and a medical termination of pregnancy at 2 months of amenorrhea by medical method 25 years ago. Check curettage had not been done at that time. She had undergone laparoscopic sterilization 17 years ago and an appendectomy 8 years ago. She developed pulmonary tuberculosis 6-7 years ago, and had received full treatment for it. She was found to be cured after that treatment. She was menopausal for 3-4 years. There was no history of use of any herbal preparations vaginally at any time in her life. A vaginal hysterectomy with vaginal prolapse repair using site specific method was done. She made an uneventful recovery. She was all right at follow up after 15 days, 1 month and 2 years.
Gross examination of the specimen showed that the uterus measured 7x0.8x1 cm. The cervix was keratinized. On cutting the uterus open, the endometrium was 0.2 cm thick, the myometrium was 0.6 cm thick. The endometrium and myometrium were grossly normal. Microscopic examination showed a small foreign body of plant origin in the endometirum of the corpus. It was composed of cells with thick, rigid cell walls arranged end to end. A brownish pigment was also seen in the cells. These features were typical of plant origin cells. Animal cells have thin cell membranes. The foreign body was surrounded by dense fibrinous material and neutrophils. Indentation of the surface was seen by the foreign body. The endometrium showed atrophic features. The myometrium showed calcification of the wall of small arterioles. The cervix showed features of chronic cervicitis with prominent keratinization of the squamous epithelium and squamous metaplasia of the endocervical glands.

Figure 1. Microphotograph showing foreign body with an intense reaction around it and indentation of the endometrial surface. Atrophic endometrial glands are seen. (H&E x100)

Figure 2. Microphotograph of a higher magnification showing the foreign body composed of plant origin cells with thick cell walls. Fibrinous material and neutrophils are seen around it. (H&E x 400)

Figure 3. Some of the plant origin cells are cut in transverse section and show brownish pigment. (H&E x 400)

Figure 4. Oil immersion view showing plant origin cells with thick rigid cell walls and cells arranged end to end. (H&E x 1000)


Insertion of foreign bodies into the vagina is much more common than into the uterine cavity, because the patient or someone else can do it easily. Insertion of foreign bodies into the uterine cavity is much more difficult. It requires some training, and is usually done as a part of therapy by the doctor or for achieving criminal abortion by quacks. Microscopic foreign particles may enter the uterine cavity along the cervical mucus, aided by the ciliary action of the endocervical cells. It occurs in case of sperm and has been shown to occur experimentally too.[1,2] Since this patient gave no history of insertion of any foreign body into the genital tract, either by self or by a doctor or a quack for any reason, the microscopic foreign body of plant origin in her endometrium cannot be explained easily.
Twigs of certain plants have been inserted into the uterine cavity to achieve illegal (criminal) abortions.[2,3,4,5] It is possible that a portion of the foreign body remains in the uterine cavity and elicits chronic inflammatory response. This patient refused having undergone any such procedure. It is possible that she had it done and was denying it out of fear of disclosure.
Aegle marmelos (Bilva, wood apple tree) is a plant with medicinal value in Ayurveda. Its fruit extracts have been used by Ayurvedic physicians for its astringent action in the management of chronic diarrhea and dysentery, hemorrhoids, and possibly genital prolapse. It is used orally for control of gastrointestinal symptoms and vaginally (pichu) for local symptoms.[6] It is possible that this patient tried the vaginal administration of this preparation for her genital prolapse and hid the fact when it failed to cure her and she presented to us for management. The particles in the pichu might have ascended to reach the endometrium and caused chronic inflammation.
Another possibility is that the patient sat on the ground without undergarments, and the prolapsed cervix picked up plant debris from the ground. Microscopic particles of the same may have traveled up the uterus passively and set up a chronic inflammatory reaction. Foreign bodies like foreign material from glove talc or suture may cause foreign body reaction in the endometrium in women who have undergone surgery in that area.  Use of surgical diathermy can also elicit such reaction in the endometrium.[7] This patient did not have any uterine surgery in the past.
The lesion found in the endometrium of this patient was a chronic inflammatory reaction to a foreign body of plant origin, distinct from all granulomas, as can be found with tuberculosis, schistosomiasis, Enterobius vermicularis infestation, coccidiomycosis, cytomegalovirus, sarcoidosis, granulomatous vasculitis, radiation, and ceroid granulomas.[9,10,11,12,13,14]


Microscopic chronic endometrial focal inflammation can be because of a number of conditions. It needs to be differentiated from granulomatous lesions which have a much worse prognosis. A foreign body of plant origin may enter the genital tract due to self insertion, criminal abortion with an abortion stick, or possibly to uterine prolapse.


1.    Brannigan R, Lipshultz L. Sperm Transport and Capacitation.  Glob Libr Women's Med 2008. DOI 10.3843/GLOWM.10316. Available from: http://www.glowm.com/section_view/item/315/recordset/23365/value/
2.      World  Health  Organization.  Unsafe abortions: global and regional estimates of the incidence of unsafe abortion  and  associated  mortality in  2000.  4 th   ed. Available from:  http://www.who.int/reproductive-health/publications/unsafe_abortion_estimates_04/estimates.pdf.  Published  2004.  Accessed August 19, 2007.
3.    Nanda  S,  Sangwan  K,  Agarwal  U. The  ugly  face  of  septic  abortion. Eur J Obstet Gynecol Reprod Biol. 2002;105(1):71-72.
4.   Singh S, Deidre W. Estimated levels of Induced Abortion in six latin American Countries. International Family Planning Perspectives. 1994;20:4-13.
5.   Fonseca W, Misago C, Correia L, Parente J, Oliveira FC. Determinants of induced abortion among women admitted to hospitals in the Nordeste region of Brazil. Revista de Saúde Pública. 1996;30:13-8.
6. Bilva (Aegle marmelos). In National R & D facility for Rasayana. Available from: http://www.frlht.org/rasayana/node/83.
7.  Riyanto, S; Sukari MA; Rahmani M; et al. (2001). "Alkaloids from Aegle marmelos (Rutacea).". Malaysian J Anal Sci. 7 2: 463–465.
8.      Smart PJ, Hetherington JF: Postoperative uterine granulomata following endometrial resection. Pathology 1995; 27:209-211.
9.   Knuth KR, Fraiz J., Fisch JA, and Draper TW. Pinworm infestation of the genital tract. Am Fam Physician. 1998; 38: 127–130.
10.  Bylund DJ, Nanfro JJ, Marsh WL Jr. Coccidioidomycosis of the female genital tract. Arch Pathol Lab Med 1986; 110:232-235.
11.  Frank TS, Himebaugh KS, Wilson MD: Granulomatous endometritis associated with histologically occult cytomegalovirus in a healthy patient. Am J Surg Pathol 1992; 16:716- 720.
12.  Pearce KF, Nolan TE: Endometrial sarcoidosis as a cause of postmenopausal bleeding. a case report. J Reprod Med 1996; 41:878-880.
13.  Lhote F, Mainguene C, Griselle-Wiseler V, Fior R, Feintuch MJ, Royer I, et al. Giant cell arteritis of the female genital tract with temporal arteritis. Ann Rheum Dis. 1992;51(7):900-3.

14.  Ooi K1, Riley C, Billson V, Ostör AG. Ceroid granulomas in the female genital system. J Clin Pathol. 1995;48(11):1057-9.


Fernandes G, Parulekar SV. Endometrial Microscopic Foreign Body. JPGO 2014. Volume 1 Number 11. Available from:  http://www.jpgo.org/2014/11/endometrial-microscopic-foreign-body.html

Myomectomy - Modified Bonney’s Hood Operation

Author Information

Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)


Myomectomy is operative removal of uterine leiomyoma(s) and reconstructing the uterus. Conventionally a posterior wall leiomyoma is removed by Bonney’s hood operation. In this operation the incision is made transversely through the posterior wall of the uterus, but the flap raised is sutured over the uterine corpus such that the final scar is on the anterior uterine wall. This prevents a posterior wall scar and related adhesions to rectum, bowel and/or omentum. A novel approach of combining half of Bonney’s hood with a lateral incision is presented, to minimize the possible complications associated with Bonney’s hood operation. A review of the world literature reveals that this is the first time this approach has been described.


The bulk of the myometrium is in the anterior and posterior walls of the uterus, and leiomyomas develop there more often.[1] Conventionally uterine incision is placed such that the scar will be on the anterior uterine wall.[2,3,4] This is achieved by making an anterior wall incision for removal of anterior wall leiomyomas, and using Bonney’s hood operation for removal of upper posterior wall leiomyomas. Another approach to avoid a scar on the peritoneum covered surface of the uterus is to use a lateral approach through the broad ligament.[5] The uterine scar gets covered by the broad ligament which is sutured back after the myomectomy. Bonney’s hood operation and lateral myomectomy prevent adhesions which can lead to infertility, retroverted fixed uterus, chronic abdominal and pelvic pain and intestinal obstruction.[6,7] Bonney’s hood operation places the final scar on the anterior surface of the uterus. But the edges of the hood often pass over the fundus of the uterus and close to the cornua, which can cause adhesions in that area. A lateral approach is not suitable if a posterior wall leiomyoma is in the center rather than on one side. A half hood and a lateral incision combined would reduce the risk of adhesions associated with Bonney’s hood operation and make a lateral approach feasible in such cases.

Operative Technique

The abdomen is opened through infraumbilical vertical or transverse incision. The bowel and omentum are packed away into the upper abdominal cavity. The uterus and pelvic structures are examined. If the leiomyoma is large and posterior-central in location, it is checked if it is exactly in the center or a little more on one side than the other. In case of the former, the lateral incision can be made on the side on which the operating surgeon stands. In case of the latter, the lateral incision is made on the side on which greater part of the leiomyoma lies. Any technique used for reducing blood loss during myomectomy can be used, such as use of Bonney’s myomectomy clamp, Rubin’s technique of rubber tourniquet, and injection of diluted vasopressin around the uterine vessels and their anastomoses with the ovarian vessels.[8] The lateral incision is made vertically downwards, behind the attachment of the uteroovarian ligament. It is started just behind the attachment of the ligament, close to the broad ligament, and extended downwards to a level not lower than 2 cm above the entry of the uterine vessels into the uterus, well posterior to them. The upper end of the incision is continued transversely across half or less of the posterior wall of the uterus parallel to the coronal plane, just posterior to the junction of the contour of the leiomyoma and the uterine fundus. The incision is deepened until the pseudocapsule is cut. Then the leiomyoma is held with a tenaculum, Allis’ forceps or vulsellum, and enucleated by making traction while it is dissected bluntly as well as sharply from inside the pseudocapsule. If the uterine incision is found to be inadequate for removal of the leiomyoma, it is removed by morcellation rather than by enlarging the incision. Any other leiomyomas present in the posterior uterine wall are removed through tunnelling incisions as have been described conventionally. Hemostasis is achieved in the bed(s) of the leiomyoma(s) by ligatures, sutures and electrocauterization as appropriate. The cavities formed by removal of the leeiomyomas are occluded, the deepest one first and the most superficial one last. The width of the half hood is reduced such that the lateral edge will approximate with the anterior edge of the lateral incision. The medial cut edge is trimmed such that the half hood will not cross the midline. Extra part of the pseudocapsule is excised to reduce the bulk of the reconstructed uterus. The inner surface of the half hood is sutured over the fundus and the anterior wall of the uterus with rows of interrupted sutures of No. 1 polyglactin, starting posteriorly and progressing anteriorly. The anterior edge of the half hood is sutured to the lower part of the anterior wall of the uterine corpus. The round ligaments are plicated with zig-zag sutures of black silk or linen. The abdomen is closed in layers.

Figure 1. Right lateral view of the uterus with a large central leiomyoma in the posterior uterine wall (M). Arrow: left ovary.

Figure 2. Vertical incision is made in the uterine wall and pseudocapsule of the leiomyoma posterior to the right uteroovarian ligament (arrow). The right fallopian tube (hollow arrow) is seen anterior to the ligament.

Figure 3. The uterine incision is extended transversely over the posterior uterine wall in continuity with the upper end of the first incision.

Figure 4. The leiomyoma is being dissected bluntly from its pseudocapsule.

Figure 5. The leiomyoma is seen being delivered from its bed.

Figure 6. The leiomyoma is enucleated almost completely.

Figure 7. Excess of the pseudocapsule is being excised from the anterior wall.

Figure 8. Excess of the pseudocapsule is being excised from the posterior wall.

Figure 9. The bed of the leiomyoma and the hood (held by a hand) are seen.

Figure 10. The bed of the leiomyoma is occluded by interrupted sutures of No. 1 polyglactin.

Figure 11. The hood is being sutured over the bed of the leiomyoma and the fundus of the uterus.

Figure 12. The hood has been sutured over the fundus and the anterior wall of the uterus. Note the right fallopian tube is not compressed by the hood, while the left half of the fundus is without any scar.


Making an incision in the posterior wall of the uterus is considered the worst option because the postoperative scar would be exposed to the general peritoneal cavity and would invite adhesions with bowel and/or omentum.[ 6,7] Unless the uterus is anteverted by plication of the round ligaments, it would get retroverted and perhaps get adherent to the rectum. An upper segment posterior uterine incision is usually managed by Bonney’s hood operation.[8] This operation involves making a transverse incision near the anterior limit of the leiomyoma over the posterior wall of the uterus, and the flap of the pseudocapsule, myometrium and uterine serosa left behind after the myomectomy is sutured over the bed of the leiomyoma and uterine wall so that the anterior edge of the flap (Bonney’s hood) lies on the anterior wall of the uterus. The back and top of the uterus is devoid of any scar and hence adhesions do not develop. However the right and left edges of the hood pass forward close to the cornua. Adhesions may develop to the edges and they may cause obstruction of the fallopian tubes. The new technique described here combines the advantages of the lateral approach and Bonney’s hood operation. A lateral incision just posterior to the uteroovarian ligament results in a scar which is not directly exposed to the peritoneal cavity, and to which bowel and omentum may get adherent. Since that incision would not be sufficient to get out a leiomyoma extending on both the sides of the midline, it is extended across the back of the fundus transversely. A half or less than a half of the width of the uterine top gets cut, and the resultant flap has one edge close to the side of the uterus and the other near the midline. Even if any adhesion develops to it, it would not be close to the fallopian tube. It needs to be noted that this edge would have invited adhesions had it been a result of a full hood too. A half hood just minimizes the risk of obstruction of one fallopian tube, over and above the other advantages of Bonney’s hood operation. The edges of the hood can be covered with oxidized regenerated cellulose barrier, polytetrafluoroethylene membrane, or bioresorbable membrane (sodium hyaluronate and carboxymethylcellulose), preventing adhesions further.[9]


Modified Bonney’s hood operation is a technique that is easy, satisfactory and associated with absence of complications of adhesions of the intraperitoneal structures to the scar seen with posterior uterine wall incisions. It reduces risk of adhesions to one edge of the hood near a fallopian tube, thereby reducing the risk of its obstruction as could occur with Bonney’s hood operation.


1.      Standring S: Gray’s Anatomy, 39th ed. Philadelphia: Elsevier; 2005.
2.      Breech LL, Rock JA. Leiomyomata uteri and myomectomy. In Rock JA, Jones HW III, editors. Te Linde’s Operative Gynecology. 10th ed. New Delhi: Wolters Kluwer Health – Lippincott Williams & Wilkins 2008; pp. 687-726.
3.      Guarnaccia MM, Rein MS. Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy. Clin Obstet Gynecol 2001;44:385-400.
4.      Parulekar SV. Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011, pp345-8.
5.      Parulekar SV. Myomectomy: lateral extraperitoneal Approach. JPGO 2014 Volume 1 Number 2 Available from: http://www.jpgo.org/2014/02/myomectomy-lateral-extraperitoneal.html
6.      LaMorte AI, Lalwani S, Diamond MP. Morbidity associated with abdominal myomectomy. Obstet Gynecol 1993;82:897-900.
7.      Iverson  RE,  Chelmow  D,  Strohbehn  K, Waldman L, Evantash ED.  Relative  morbidity of  abdominal  hysterectomy  and  myomectomy  for  management  of uterine leiomyomas. Obstet Gynecol 1996;88:415–419.
8.      Tito Lopes T, Spirtos NM, Naik R, Monaghan JM. Bonney’s Gynaecological Surgery. 11th ed. Wiley Blackwell:2011; Pp 121-124.
9.      Diamond MP. Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a blinded, prospective, randomized, multicenter clinical study. Fertil Steril 1996;66:904-911.


I thank Dr Durga Valvi, Dr Vibhav Manjrekar and Dr Digvijay Raut for taking pictures of the operative steps.

Parulekar SV. Myomectomy - Modified Bonney’s Hood Operation. JPGO 2014 Volume 1 Number 11. Available from: http://www.jpgo.org/2014/11/myomectomy-modified-bonneys-hood.html

Post Criminal Abortion Retroperitoneal Abscess

Author Information

Kulkarni S*, Parulekar SV**, Hira Priya***
(* Third Year Resident, **Professor and Head of the department, Department of Obstetrics and Gynecology; *** Associate Professor, Department of radiology, Seth GS Medical College & KEM Hospital, Mumbai, India.)


Retroperitoneal abscess is an uncommon complication of a first trimester medical termination of pregnancy. It would be more likely after a criminal abortion. We present a rare complication of first trimester criminal abortion in the form a retroperitoneal abscess which continued to drain through the uterus vaginally. This is the first case of this occurrence in the world literature.


Retroperitoneal infection may occur either as direct invasion from the contained organs (as in case of kidneys, ureters, pancreas, abdominal aorta, and inferior vena cava), contiguous organs (as in case of ascending colon, de­scending colon, duodenum, bladder, uterus, and rectum) or hematogenous and lymphatic spread from areas of drainage.[1-15] It may occur after a delivery or an abortion. It may follow a first trimester medical termination of pregnancy in case the uterus is perforated. It may be associated with a high mortality rate (22-46%).[16] We present a postabortal case with a retroperitoneal abscess in which the pus continued to drain through the uterus and cervix. This is the first case of this occurrence in the world literature.

 Case report

A 28 yrs old woman , P2L2A1, presented on  day 28 of evacuation of products of conception for probably missed or inevitable abortion by a nonqualified person. She had complaints of  excessive foul smelling discharge per vaginum for 25 days, and fever on and off for 1 week. On examination she was afebrile and her vital parameters were within normal limits. Mild tenderness was present in left iliac fossa. A speculum examination  showed foul smelling purulent discharge pouring out of the cervix. On bimanual pelvic examination there was vaginal warmth, a retroverted and normal sized uterus, and a firm to hard band leading from the left uterine wall to the left lateral pelvic wall. The pus was sent for microbiological studies. She was administered cefotaxime, gentamycin and metronidazole parenterally. Abdominopelvic ultrasonography (USG) showed features of endometritis and a 2×2 cm ovarian cyst on left side. Despite therapy she continued to get fever up to 400 C and pour out pus through the cervix. The pattern of discharge of the pus was unusual. There would be alternating dry days and days with abundant discharge of pus. The pus and blood culture showed no growth of any organisms. Another sample of the pus showed growth of Enterococcus fecalis, Klebsiella pneumoniae and Gram-Negative bacilli. Injectable Linezolid and Piperacillin were started according to culture and sensitivity report. The patient continued to be symptomatic with fever and discharge per vaginum with increasing tenderness in left iliac fossa. Hence computerized tomography (CT) of the abdomen and pelvis was done. It showed a retroperitoneal collection of pus with air specs. It measured 6×7cm (about 500 ml). It extended from the left kidney pushing it forwards, behind the descending colon, along the left iliopsoas region.

Figure 1. CT scan of the abdomen and pelvis. The left kidney (LK) is pushed forward by the abscess.

Figure 2. CT scan of the abdomen and pelvis. The uterus with pus, the abscess and the communication between them are seen.

Retroperitoneal drainage of abscess was done. All the loculi were broken About 400 ml of pus was removed. A large bore drainage tube was left in the abscess cavity. The cervical drainage of the pus stopped following the operation. The pus stopped draining after 6 days. The drainage tube was removed on the seventh postoperative day, and the wound was dressed regularly. The patient recovered uneventfully and was discharged on eighth postoperative day. She was well at follow up after 15 days. Repeat USG did not show any collection of pus in the left retroperitoneum. It was likely that the tract connecting the uterine cavity to the retroperitoneal space remained, and would not close down. Since closing it surgically would perhaps lead to further complications, and the patient was not keen on having another pregnancy, she was advised to use barrier contraception. She accepted that.

Figure 3. Exploration of the abscess cavity with a finger passed through an incision above the left iliac crest.

Figure 4. A wide bore drainage tube has been passed into the abscess cavity.


The retroperitoneal space is a potential space which lies between the posterior parietal peritoneum and transversalis fascia of the posterior abdominal wall, extending superiorly to the diaphragm, inferiorly to the pelvis, and laterally to the edges of the quadratus lumborum muscles. Though it is a potential space, it can accommodate up to 2000 ml of pus.[17,18] Retroperitoneal infection may occur either as direct invasion from the contained organs (as in case of kidneys, ureters, pancreas, abdominal aorta, and inferior vena cava), contiguous organs (as in case of ascending colon, de­scending colon, duodenum, bladder, uterus, and rectum) or hematogenous and lymphatic spread from areas of drainage. A retroperitoneal abscess may spread to the iliopsoas area through the iliopsoas bursa.[19] Uterine perforation may occur during rapid dilatation of cervix and evacuation of uterine contents for performance of a first trimester termination of pregnancy. It is not very common if due care is exercised. It is more likely to happen and be associated with infection in cases of first trimester criminal abortion performed by untrained and unqualified persons. A uterine perforation may not be diagnosed when it occurs. Usually it occurs in the anterior or the posterior wall of the uterus. If it occurs in the lateral wall, it leads to the broad ligament area.[20] It would escape immediate detection if the uterine vessels are not injured. Extraperitoneal hemorrhage followed by its infection would lead to the development of a retroperitoneal abscess, as occurred in our case. Intraperitoneal hemorrhage and infection are detected early because of associated pain and local signs like tenderness, guarding and rigidity. These features are absent in case of a retroperitoneal abscess. So the onset is insidious and diagnosis late. Our patient developed vaginal discharge early, because the abscess cavity communicated with the uterine cavity through a track opening in its left lateral wall. The pus escaped periodically by overflow. But the diagnosis was missed during USG.
Retroperitoneal abscesses are often polymicrobial, and the predominant isolates are E. coli, K. pneumoniae, S. aureus, and enterococci.[21] Our patient also had polymicrobial growth from the pus. Tuberculosis can also cause a retroperitoneal abscess.[22] CT is particularly useful for evalua­tion of the retroperitoneum. It permits precise anatomic delineation of the extent of the abscess, which is useful in planning a surgical approach.[23-26] In our case the CT showed the exact extent of the abscess and even showed the communicating track between the abscess and the uterus.
Transperitoneal drainage should be avoided as contamination of the peritoneal cavity would lead to generalized peritonitis. Failure, recurrence or mortality occurs in 67%  cases with this approach. If the abscess is unilocular and the pus is relatively free of particulate matter, insertion of a pigtail catheter for drainage may be done.[27,28] If there is poor response to treatment, surgical drainage is done. It is done by a flank approach as in our case.[29] The catheter can be connected to low intermittent suction. If drainage stops suddenly, a block in the catheter is suspected, and it is irrigated gently with small quantity of normal saline. The catheter is withdrawn gradually as the abscess cavity shrinks and the drainage decreases in volume.[30]


Retroperitoneal abscess is a serious condition that may have few localizing signs. It may occur as a complication of perforation of a gravid uterus, especially after a criminal abortion. A high degree of suspicion aided by modern imaging techniques like CT and magnetic resonance imaging helps make an accurate diagnosis. Early diagnosis and treatment by catheter or open drainage help reduce morbidity and mortality associated with the condition.


We thank Dr Deshpande AA for extraperitoneal drainage of the abscess.


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Kulkarni S, Parulekar SV, Hira P. Post Criminal Abortion Retroperitoneal Abscess. JPGO 2014 Volume 1 Number 11. Available from: http://www.jpgo.org/2014/11/post-criminal-abortion-retroperitoneal.html