Volume 5 Number 5

Editorial
Gupta AS

Posthysterectomy Fimbrial Prolapse – Unusual Presentation
Parulekar SV

Recurrent Giant Cervical Polyp Of Unusual Appearance
Parulekar M, Parulekar SV.

Classical Cesarean Section In Case Of Lower Segment And Broad Ligament Fibroids
Gupta P, Chaudhari HK, Kambhampati L.


Posterior Vaginal Wall Leiomyoma
Singhania N, Prasad M, Gupta AS.

Classical Cesarean Section For Large Central Cervical Fibroid
Singhania N, Pardeshi S, Gupta AS.

Ruptured Ovarian Ectopic Pregnancy
Jha N, Tiwari N, Chaudhari HK.

Isthmocele - a cesarean scar defect managed hystero-laparoscopically
Shah NH, Deshmukh M, Adsul SD, Paranjpe SH.

Takayasu Arteritis In Pregnancy: A Case Report From A Tertiary Hospital In South India
Fernandes S, Rao SV, D’Almeida J, Kumari P.

Remembering Past Greats: Grantly Dick-Read
Madhva Prasad Sarvothaman

Editorial

Gupta AS

Leiomyomas and abnormal uterine bleeding are the most common reasons for consultation with a gynecologist. Obstetricians are increasingly seeing patients with leiomyomas complicating pregnancy. Prevalence of fibroids in pregnancy ranges anywhere between 1.6 to 10.7 %. This wide range is probably due to the varying sizes and the varying gestational ages at the time of detection of the fibroids. The general belief regarding the behavior of fibroids in pregnancy that they increase in size is being challenged by various researchers who are following the size of a fibroid by serial ultrasound examinations. The current information that is gathering shows that 50-60% of the fibroids do not show significant change in their size and only about 22-32 % fibroids increase during pregnancy. Fibroids commonly cause pain during pregnancy and the occurrence of reproductive loss, placentation disorders, malpresentations, accidental hemorrhage, dysfunctional and preterm labors may increase slightly in some women.
Route of the delivery is influenced by multiple factors like the fetal presentation, size and position of the myomas. Most of the time if there is no malpresentation, the placenta is not below the presenting part or not obstructing the birth canal, uterus is unscarred it would be prudent to consider a vaginal delivery in a center equipped with facilities for emergency cesarean section and a well equipped blood bank. In the eventuality that a cesarean delivery is considered the placement of the hysterotomy incision should be carefully evaluated. If the lower segment can be reached, an incision transecting the myoma can be avoided, exposure for delivery would be adequate then a lower segment cesarean section should be done. However,  a classical cesarean delivery may be needed in case the myoma is occupying the lower segment, and an incision over the myoma to reach the fetus cannot be avoided.
Conventional practice and teaching discourages myomectomy during pregnancy or delivery especially during cesarean sections. The chances of torrential bleeding and maternal mortality being the real dangers which still exist. However, myomectomy is still indicated in pregnancy for pedunculated subserosal fibroids that can be clamped and removed or such fibroids undergoing torsion and resulting in acute abdomen. Sometimes the fibroid protrudes into the hysterotomy incision and prevents suturing of the same. Myomectomy will inadvertently have to be performed prior to closure of such an incision.  Focally morbidly adhered placenta may necessitate a myomectomy. But this may not be successful in all cases and life threatening hemorrhage may require a hysterectomy.
Adequate counseling of such patients and consent for an inadvertent myomectomy or an obstetric hysterectomy for uncontrollable hemorrhage during the time of cesarean section may prevent future litigation.

From this issue we have added a write up on one of the personalities who has made significant contributions in the field of Obstetrics & Gynecology. We hope the readers  would enjoy this additional feature.

Posthysterectomy Fimbrial Prolapse – Unusual Presentation

Author Information

Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)

Abstract

Prolapse of the fimbria of the fallopian tube is an uncommon complication of hysterectomy. It is usually confused for vault granulation tissue in the vault of vagina. Usually the patient presents with blood stained vaginal discharge or postcoital vaginal bleeding and lower abdominal pain. A case with a different presentation is presented here. Such a presentation has not been reported in the world literature before.

Introduction

The incidence of fimbrial prolapse after hysterectomy is  less than 1%. It is much lower in better centers. It is a benign condition, but needs to be treated as it causes inconvenience to the patient. It is very often misdiagnosed in cases of vault granulations. Pain is often a distressing symptom in cases of fimbrial prolapse, which is absent in cases of vault granulations. A case with a different location of severe pain is presented here.

Case Report

A 44 year old woman, gravida 2 para 2 with two living children, presented with a complaint of intense pain in left lower abdomen, left lumbar region, and left side of the chest up to the left axilla. This pain was experienced more intensely during coitus. She had undergone an abdominal hysterectomy for abnormal uterine bleeding due to uterine leiomyomas one year ago. The pain started about one month after that operation, and rapidly progressed to its severe form in another month. She visited her doctor for this pain, who referred her to us for further management. She had suffered from menorrhagia for four months, prior to which her menstrual cycles had been regular and with moderate flow and mild pain in lower abdomen and back. She was diagnosed to have multiple uterine leiomyomas and had undergone an abdominal hysterectomy for the same. Her recovery from that operation had been uneventful. Her past medical history was not contributory. She had two normal deliveries in the past.
On examination her vital parameters were within normal limits. General and systemic examination revealed no abnormality. A speculum examination showed a 2x2x1 mm pink fleshy mass with three finger-like projections near the left angle of the vault of the vagina. It did not bleed to touch during the process of obtaining of a Pap smear, but there was intense pain similar to the pain she had during coitus. Bimanual pelvic examination revealed no pelvic mass, but intense pain as described before. The mass was held gently with sponge-holding forceps and mild traction was made. This resulted in reproduction of her pain. So a diagnosis of fimbrial prolapse was made. A pelvic ultrasonography (USG) did not show any pelvic mass. The patient was counseled to undergo excision of the prolapsed left tubal fimbria vaginally. But she was lost to follow up. She followed up after one and a half year with a complaint of pain in the left iliac fossa. She stated that she had got the prolapsed fimbria excised by abdominal route at a center near her place of residence. Histopathological examination had confirmed the diagnosis. Her examination at that time showed that she had mild pelvic infection. There was a cyst in the left adnexa measuring 2 cm in diameter. USG confirmed the diagnosis of left simple ovarian cyst. She was given a course of cefixime, doxycycline and metronidazole over 14 days as per national guidelines for management of pelvic infection. She came back after one month, with a complaint of pain in right part of her Pfannensteil scar and continuation of the pelvic pain. On palpation, a tender irregular nodular mass measuring 2 cm in width and 1 cm in diameter was felt in the left part of the Pfannensteil scar. A differential diagnosis of abdominal wall sepsis and scar endometriosis was made. She was given ceftriaxone, gentamycin  and metronidazole parenterally for 7 days. The symptoms did not resolve. She was asked to report during her next episode of pain. She came back after a week with pain. At that time the pain in her pelvis and abdominal wall were found to have increased. The abdominal wall lesion had become bigger and more tender. There was no palpable pelvic mass. A diagnosis of scar endometriosis was made. She was given leuprolide depot 11.25 mg intramuscularly. Her pain did not recur on a monthly basis after that. The abdominal lesion regressed over 6 months. She was advised to report in case of recurrence of her symptoms.


Figure 1. Speculum examination of the vagina showing fimbrial prolapse near the left angle of the vault of the vagina.

Discussion

Pozzi reported a prolapse of the of the fallopian tubal fimbria for the first time in 1920.[1] It is an uncommon complication after hysterectomy. Its incidence is 0.06% after an abdominal hysterectomy, 0.5% after a vaginal hysterectomy.[2]  Risk factors for development of this condition include low socio-economic status, postoperative formation of hematoma and/or infection of the vault, and an open vaginal cuff are risk factors for the development of this condition.[3]  The lower incidence in better centers may be related to adequate closure of the pelvic peritoneum, achieving proper hemostasis so as to prevent formation of a vault hematoma and low occurence of sepsis in the vault of vagina. Use of modified Heaney's technique of vault suspension rather than Bonney's technique could also contribute to this lower incidence, as the latter involves suspension of the center of the vault of vagina from the cornual and uterosacral pedicles tied together, which puts the tubes right next to the vault. Fimbrial prolapse develops usually about four months after the hysterectomy, while the longest reported time is 32 years.[4]
The diagnostic test for fimbrial prolapse is the traction test. It involves holding the lesion with sponge holding forceps and making gentle traction on it.[5] If it fimbria have prolapsed, the fallopian tube above the vault gets pulled and the patient experiences the same pain that she gets at other times. In case of vault granulation tissue, it gets detached painlessly and easily. This tissue can be examined histologically and its nature determined. Histopathological examination of the tissue removed confirms the diagnosis of granulation tissue.[6] 
The case presented here was unique. Normally the pain elicited on traction test is confined to the pelvis and lower abdomen on the side of the fallopian tube. In this case the pain was experienced from pelvis up to the axilla on the same side. This can be explained partly by the nerve supply of the peritoneum of the infundibulopelvic ligament (T6 level). Thus traction on the ligament would cause pain at the level of sixth intercostal space on the lateral thoracic wall. However the axilla is supplied by the second intercostal nerve (T2). The pain experienced by this patient in the axilla cannot be explained by normal anatomy.
Endometriosis can develop in the abdominal wall after a laparotomy, when the uterine cavity is opened during the operation, as after cesarean section, hysterotomy and sometimes myomectomy. None of these conditions was applicable to the given case. However it is possible that metaplasia occurred in tubal cells implanted in the incision during abdominal removal of the prolapsed fallopian tube. There is no way this can be proved in this case.

Conclusion

It is extremely unusual that fimbrial prolapse causes pain in the axilla. This is the first case of this nature in the world literature. Removal of a fallopian tube through an abdominal incision can cause implantation endometriosis.

References
  1. Pozzi M. Hernie de la trompe dans le vagin au niveau de la cicatrice opératoire d’hystérectomie vaginale. C R Soc Obstet Gynecol Paediat Paris 1902 ;4:255-257.
  2. Fan QB, Liu ZF, Lang JH, et al. Fallopian tube prolapse following hysterectomy. Chin Med Sci J. 2006;21(1):20-23.
  3. Ramin SM, Ramin KD, Hemsell DL. Fallopian tube prolapse after hysterectomy. South Med J 1999;10:963–966.
  4. Ouldamer L, Caille A, Body G. Fallopian Tube Prolapse after Hysterectomy: A Systematic Review. PLOS ONE 2013;8(10):e76543.
  5. Parulekar SV. Fimbrial Prolapse: Diagnostic Clinical Test. JPGO 2014 Volume 1 Number 10. Available from: http://www.jpgo.org/2014/10/fimbrial-prolapse-diagnostic-clinical.html
  6. Vandana M Sanklecha, Shantilal M Sisodia, Sameer A H. Ansari and Smita Pol.  Posthysterectomy fallopian tube prolapse. J Midlife Health, 2012;3(1):40-41.

Citation

Parulekar SV. Posthysterectomy Fimbrial Prolapse – Unusual Presentation. JPGO 2018 Volume 5 Number 5. Available from: http://www.jpgo.org/2018/05/posthysterectomy-fimbrial-prolapse.html

Recurrent Giant Cervical Polyp Of Unusual Appearance

Author Information

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

Abstract

Cervical polyps are relatively common benign lesions seen often in 4th-5th decade of life. They usually develop as a reactive change to chronic inflammation, with dilated cervical glands and microglandular hyperplasia can be seen on histopathology. Giant polyps are rare and can be a diagnostic dilemma. Here we present a report on a giant cervical polyp in a 43 year old multigravida.

Introduction

A cervical polyp is usually a benign, small, pedunculated tumor less than 2 cm, incidentally diagnosed on routine examination. Large cervical polyps (>4 cm) are rare.[1,2] They could present as a mass protruding out of vaginal introitus,. Their size and clinical presentation can mimic a cervical neoplasia.  They are commonly seen in multiparous  women, usually in the 4- 5th decade of life.[2] Radiological investigations like ultrasonography (USG) can help in distinguishing cervical polyps from large protruding submucous leiomyomatous  polyps. They are generally treated surgically (simple hysterocopic or under vision polypectomy).

Case Report

A   43  year old woman, para 2 living 2, with previous 2 uneventful normal vaginal deliveries,  presented with complaints of a soft painless mass in vagina, progressively increasing in size over 1.5 years, protruding on increased abdominal pressure like coughing or straining since 6 months.  She complained of menorrhagia for 4-5 cycles, associated with a dull abdominal pain radiating to lower back. She also noticed a change in the size of the mass with menses - it would increase in size during menses. She had a similar history 4 years ago, when she was operated for the same and the histopathological report of the mass showed the growth to be a cervical leiomyoma. On per speculum examination, there was a 4X5X3 cm sessile mass arising from the posterior lip of the cervix, extending out beyond the vulva. It was firm and variegated in  consistency. It was covered over by healthy epithelium, like that of portio vaginalis. Did no bleed on touch, was reducible but with difficulty. The first impression was that it was an enterocele. But the diagnosis was made when the cervical external os was seen in front of the mass. On per vaginal examination, uterus was 6 weeks sized and anteverted; lateral fornices were free and nontender. Pelvic USG revealed the mass to be cervical polypoidal growth. Pap smear was severe inflammatory. The patient was counseled and she opted for vaginal hysterectomy rather than removal of the polyp, since the abnormal uterine bleeding would not be cured by polypectomy.
Intraopertaively, it was difficult to access the posterior peritoneal pouch due to the growth protruding from posterior cervical lip. After meticulous dissection of the anterior as well as posterior peritoneal pouch, uterosacral and cardinal ligaments were clamped, cut and transfixed with No. 1 polyglactin suture, without excising the large growth on the posterior lip of cervix. Uterine arteries bilaterally were clamped, cut and ligated. Uterus was bisected into two halves above the level of the polyp, cornual ends  were clamped and transfixed, and specimen (uterus+cervix+polyp) was delivered and sent for histopathological examination. 
She did well postoperatively and subsequently on followup. Histopathological examination revealed the section from the cervical growth showing polypoidal tissue covered with stratified squamous epithelium, underlying tissue showed odematous stroma, cervix showed squamous metaplasia.


Figure 1.  Polyp (P) arising from the posterior lip of the cervix. Anterior  lip of the cervix (A) is seen held with a vulsellum.


Figure 2.  Dissection of the uterovesical pouch of peritoneum.


Figure 3.  Dissection of the posterior pouch of peritoneum. Posterior aspect of the polyp is seen (P). Soonawala's speculum is seen inserted into the open posterior peritoneal pouch (arrow).


Figure 4.  Surgical specimen showing bisected uterus (U) and polyp (P).

Discussion

This is a case report of a giant cervical polyp in a multiparous adult patient. Benign cervical polyps  are common tumors of the cervix, although usually they are small and found in middle aged and older women, rare in adolescent  age group.[3-5] They may arise from the endocervix (lined by glandular epithelium) and ectocervix (lined by squamous epithelium- less commonly observed). Cervical polyps can present with symptoms of leucorrhoea or malodorous discharge, protruding mass, postcoital bleeding, dyspareunia.[2] Large polyps could also present as  mass protruding through introitus, with micturition difficulties and pelvic discomfort.  The differential diagnosis clinically could be of cervical leiomyoma, cervical malignancy, large endometrial polyps protruding through the os, large nabothian cyst, vascular neoplasms, squamous papilloma, chronic uterine inversion, uterine rhabdomyosarcoma.[6,7] The possible complications of polyp can range from ulcerations leading to secondary infection, infertility due to obstruction of the canal, and torsion of large polyps causing excruciating pain. Only 1.7% of cervical polyps undergo malignant transformation.[7] Pap smear should be done as a screening procedure. Radiological investigations such as USG or magnetic resonance imaging can be used to ascertain the diagnosis and the extent in the large polyps. Definitve diagnosis is always histological, hence surgical excision of the polyp, especially a large polyp is done.[6-8] Small asymptomatic polyps are not necessarily excised, the patient can be followed up over a long time. Smaller polyps can be grasped with a clamp and twisted free and base can be cauterized for hemostasis. Resection should be as complete as possible to avoid regrowths. Most of the giant cervical polyps reported are benign but histopathological examination is must to rule out malignancy. 
The polyp in the patient presented here was unusual. Its base was of the same diameter as its pedicle, like downward continuation of the posterior lip of the cervix. There was no ulceration of the epithelium over it, which was very unusual. It was a recurrent polyp. The recurrence must have been due to residual part of the polyp after the first excision, and the residue must have been left behind due to absence of a well defined pedicle as was found this time too.

References
  1. Grigore M. Giant cervical polyps: Three cases with different pathologies. Journal of Obstetrics and Gynaecology. 2015;Volume 35 Issue 5, available at: https://www.tandfonline.com/doi/full/10.3109/01443615.2014.961909
  2. Bucella D, Frédéric B, Noël JC. Giant cervical polyp: a case report and review of a rare entity. Arch Gynecol Obstet. 2008 Sep;278(3):295-8. doi: 10.1007/s00404-008-0575-x.
  3. Lippert LJ, Richart RM, Ferenczy A. Giant benign endocervical polyp : report of a case. Am J Obstet Gynaecol 1974;118:1140-1. 
  4. Duckman S, Suarez JR, Sese LO. Giant cervical polyp. Am J Obstet Gynaecol 1988;159:852-4. 
  5. Aridogan N, Cetin MT, Kadayifci O, Atay Y, Bisak U. Giant cervical polyp due to a foreign body in a “virgin”. Aust NZ J Obstet Gynaecol 1988;28:146-7. 
  6. Israel SL. A study of cervical polyps. Am J Obstet Gynecol 1940;39:45-50.
  7. Wu WH, Sheu BC, Lin HH. Giant cervical polyps : Report of two cases and literature review. Taiwanese J Obstet Gynecol 2005;44(1):65-8.
  8. Simavli S, Kinay T. Giant cervical polyp ; A case report and review of the literature. Turkiye Klinikleri J Gynecol Obst 2013;23(2):119-22. 
Citation

Parulekar M, Parulekar SV. Recurrent Giant Cervical Polyp Of Unusual Appearance. JPGO 2018. Volume 5 No.4. Available from:http://www.jpgo.org/2018/05/recurrent-giant-cervical-polyp-of.html

Classical Cesarean Section In Case Of Lower Segment And Broad Ligament Fibroids

Author Information

Gupta P*, Chaudhari HK**, Kambhampati L***.

(* Senior Resident, ** Associate Professor, *** Junior Resident. Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)


Abstract

This is a case report of fibroids in the lower segment of the uterus and broad ligament with live fetus in a multiparous woman that was managed by classical cesarean section. This case report depicts the successful method of management of such cases if encountered especially in case where lower segment cesarean section cannot be done due to the presence of fibroids.

Introduction

Leiomyoma or uterine fibroids are one of the most common benign tumors of the reproductive age group. These may remain asymptomatic or may present as an incidental finding in approximately 50% of the cases.[1] Generally fibroids are associated with complications in pregnancy like malpresentations, dysfunctional labor, APH, PPH and also secondary infertility.[2,3]  As these are estrogen dependent they may grow or undergo red degeneration during the course of pregnancy.[4] Excessive blood loss may occur during surgery. However, in this case good preoperative workup and mapping of the fibroid along with careful planning of the classical cesarean section helped in the safe management of this patient.

Case Report

A 35 year old G3P2L2 was referred to our  hospital with 36 weeks of pregnancy. Her general and systemic examination were normal. Her  hemoglobin was 10.2 g/dl. On obstetric examination she was 36 weeks pregnant had a transverse lie and an additional firm mass of around 20 x 19 cms palpable below the umbilicus. On vaginal examination fibroid was felt below the presenting part. Ultrasound showed a single live fetus of about 36 weeks of gestation, with an estimated fetal weight of 2.45 kg and a fundal placenta. Multiple fibroids were also detected. A large fibroid of 21 x 5.6 x 11 cms extending from the fundus right up to the cervix in a ‘L’ shaped manner was seen; a 2nd intramural  fibroid of 2.3 x 1.4 cms was seen in the anterior uterine wall. Another 5.6 x 3 cm intramural fibroid on the lower segment of the uterus was identified. A 4th intramural fibroid measuring 4.7 x 3 cm  on the anterior wall of the uterus was also seen. As fetus was in the transverse lie, fibroid was felt below the  presenting part, and the fibroid was in a L shaped manner going from the uterine fundus across the lower uterine segment, we counseled the patient for need of classical cesarean section as the lower segment cesarean section may have resulted in the extension of the incision  onto the fibroid which would have caused excessive blood loss and possibility of an emergency obstetric hysterectomy. After the necessary preoperative investigations she underwent classical cesarean section. A live male baby weighing 3.07 kg was delivered out by breech presentation. Intraoperative observations also included the presence of multiple fibroids. (Figure 1, 2) A 4 x 3 cm fibroid was seen in the lower segment towards the left side, another fibroid with similar dimensions was near the fundus on the anterior wall. A  large 15 x 10 x 10 cms broad ligament fibroid towards the right side extending from the infra hepatic region of the uterus to the lower segment of the uterus was seen. The fibroids were left alone to avoid any complications which might have occurred as pregnancy results in a hyper vascularized state of the uterus. The operation and the postoperative period were uneventful and the mother and the baby were both discharged on the 7th post operative day. The uterus was 20-22 weeks in size at the time of discharge.


Figure 1. A 4 x 3 cm fibroid in the lower segment towards the left side.

Figure 2. Oblique arrow showing 15x10x10 cm broad ligament fibroid towards the right side extending from the fundus below infra hepatic region to the lower segment of the uterus. Vertical arrow showing 4x3 cm fibroid in the lower segment towards the left side.

Discussion

Incidence of fibroids may vary from 0.1% to as high as 12.5%.[5] Generally the fibroids are unaffected with pregnancy but in some cases it may increase in size by about 10%.[6] Pregnancy complicated by fibroids increases the rate of cesarean section due to malpresentation and difficult labor. About 10– 30% of patients develop complications like red degeneration, infertility and torsion.[3] In this case we were lucky that there were no complications seen.
A classical cesarean section was planned as on ultrasonography the fibroid was visualized from fundus to the cervix and hence, any incision taken through the lower segment entailed the risk of going through the fibroid that would have entailed doing a myomectomy. Even though recent studies have shown that there is no increased risk in performing myomectomy along with the cesarean section[7] we wanted to avoid such an event in this patient as there were multiple fibroids present. As a huge fibroid extending from the fundus to the cervix would have got incised during a lower segment transverse incision and a myomectomy of this fibroid would have caused extensive blood loss a decision to perform classical cesarean section was taken. Therefore, the decision of not doing myomectomy with cesarean seems to be justified.
In a study to evaluate the significance of number and the size of fibroids on the outcome of pregnancy by Ciavattini A. et al it was seen that increase in the size and the number of fibroids with pregnancy were associated with preterm births, malpresentations and higher incidence of cesarean section.[8] Our patient also had a transverse lie and hence required a cesarean delivery.
In a recent study by Ezzedine et al it has been advocated that cesarean section should only be advocated in cases where there are obstetric indications. In this case to the presence of transverse lie and huge fibroids in the lower segment favored the indication of a cesarean section and that to a classical one.[9] It has also been advocated not to go for myomectomy during cesarean or during the course of pregnancy as it may complicate the pregnancy. Hence, in this case also the fibroids were left as such during the cesarean section.

Conclusion

Our patient having multiple fibroids with pregnancy was managed successfully with classical cesarean section. The decision of not doing the myomectomy with cesarean section is also justified as the size, number of fibroids and chances of future complications were a deterring factor. Also we feel that in such cases a classical cesarean section should be the first choice of surgical management and not the lower segment cesarean section.

References
  1. Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990;94(4):435-8.
  2. Jayakrishnan K, Menon V, Nambiar D. Submucus fibroids and infertility: Effect of hysteroscopic myomectomy and factors influencing outcome. J Hum Reprod Sci 2013;6(1):35-9.
  3. Lee HJ, Norwitz ER, Shaw J. Contemporary Management of Fibroids in Pregnancy. Rev Obstet Gynecol. 2010;3(1):20-27.
  4. Levy G, Hill MJ, Beall S, Zarek SM, Segars JH, Catherino WH. Leiomyoma: genetics, assisted reproduction, pregnancy and therapeutic advances. J Assist Reprod Genet 2012;29(8):703-12.
  5. Cooper NP, Okolo S. Fibroids in pregnancy--common but poorly understood. Obstet Gynecol Surv 2005;60(2):132-138.
  6. Aharoni A, Reiter A, Golan D, Paltiely Y, Sharf M. Patterns of growth of uterine leiomyomas during pregnancy. A prospective longitudinal study. BJOG 1988;95(5):510-513.
  7. Lolis DE, Kalantaridou SN,  Makrydimas G, Sotiriadis A, Navrozoglou I, Zikopoulos K, et al. Successful myomectomy during pregnancy. Human Reproduction. 2003;18(8):1699–1702.
  8. Ciavattini A, Clemente N, Delli CG, Di Giuseppe J, Giannubilo SR, Tranquilli AL. Number and size of uterine fibroids and obstetric outcomes. J Matern Fetal Neonatal Med. 2015;28(4):484-8.
  9. Ezzedine D, Norwitz ER. Are Women With Uterine Fibroids at Increased Risk for Adverse Pregnancy Outcome? Clin Obstet Gynecol. 2016;59(1):119-27.
Citation

Gupta P, Chaudhari HK, Kambhampati L. Classical Cesarean Section In Case Of Lower Segment And Broad Ligament Fibroids.  JPGO 2018. Volume 5 No.3. Available from: http://www.jpgo.org/2018/05/classical-cesarean-section-in-case-of.html

Posterior Vaginal Wall Leiomyoma

Author Information
Singhania N*, Prasad M**, Gupta AS***.
(* First Year Resident, ** Assistant Professor, *** Professor, Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)

Abstract

Primary vaginal tumors are uncommon. Vaginal leiomyoma is an even rarer entity. A case of vaginal leiomyoma in a parous woman who underwent successful excision is reported here.

Introduction

Leiomyoma is a benign smooth muscle tumor. While it can occur in any part of the body, female genital tract is a common place for its occurrence. While uterine leiomyoma is the most commonly encountered entity in common gynecological practice, it can be present in any other tissue. A case of vaginal leiomyoma is described below

Case Report

A 36 year old married woman, para 2 living 2 presented with something coming out of vagina since one month. She felt a nodule like mass in her private parts, which reportedly increased with micturition. She had no other complaints. She had undergone tubal ligation. She had regular menstrual cycles, and no other medical or surgical co-morbidities. On examination, abdomen was soft and scar of tubal ligation was present. On speculum examination, cervix was torn with no descent and a firm mass of around 2 inch in size was seen prolapsing from the middle part of the posterior vaginal wall on coughing. Rectocele was also present. On per vaginal examination, the uterus was retroverted, parous and the fornices were free, non-tender. The mass was felt fixed to the posterior wall of the vagina, and the entire margin of the mass was felt in the posterior vaginal wall. On rectal examination, mass could not be felt and the rectal mucosa was free. Clinical impression was posterior vaginal fibroma that was confirmed by ultrasonography. Transrectal ultrasonography showed 2.7x1.7 cm posterior vaginal wall solid mass with internal vascularity with preserved plane between the anterior rectal wall and the mass. (Figure 1) Pre-operative investigations were within normal limits. Posterior vaginal wall fibroma excision with posterior colpoperineorraphy was performed. A midline incision was taken from the mucocutaneous junction to a point at the upper limit of the tumor, triangular flaps of vagina were dissected by sharp and blunt dissection (figure 2). The tumor was enucleated by sharp and blunt dissection from the loose recto vaginal fascia. Posterior colpoperineorraphy was completed. Specimen was sent for histopathology (figure 3). Histopathology report was suggestive of bundles of smooth muscle spindle cells suggestive of a benign leiomyoma. She was discharged on 3rd postoperative day. She had no complaints at her follow-up visit after 3 weeks.


Figure 1. Ultrasonography showing preserved plane between rectum (R) and leiomyoma (F) 

.
Figure 2. Intraoperative image showing posterior vaginal wall mass.


Figure 3. Leiomyoma being enucleated.

Discussion

Leiomyomas are common tumors of the uterus and sometimes of the cervix. Rarely they can occur in the round ligament and other rare locations.[1,2] The vaginal location is indeed a rare entity. As recent as 2011, only around 300 cases had been reported in medical literature.[3]
Our patient presented with complaint of a mass prolapsing out of vagina during micturition. Vaginal leiomyomas can present with varied symptoms. The commonly reported problems are vaginal bleeding, dyspareunia, dysuria and urinary obstruction.[4] Though our patient felt a mass, there was no overt uterovaginal prolapse. The mass mimicked the symptom of prolapse in our case. When the mass is big, it may present with prolapse, as described by Gurung et al.[5]  Our patient presented with prolapse symptoms but with a small leiomyoma. However, large masses causing contiguous spread and presenting as fistulae necessitating abdomino-perineal approach have also been described.[6]
Pelvic ultrasonography in our patient did not show any other significant leiomyoma in other locations. However, simultaneous presence in multiple areas is well documented.[7] When urinary complaints predominate, intravenous pyelography or cystoscopy may be required to ascertain the relationship of the mass with the urinary tract.[8] We ascertained our diagnosis preoperatively by a transrectal ultrasonography. Sorensen et al in their case, had suggested that translabial ultrasonography or MRI could be useful modalities. In their case, cervical leiomyoma was a close differential diagnosis.[9] However, in our case, the cervix was distinctly seen (at least 2 cm away) and identifying its origin from the posterior vaginal wall unrelated to cervix was not a clinical difficulty. MRI may be an option in cases with diagnostic dilemma.[10]
Simple surgical excision and posterior colpoperineorrhapy completed her treatment. No preoperative biopsy of the mass was done as the mass was small, margins were easily delineated and imaging did not suggest any chances of malignancy. It is important to note that in the case of vaginal leiomyoma there is a definite chance of misrepresented sample and hence delayed/ misleading diagnosis, as reported by Woo et al.[11]

Conclusion

Vaginal leiomyoma is a rare entity. Accurate clinical examination and transvaginal ultrasonography helps in ascertaining diagnosis. Rectal involvement should be meticulously ruled out. Simple surgical excision completes the treatment.

References
  1. Verma ML, Singh U, Jaiswal R, Sharma R. Huge Fibroid Of The Round Ligament Masquerading As Adnexal Mass. JPGO 2018. Volume 5 No.2. Available from: http://www.jpgo.org/2018/02/huge-fibroid-of-round-ligament.html
  2. Bora A, Madhva Prasad S, Gupta AS Large Degenerated Broad Ligament Fibroid. JPGO 2017. Volume 4 No. 1. Available from: http://www.jpgo.org/2017/01/large-degenerated-broad-ligament-fibroid.html
  3. Chakrabarti I, De A, Pati S. Vaginal leiomyoma. J Mid-life Health 2011;2(1):42-3.
  4. Imai A, Furui T, Hatano Y, Suzuki M, Suzuki N, Goshima S. Leiomyoma and rhabdomyoma of the vagina . Vaginal myoma. J Obstet Gynaecol. 2008;28(6):563-6.
  5. Gurung G, Rana A, Magar DB. Utero-vaginal prolapse due to portio vaginal fibroma. J Obstet Gynaecol Res. 2003;29(3):157-9.
  6. Gowri R, Soundararaghavan S, Oumachigui A, Sistla SC, Iyengar KR. Leiomyoma of the vagina: an unusual presentation. J Obstet Gynaecol Res. 2003;29(6):395-8.
  7. Meniru GI, Wasdahl D, Onuora CO, Hecht BR, Hopkins MP. Vaginal leiomyoma co-existing with broad ligament and multiple uterine leiomyomas. Arch Gynecol Obstet. 2001; 265(2):105-7.
  8. Daskalakis GJ, Karabinas CD, Papantoniou NE, Papaspyrou IA, Antsaklis AJ, Michalas S. Vaginal fibroma. Case report. Eur J Gynaecol Oncol. 2002;23(6):575-6.
  9. Sørensen M, Chauhan P. [Leiomyoma can also be located in the vagina]. Ugeskr Laeger. 2011 May 23;173(21):1510-1.
  10. Scialpi M, Benagiano G, Frati S, Piscioli I, Barberini F, Lupattelli L. Magnetic resonance imaging features of myxoid leiomyoma of the vagina: A case report. Indian J Radiol Imaging. 2009;19(3):238-41.
  11. Woo A, Scurry J, Jaaback K. Delayed diagnosis of vaginal leiomyoma following misrepresentative core biopsy. Pathology. 2013;45(4):429-30.
Citation

Singhania N, Prasad M, Gupta AS. Posterior Vaginal Wall Leiomyoma. JPGO 2018. Volume 5 No.4. Available from: http://www.jpgo.org/2018/05/posterior-vaginal-wall-leiomyoma.html

Classical Cesarean Section For Large Central Cervical Fibroid

Author Information
Singhania N*, Pardeshi S**, Gupta AS***.
(* First year Resident, ** Assistant Professor, *** Professor, Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, India.)

Abstract

A case of a 27 year old primigravida with an incidental finding of a large central cervical fibroid in pregnancy is being reported. She was managed conservatively throughout her pregnancy and subsequently had to have a classical cesarean section to deliver a female child.

Introduction

Cervical fibroid in pregnancy can make pregnancies high risk as complications in the antepartum, intrapartum and postpartum period can occur. [1] It may lead to malpresentations. Sometimes they are so big that they fill the entire pelvis making vaginal deliveries impossible.They tend to increase in size during pregnancy, which eventually decrease in the postpartum period. Patient after puerperium can have a definitive treatment like myomectomy or hysterectomy.

Case Report

A 27 year old, primigravida registered in our hospital at 34 weeks of gestation with cervical fibroid. She had registered in a private hospital in her 2nd month of pregnancy. Routine ultrasonography was suggestive of an anterior wall fibroid of 8.3*7.6 cms. She was given more vigilant antenatal care and underwent serial ultrasound at different weeks of gestation. The serial ultrasound showed increasing sizes of the fibroid; which were like 8.3*7.6 cm at 8.3 weeks of gestation, 11*7 cm at 15 weeks, and 13.5 *9.5 cm at 20.3 weeks.The fibroid regressed in size to 11.5*11.5 cm at 29-30 weeks, which decreased further to 8.3*7 cm at 36 weeks of gestation. At 34 weeks she was referred to our hospital for registration for further management. She had no other medical or surgical high risk factors. At 37 weeks of gestation her abdominal examination findings showed the the uterus corresponding to 36 weeks in size was relaxed, central cervical fibroid was felt below the fetus. Fetus was in the right dorso superior position. Fetal heart sounds were present/ regular/ 140 beats per minute.  Vaginal examination found a high placed closed cervix, fibroid was felt through the anterior right and posterior fornix and also through the right and the left fornix. Pelvis was empty. No fetal part or the fibroid was felt in the pelvis.  Decision to perform elective cesarean section was made and she was admitted for the same. Serological and biochemical investigations were done and they were within normal limits. She was counseled and she consented for a classical/ Lower segment cesarean birth. She also consented for a cesarean myomectomy or a cesarean hysterectomy if required. During cesarean section uterus was extremely dextrorotated by 90 degrees bringing the left adnexa anteriorly in the midline, huge cervical fibroid of 20*15 cm was seen. The lower uterine segment was replaced with the fibroid that was extending to the broad ligament (Figure 1). Uterovesical fold was not elevated. Bladder and uterovesical fold were below the largest diameter of the cervical fibroid. Delivery of fetus was not possible through an incision through the lower segment without incising the myoma hence classical incision was taken on the upper part of the uterus (Figure 2). A female fetus weighing 2.450 kg was delivered by breech. Fibroid was left untouched. Uterus was closed in 2 layers. Hemostasis was confirmed. Abdomen was closed in layers. She was stable in the postoperative phase and was discharged on after 4 days. Sutures were removed  on postoperative day 14, wherein the wound had healed well. She was called after 6 weeks for fibroid size evaluation.


Figure 1. Uterus with big central cervical fibroid. ‘F’ is the anterior part of the cervical fibroid. Yellow arrows show the posterior part of the cervical fibroid. ‘O’ is the ovary. Babcocks forceps are holding the cut edges of the classical cesarean incision.


Figure 2. Vertical midline classical cesarean sutured incision on uterus with the large cervical fibroid below.

Discussion

Fibroids are most commonly found in the uterus but rarely can be present in the cervix or the vagina. On the cervix they are most commonly found in its supravaginal part.[2] These supravaginal fibroids can be found at various positions, on the right, left or they can be centrally placed, filling up the pelvis. The central cervical fibroid pushes the uterine body  superiorly and the cervical os is found high up on digital pelvic examination.[3] The uterus usually sits on the tumor and this appearance is typically described as a ‘lantern on top of St Pauls’ cathedral’.[4] According to a study conducted by Laughlin SK et al. pregnancy with cervical fibroid has a prevalence of 10.7%.[5] These can present as recurrent abortions, acute abdominal pain due to red degeneration, preterm deliveries, non cephalic presentations, obstructed labor leading to increased cesarean section.[6] Rarely, these fibroids may not interfere in normal vaginal deliveries as represented in a case report by Kanti et al.[7] The fibroids usually increase in size during pregnancy and reduces considerably in the postpartum period. Woman presenting with central cervical fibroid generally undergo  elective cesarean section as a mode of delivery, as was done in our case. The size of fibroid is an important factor in deciding type of incision, bigger fibroids usually require a midline vertical incision.[3] Sometimes delivery of the fetus is not possible through a lower uterine incision even if it is possible to place the incision as big fibroids sitting just superior to the lower segment interfere in the delivery of the fetus necessitating the need for a classical cesarean incision, as was required in our case. The anterior and central cervical fibroid, specially which spreads into the broad ligament tends to undermine the bladder and displace the ureters leading to increased risk of ureteric injury during hysterectomy.[8] Fibroids in pregnancy should be managed conservatively during the antepartum, intrapartum and postpartum periods and this management has shown to give good clinical outcomes. Myomectomy can be delayed till the size of the tumor decreases following which they are easy to remove.

References
  1. Ng AX, Sulaiman S, Tagore S. Challenges of a Large Cervical Fibroid in Pregnancy. Obstet Gynecol Int J. 2016;5(3):00161.
  2. Kumar P, Malhotra N. Tumours of the corpus uteri. In: Kumar P, eds. Jeffcoat’s Principles of Gynaecology. 7th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd. 2008; 491.
  3. Keriakos R, Maher M. Management of Cervical Fibroid during the Reproductive Period. Case Reports in Obstetrics and Gynecology. 2013;2013:3 pages.
  4. Kavitha B, Jyothi R, Devi AR, Madhuri K, Avinash KS, Murthy SGK. A rare case of central cervical fibroid with characteristic “LANTERN ON TOP OF ST.PAUL” appearance. Int J Res Dev Health. 2014; Vol 2(1): 45-47
  5. Laughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: an ultrasound-screening study. Obstet Gynecol. 2009;113(3):630-5.
  6. Chowdhury M, Gupta V, Jain VJ, Bhardwaj A. A rare case of cervical fibroid presenting as retained placenta with postpartum hemorrhage. Int J Reprod Contracept Obstet Gynecol 2015;4(2):505-7.
  7. Kanti V, Mishra P, Gupta V, Vishwakarma S, Kumari K, Pandey P. A rare case of repeated expulsions of a giant cervical fibroid per vaginum followed by delivery of near term babies in two consecutive pregnancies. Int J Reprod Contracept Obstet Gynecol. 2014;3(3):790-2
  8. Basnet N, Banerjee B, Badani U, Tiwari A, Raina A, Pokharel H et al. An unusual presentation of huge cervical fibroid. Kathmandu University Medical Journal. 2005;3(2)(10):173- 174.
Citation

Singhania N, Pardeshi S, Gupta AS. Classical Cesarean Section For Large Central Cervical Fibroid. JPGO 2018. Volume 5 No.5. Available from:http://www.jpgo.org/2018/05/classical-cesarean-section-for-large.html

Ruptured Ovarian Ectopic Pregnancy

Author Information

Jha N*, Tiwari N**, Chaudhari HK***.

(* Second Year Resident, ** Assistant Professor, ***Associate Professor. Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai.)

Abstract

Ectopic pregnancy constitutes 2% of all pregnancies and is responsible for 9 % of all maternal deaths. Common sites of an ectopic pregnancy include tubal (97 %), ovarian (0.5 %), abdominal (1%) and uterine sites other than endometrial cavity.
Here we present a case of a woman presenting in emergency with complaints of spotting per vagina and severe abdominal pain diagnosed to be a case of ruptured ovarian ectopic pregnancy. Patient was managed successfully by emergency exploratory laparotomy with oophorectomy.

Introduction

An ectopic pregnancy is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity. Ovarian ectopic pregnancy is one of the rarest forms of ectopic pregnancy. Its incidence is 1 in 2000 to 1 in 60000 pregnancies and account for 0.5 to 3 % of all ectopic pregnancies. The classic symptoms of an ovarian pregnancy are pelvic pain, amenorrhea and vaginal bleeding, of which persistent pelvic pain alone is the most common manifestation. Beta human chorionic gonadotrophin immunoassay and ultrasonography can be helpful in diagnosis, but a discrete gestational sac is seen only in an advanced ovarian pregnancy. Spiegelbergs criteria used in the diagnosis of ovarian ectopic pregnancy consists of intact tube on the affected side, gestation sac in the position of ovary, gestation sac connected to uterus by ovarian ligament and ovarian tissue found on the wall of the gestational sac on histological examination.[1] Management mainly consists of ovarian resection with postoperative methotrexate therapy. Rarely oophorectomy may be required in case of massive hemorrhage.

Case Report

A 30 year old woman married since 7 years; Gravida 4 Para 2 Living 1 having previous one spontaneous abortion and one medical termination of pregnancy came with complaint of severe abdominal pain and backache since 2 days. She gave history of minimal vaginal bleeding 2 days ago. Urine pregnancy done at home was negative. She gave history of Hepatitis B antigen positive status that was detected in her previous pregnancy. No other significant medical or surgical history was present. Previous menstrual cycles were regular. She had undergone one lower segment cesarean section in view of meconium stained amniotic fluid 4 years ago.
On general examination her pulse was 120 beats per minute  and blood pressure was 90/60 mm Hg. She looked pale. On per abdominal examination there was generalized abdominal tenderness. On per vaginal examination uterus was normal size, anteverted and left sided fornix tenderness was present.
On transvaginal ultrasonography, a 2.3x2 cm hypoechoic mass lesion was noted on right side with free fluid levels having mixed echogenicity that was suggestive of right ruptured ectopic pregnancy with hemoperitoneum approximately 15-20 cc.  Her hemoglobin was 6.5 gm%. Immediately she was resuscitated. Two units of packed cell volumes were transfused, and she was shifted to operation theater for emergency exploratory laparotomy. On exploratory laparotomy, around 1000 ml hemoperitoneum and 150 grams of clots were found. Uterus was normal size and adherent to anterior abdominal wall. Left fallopian tube and ovary was normal. Right fallopian tube was normal.  Around 3x2 cm ruptured ovarian pregnancy was seen in the right ovary.(Figure 1) The ovary seemed very vascular and it was too friable to attempt enucleation of the gestational sac. Therefore, decision of oophorectomy was taken. Hemoperitoneum was drained, right oophorectomy was done and peritoneal wash was given with 500 cc of normal saline
On histopathological examination, sections identified ovarian tissue showing large hematoma with admixed fibrin. Many entrapped chorionic villi surrounded by cytotrophoblast and syncytiotrophoblast were seen in the ovarian tissue. Adjacent ovarian tissue and corpus luteum seemed normal. Findings were suggestive of right ovarian ruptured ectopic pregnancy.


Figure 1. Showing ruptured ovarian ectopic pregnancy.

Discussion

Mercer was the first to describe ovarian pregnancy for the first time in 1614.[2] In 1899 Catherine Van Tussenbroek proved its existence by providing the first accurate clinical and histological description of a case.[3] Ovarian pregnancies constitute about 0.15 to 3 % of ectopic pregnancies. Etiology of ovarian pregnancy is not understood completely. In vitro fertilization and intra uterine devices appear to increase the chances of ovarian ectopic pregnancy. IUD appears to be the most important cause. Among 1 of every 9 ectopic pregnancies among IUD users is an ovarian pregnancy. Of total pregnancies among IUD users 4.3% are extrauterine. Only 15% of cases of ovarian pregnancy are intrafollicular in origin.
Persistent pelvic pain alone is the most important clinical manifestation of an ovarian pregnancy. An adnexal mass is palpable in 60 % of ovarian pregnancies which can be confused with a leaking corpus luteum hematoma.
Treatment mainly consists of methotrexate therapy and ovarian resection. Oophorectomy may be required in cases of massive hemorrhage. Raziel and Golan reported cases in which an intact ovarian pregnancy was diagnosed by laparoscopy and systemic methotrexate (MTX) treatment was successful.[4] Chelmow and colleagues also reported successful treatment of an ovarian pregnancy with methotrexate therapy only.[5] Einenkel and associates reported successful conservative resection of an ovarian pregnancy.[6] Seinara and colleagues reported successful laparoscopic treatment of ovarian pregnancy in 8 patients over a 12 year life span.[7] Patel et al showed that surgical treatment of ovarian pregnancy consists of wedge resection or oophorectomy.[8]

Conclusion

Ovarian ectopic is one of the rarest forms of ectopic pregnancy. Accurate diagnosis with prompt resuscitative measures and laparotomy can be lifesaving in acute emergency cases of ruptured ectopic pregnancy. When there is profuse hemorrhage, like in this case ovaries cannot be preserved and oophorectomy is the only choice.

References
  1. Spiegelberg O. Casuistry in ovarian pregnancy. Arch Gynaekol 1878; 13: pp. 73-79.
  2. Ismail M. Ovarian Pregnancy. https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1471-0528.1950.tb05210.x
  3. Hill, M.A. Embryology Paper 2- An Early Ovarian Pregnancy. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Paper_2-_An_Early_Ovarian_Pregnancy
  4. Raziel A, Golan A. Primary ovarian pregnancy successfully treated with methotrexate.  Am J Obstet Gynecol 1993; 169:1362.
  5. Chelmow D, Gates E, Penzias AS. Laparoscopic diagnosis and methotrexate treatment of an ovarian pregnancy: a case report. Fertil Steril. 1994;62(4):879-81.
  6. Einenkel J, Baier D, Horn LC, Alexander H. Laparoscopic therapy of an intact primary ovarian pregnancy with ovarian hyperstimulation syndrome: case report. Hum Reprod. 2000;15(9):2037-40.
  7. Seinera P, Di Gregorio A, Arisio R, Decko A, Crana F. Ovarian pregnancy and operative laparoscopy: report of eight cases. Hum Reprod. 1997;12(3):608-10.
  8. Patel Y, Wanyongi SZ, Rana SF. Laparoscopic management of an ovarian ectopic pregnancy: case report. East Afr Med J. 2008;85(4):201-204.
Citation

Jha N, Tiwari N, Chaudhari HK. Ruptured Ovarian Ectopic Pregnancy.  JPGO 2018. Volume 5 No.5. Available from: http://www.jpgo.org/2018/05/ruptured-ovarian-ectopic-pregnancy.html

Isthmocele - A Cesarean Scar Defect Managed Hystero-Laparoscopically

Author Information
Shah NH*, Deshmukh M**, Adsul SD ***, Paranjpe SH****.
(* Consulting gynecologist/obstetrician, Hon. Endosopic Surgeon, Wadia hospital & Railway Hospital (Byculla), ** Consulting Gynecologist/Obstetrician, Vardann Hospital, *** Consulting Gynecologist/Obstetrician, **** Director, Velankar Hospital & Paranjpe Maternity Home, Mumbai, India.)
Abstract
With the increasing evaluation by diagnostic hysteroscopy and an increase in rate of cesarean sections, a new entity called the isthmocele is coming up. Isthmocoele is nothing but a defect in the previous cesarean scar, incidence of which is increasing. We report here a case of such an isthmocoele causing secondary infertility and abnormal postmenstrual bleeding which was repaired with a concomitant hysteroscopy and laparoscopy. This also resulted in a successful outcome of IVF pregnancy.

Introduction

Isthmocele is a pouch-like defect on the anterior wall of the uterus at the isthmus. It appears as a fluid-filled pouch in the anterior uterine wall at the site of a previous cesarean section scar. The flow of blood during menstruation through the cervical region may be hampered by the presence of isthmocele. This is because the blood may accumulate in the pouch-like defect because of the presence of fibrotic tissue. This can also cause pelvic pain in the suprapubic area, infertility and abnormal post menstrual bleeding. The global incidence is somewhere between 6.2% and 36%, with an average rate of 21.1%.[1] These symptoms, taken together, have been closely investigated and are called cesarean scar syndrome.[2] Other complications of cesarean scar defect include complications occurring during subsequent pregnancy such as scar dehiscence, scar ectopic pregnancy, placenta previa and accreta. Complications can occur during gynecological procedures like uterine evacuation, hysteroscopy, or during intra uterine device insertion.[3]
Case Report

A 32 year old lady para 1 living1, married since 6 years with previous one cesarean section 4 years back presented with secondary infertility. She had irregular menses with intermenstrual bleeding. She had moderate to severe pain during menses which lasted for about 2 days only. About 7 to 10 days after menses, she had spotting and mild bleeding which again lasted for 2 to 3 days. General and systemic examination was normal. Per speculum and per vaginal examination showed normal findings. All routine blood investigations, hormonal assays, baseline follicular study and husband’s semen analysis were within normal limits. A transvaginal ultrasonography was done which was suggestive of a normal sized uterus with a diverticulum in the anterior wall of the uterine isthmus, at the site of her previous cesarean scar tissue (figure 1).


Figure 1. Ultrasonography picture of the defect

A diagnostic hystero-laparoscopy was done. An isthmocele was identified on hysteroscopy and also bilateral pathological tubal blockage was encountered during chromo-pertubation and cannulation. Hence, she underwent laparoscopic repair of ishtmocoele following which an IVF was planned.
Laparoscopic repair was done in the following manner. Bladder dissection was done by separating the uterovesical fold. Hysteroscopy was done concomitantly and transillumination seen laparoscopically. Scar was demarcated and excised by harmonic scalpel under guidance of transilluminesence. Intermittent suturing with barb sutures was performed in the first layer. Second layer suturing with same material to imbricate the first layer was done (figures 2 to 6).


Figure 2. Defect seen after separation of bladder fold.


Figure 3. Defect seen after transillumination.


Figure 4. After resection of the scar.


Figure 5. Suturing with barbed suture.


Figure 6. Final picture after completion of suturing.

Post operatively she was put on oral contraceptive pills for 6 months. This was followed by an IVF cycle and she conceived successfully with an intrauterine gestation. Thus an infertility was managed with planned scar defect repair and IVF since the tubes were blocked and also to prevent implantation at scar site.
Discussion

"Isthmocele” is defined as the presence of a diverticulum on the anterior uterine wall at the isthmus at the site of a previous cesarean scar. It represents a possible consequence of one or more cesarean deliveries. The presence of fibrotic tissue below the previous cesarean delivery scar (PCDS) defect may impair the drainage of menstrual flow through the cervix, acting like a valve and producing blood accumulation in the pouch, which in turn leads to secondary postmenstrual spotting.[4] This results in the stasis of the menstrual blood after menstruation in the cervix and may affect the mucus quality and sperm quality, obstruct sperm transport through the cervical canal leading to secondary infertility.[5] Isthmocele can also cause abnormal uterine bleeding due to the stasis of blood and abnormal accumulation of blood in the pouch-like areas. This results in inter- menstrual bleeding and pelvic pain. Also the retained blood and debris can interfere with sperm transport and embryo implantation.[6]
There are as such no studies relating to IVF and isthmocele, but there may be problems during the embryo transfer like – the deposition of the scar fluid or old blood on the catheter which is used for embryo transfer. Also, as there may be fluid present in the isthmocele, the effect of ovarian stimulation on this fluid and its release into the endometrial cavity has not been studied. And furthermore, the isthmocele scar fluid and old blood itself can cause difficulty in embryo implantation. This may be similar to patients with endometrial fluid with tubal factor infertility and hydrosalpinx.[7]
It can be diagnosed on hysteroscopy and can be successfully treated by laparoscopic or resectoscopic repair. Menstrual suppression can also improve symptoms.[8] In laparoscopy, different methods are described to locate the isthmocele. Klemm and colleagues had suggested to do a transvaginal ultrasonography under laparoscopic vision if the scar cannot be easily seen after bladder dissection.[9] In our case we have used transillumination from inside the uterus which showed clear demarcation of the isthmocele.

Conclusion

It is suggested that every patient of previous scar pregnancy with complaints of pelvic pain or infertility, or abnormal bleeding should be evaluated with transvaginal ultrasound, saline infused sonohysterogram, hysterosalpingogram, hysteroscopy, or magnetic resonance imaging and isthmocele should be considered.[10] An isthmocele may not only result in above symptoms but it can also be a site for implantation of pregnancy leading to scar ectopic pregnancy. These women may develop complications like scar rupture either spontaneous or during evacuation of the uterine cavity.  We also encourage gynecologists to include previous cesarean delivery scar as a differential diagnosis of those with bleeding disorders and previous cesarean delivery, because it is easy to identify and correct. Further prospective controlled trials would be necessary to evaluate the effectiveness of the surgical treatment in those with unknown infertility in order to confirm its effect in restoring fertility.

References
  1. Nezhat CM, Grace L, Soliemannjad R, Razavi GM, Nezhat A. Cesarean Scar Defect: What Is It And How Should It Be Treated? Obg Management 2016; 28(4): 32-53.
  2. Morris H. Surgical Pathology Of The Lower Uterine Segment Caesarean Section Scar: Is The Scar A Source Of Clinical Symptoms? Int J Gynecol Pathol. 1995;14(1):16–20.
  3. Perez-Medina T, Sancho-Sauco J, Rios M, Pereira A, Argila N, Cabezas E et al. Hysteroscopy In Pregnancy-Related Conditions: Descriptive Analysis In 273 Patients. J Minim Invasive Gynecol. 2014;21(3):417–25.
  4. Fabres C, Aviles G, De La Jara C, Escalona J, Munoz Jf, Mackenna A et al. The Cesarean Delivery Scar Pouch: Clinical Implications And Diagnostic Correlation Between Transvaginal Sonography And Hysteroscopy. J Ultrasound Med. 2003;22(7):695–700
  5. Thurmond AS, Harvey WJ, Smith SA. Cesarean Section Scar As A Cause Of Abnormal Vaginal Bleeding: Diagnosis By Sonohysterography. J Ultrasound Med. 1999;18(1):13–6.
  6. Bij De Vaate AJ, Van Der Voet LF, Naji O, Witmer M, Veersema S, Brolmann HA et al. Prevalence, Potential Risk Factors For Development And Symptoms Related To The Presence Of Uterine Niches Following Cesarean Section: Systematic Review. Ultrasound Obstet Gynecol. 2014;43(4):372–82.
  7. Akman MA, Erden HF, Bahceci M. Endometrial Fluid Visualized Through Ultrasonography During Ovarian Stimulation In Ivf Cycles Impairs The Outcome In Tubal Factor, But Not PCOS Patients. Human Reproduction. 2005;20(4):906–9.
  8. Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection Of Cesarean Scars By Transvaginal Ultrasound. Obstet Gynecol. 2003; 101(1): 61-65.
  9. Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. Laparoscopic And Vaginal Repair Of Uterine Scar Dehiscence Following Cesarean Section As Detected By Ultrasound. 2005; J Perinat Med 33(4): 324-331.
  10. Gubbini G, Casadio P, Marra E. Resectoscopic Correction Of The "Isthmocele" In Women With Postmenstrual Abnormal Uterine Bleeding And Secondary Infertility. J Minim Invasive Gynecol. 2008;15(2):172-5.
Citation

Shah NH, Deshmukh M, Adsul SD, Paranjpe SH. Isthmocele - a cesarean scar defect managed hystero-laparoscopically. JPGO 2018. Volume 5 No.5. Available from:http://www.jpgo.org/2018/05/isthmocele-cesarean-scar-defect-managed.html

Remembering Past Greats: Grantly Dick-Read

Author Information

Madhva Prasad Sarvothaman
(Assistant Professor, Department of Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)

Grantly Dick-Read (1890 - 1959) was a British practitioner who is most popularly known for his advocacy of the process of "natural birth". It is important to acknowledge that he lived in an era where there was extensive reliance of interventions by obstetricians leading to a significant amount of medical mishaps, which were hereto unaudited. His main contribution was a book titled "Natual childbirth", released in 1933 which shot him to international fame.

He contended that each pregnant woman should be meticulously informed in detail about the process of labour. By this they should become well prepared for the same. He advocated rhythmic breathing manoeuvres in relation to labour pain. He stressed on the possibility that labour, being a physiological process, could be made a joyful experience. He also said that lay public should not be given access to medical journals, which causes irrational fear of labour, because most journals deal with abnormalities. These opinions, which were ahead of his time, were met with stiff opposition.

In today's world, the above measures correspond to informed consent, planned parenthood and natural birthing measures. His measures appear to have laid the foundation for modern day antenatal care, and holistic obstetric care.

References
  1. Biographies. In O’Dowd MJ, Philipp EE, editors. The History of Obstetrics and Gynecology. 1st ed. Lancs: Parthenon Publishing Group 2000; pp. 645-6.
  2. Allen V. Dr Grantly Dick-Read. Arch Dis Child Fetal Neonatal Ed. 1995 Nov;73(3): F197-8.
Citation

Madhva Prasad Sarvothaman. Remembering Past Greats: Grantly Dick-Read. JPGO 2018 Volume 5 Number 5 Available from: http://www.jpgo.org/2018/05/remembering-past-greats.html

Takayasu Arteritis In Pregnancy: A Case Report From A Tertiary Hospital In South India

Author Information

Fernandes S*, Rao SV**, D’Almeida J*, Kumari P***
(* Assistant Professor, ** Professor, *** Senior Resident, Department of Obstetrics and Gynecology, Father Muller Medical College, Mangalore, India.)

Abstract

Takayasu arteritis is a vasculitis of unknown etiology affecting women of the reproductive age group and involving branches of the aortic arch. Pregnancy may have a favourable outcome, but complications are bound to happen particularly for those diagnosed for the first time in pregnancy. Although, those already diagnosed may enter pregnancy in remission and on medications. Here a case of pregnancy with Takayasu arteritis is presented.
Introduction    

Takayasu arteritis (TA), also known as pulseless disease/ aortoarteritis, is a chronic inflammatory progressive large vessel vasculitis of unknown etiology affecting women of childbearing age.[1–3] It leads to narrowing, occlusion and aneurysms of systemic and pulmonary arteries, affecting primarily the aorta and its branches.[4] Patients warrant special attention during the peripartum period owing to stenosis hindering regional blood flow.[5,6] An interdisciplinary collaboration of obstetricians, cardiologists, rheumatologists, and neurologists is necessary for optimal maternal and fetal prognosis.
Case Report
26 year old gravida 3 para 1 living 1 abortion 1 presented to the outpatient department at 34 weeks for the first time. She was admitted for evaluation of elevated blood pressure. She had prior antenatal visits elsewhere and was on tablet labetalol 100 mg since third month of pregnancy. Upon detailed clinical examination, a difference of more than 20 mm Hg was noted between the two upper limbs. On detailed questioning, she revealed a history of takayasu arteritis. Previous medical records revealed that almost 10 years prior, she had presented with claudication in both lower limbs. Lower limb pulses were feeble bilaterally, with an abdominal bruit. ESR and CRP had been elevated with mild anemia and ANA negative. CT Angiogram had revealed an occluded infra renal abdominal aorta with focal stenotic lesions at origin of celiac axis and superior mesenteric artery and few circumferential aortic wall thickening involving descending thoracic aorta suggestive of aorto-arteritis. She had undergone angiography with stenting of infra renal abdominal aorta. She had been discharged on steroids, methotrexate and folinic acid. She was on regular follow up with rheumatologist. Doppler done two years later showed monophasic waveform of the left lower limb arterial system suggesting abdominal aorta stenosis and normal colour flow in right lower limb arterial system with the stent in situ. Following this, she got married and had a spontaneous abortion at 2 months for with suction evacuation was done.
Her second pregnancy was four years later. She presented at term in labour to our hospital. She was on tablet labetalol 200 mg once a day at the time of admission. She had at no point of time revealed history of TA. She delivered a female 3 kg baby uneventfully.
In the present pregnancy, she had no history of claudication. She was found to be anemic and was treated with parenteral iron. Tablet labetalol was stepped up to 200 mg thrice a day in view of persistently elevated BP.  Rheumatologists opined that gadolinium enhanced MR Angiography was to be done post-delivery.
She was induced at 37 completed weeks with dinoprostone gel and delivered a male child of 2.575 kg baby. She was discharged on tablet nifedipine sustained release 20 mg twice a day.
At follow up postnatally, right arm blood pressure was 150/80 mm Hg and left arm blood pressure was 120/70 mm Hg. She was advised to follow up regularly and ensure that she declares her medical condition to any medical practitioner she visits for any reason.

Discussion
Takayasu’s arteritis is an inflammatory condition. It can lead to proximal occlusion or aneurysms of aortic branches like subclavian, carotid, renal or iliac arteries.[3,7] Mean age is reported between second and third decade of life.[8,9] Etiology remains predominantly idiopathic. Autoimmunity, sex hormones, and genetic factors have been hypothesized as plausible causes.[10]
Disruption of the elastic fibres of the vessel wall, inflammatory cell infiltration with occasional granulomatous reaction, fibrotic adventitial thickening and intima are histological features.
The disease has a triphasic course, with an initial active phase where patients may have malaise, weight loss, fever, myalgia, arthralgia, and is associated with an increase in acute phase reactants. The second stage presents with cerebral, extremity or visceral ischemic changes before resulting in a quiescent phase of fibrosis. Unfortunately, such a typical course seen in only 33% of patients and the severity and progression of vessel involvement are extremely variable.[11]
Pregnancy does not interfere with disease progression.[1–3] Hypertension may be associated with abortion, preterm labor, IUGR, abruption ,IUD.[2,9,12] BP in such patients should be measured in the lower extremity to identify discrepancies.  Our patient had a measurable difference in the blood pressure of the extremities. Adverse pregnancy outcomes are associated with involvement of abdominal aorta. Arterial ultrasound Doppler quantifying uterine artery flow may have benefit in women with TA.
According to the Angiographic Classification(1994), our patient was of Type 3 TA.[13] The disease can be staged depending on the presence of major complications like hypertension, retinopathy, aneurysms, and aortic insufficiency[14,15] Our patient did not have any of these complications.
Diagnosis is usually based on clinical findings, raised inflammatory markers and angiographic  demonstration of stenosis. However, vessel biopsy remains the gold standard.[16]
Management requires an interdisciplinary approach in a tertiary care center aiming to control inflammation, prevention and treatment of complications and revascularization by percutaneous angioplasty or surgical correction of lesions.  Preconception counselling is essential.  Dosage adjustment or cessation of cytotoxic drugs, periconceptional folic acid and optimal timing of pregnancy which is when the disease is in remission. However, despite having diagnosis in the prior pregnancy itself, our patient came out with the history of such disease only late in pregnancy. This is probably because the patient did not completely understand the possible severity and importance of the condition.
Along with routine antenatal visits, blood pressure monitoring, renal function, cardiac status, and preeclampsia screening are vital as is fetal surveillance.[17]
Antihypertensives and antiplatelets may be started. Some symptoms of TA may respond to steroid therapy.[18] Vaginal delivery is the preferred mode of delivery. Epidural analgesia can be advocated for labor and delivery. In women with advanced stages, LSCS may be preferred to prevent cardiac decompensation due to increased cardiac output observed during labor.
The overall five-year survival rate after diagnosis is around 80%. Death is a consequence of congestive heart failure or cerebrovascular events. Survival is better in patients without a progressive course and in those below 35 years of age.

Conclusion

Early diagnosis with proper medical or surgical management is essential for a good prognosis. A high index of clinical suspicion in patients presenting with pulseless peripheral vessels should be kept in mind to optimize the management following a multidisciplinary approach.

References
  1. Koster MJ, Matteson EL, Warrington KJ. Recent advances in the clinical management of giant cell arteritis and Takayasu arteritis. Curr Opin Rheumatol. 2016 May;28(3):211-7.
  2. Assad APA, da Silva TF, Bonfa E, Pereira RMR. Journal of Rheumatology. 2015; 42 (10): 1861-4
  3. Ishikawa K, Maetani S. Long-term outcome for 120 Japanese patients with Takayasu's disease. Clinical and statistical analyses of related prognostic factors. Circulation. 1994 Oct; 90(4):1855-60.
  4. Marwah, S, Rajput M, Mohindra R, Gaikwad HS, Sharma MS, Topden SR. Takayasu’s Arteritis in Pregnancy: A Rare Case Report from a Tertiary Care Infirmary in India. Case Reports in Obstetrics and Gynecology. 2017; 2403451. Available from: https://doi.org/10.1155/2017/2403451
  5. Kathirvel S, Chavan S, Arya VK, Rehman I, Babu V, Malhotra N et al. Anesthetic management of patients with Takayasu’s arteritis: a case series and review. Anesth Analg. 2001; 93:60–65.
  6. Suri V, Aggarwal N, Keepanasseril A, Chopra S, Vijayvergiya R, Jain S et al. Pregnancy and Takayasu arteritis: a single centre experience from North India. J Obstet Gynaecol Res. 2010 Jun;36(3):519-24.
  7. de Souza AW, de Carvalho JF. Diagnostic and classification criteria of Takayasu arteritis. J Autoimmun. 2014; 48-49:79-83
  8. Pagnoux C, Mahendira D, Laskin CA. Fertility and pregnancy in vasculitis. Best Practice & Research Clinical Rheumatology. 2013; 27(1):79-94
  9. Gatto M, Iaccarino L, Canova M, Zen M, Nalotto L, Ramonda R et al. Pregnancy and vasculitis: a systematic review of the literature. Autoimmun Rev. 2012 May;11(6-7): A447-59
  10. Mandal D, Mandal S, Dattaray C, Banerjee D, Ghosh P, Ghosh A et al. Takayasu arteritis in pregnancy: an analysis from eastern India. Arch Gynecol Obstet. 2012 Mar;285(3):567-71
  11. Sise MJ, Counihan CM, Shackford SR, Rowley WR. The clinical spectrum of Takayasu's arteritis. Surgery. 1988 Nov;104(5):905-10.
  12. Hauenstein E, Frank H, Bauer JS, Schneider KT, Fischer T. Takayasu's arteritis in pregnancy: review of literature and discussion. J Perinat Med. 2010;38(1):55-62.
  13. Moriwaki R, Noda M, Yajima M, Sharma BK, Numano F. Clinical manifestations of Takayasu arteritis in India and Japan--new classification of angiographic findings. Angiology. 1997 May;48(5):369-79.
  14. Arend WP, Michel BA, Bloch DA, Hunder GG, Calabrese LH, Edworthy SM et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum. 1990 Aug;33(8):1129-34.
  15. Wilke WS. Large vessel vasculitis (giant cell arteritis, Takayasu arteritis). Baillieres Clin Rheumatol. 1997 May;11(2):285-313.
  16. Sharma BK, Sagar S, Singh AP, Suri S. Takayasu's arteritis in India. Heart Vessels 1992; 7(Suppl):37-43.
  17. Papandony MC, Brady SR, Aw TJ. Vasculitis or fibromuscular dysplasia? Med J Aust. 2015 Feb 2;202(2):100-1.
  18. Ioscovich A, Gislason R, Fadeev A, Grisaru-Granovsky S, Halpern S. Peripartum anesthetic management of patients with Takayasu's arteritis: case series and review. Int J Obstet Anesth. 2008 Oct;17(4):358-64.
Citation

Fernandes S, Rao SV, D’Almeida J, Kumari P. Takayasu Arteritis In Pregnancy: A Case Report From A Tertiary Hospital In South India. JPGO 2018. Volume 5 No.5. Available from:http://www.jpgo.org/2018/04/takayasu-arteritis-in-pregnancy-case.html

Volume 5 Issue 4, April 2018

Editorial - WHO Surgical Safety Checklist

Parulekar SV

Healthcare is broadly speaking preventive and curative. Therapeutic measures are medical surgical and medical. Both of these methods are likely to create complications through negligence. About 50% of the surgical cases which caused harm to the patient by surgery were due to preventable actions or unsafe surgical practices. Hence WHO created a document called 'WHO Surgical Safety Checklist'. Working groups of international specialists reviewed the literature and the experiences of clinicians, the results of which were used to develop this checklist by WHO in collaboration with the Harvard School of Public Health. Global implementation of this 19-item tool was recommended by WHO. The job done by WHO was indeed commendable. A good surgical team always has a checklist in mind, and it was so even before WHO brought out the document in 2009. But all teams or team members not always so careful, and a point or two can be left out. A checklist prevents such a mishap. Hence I am all in favor of a checklist. Our readers will remember that we have devoted an entire issue to checklists in department of Obstetrics and Gynecology of K E M Hospital, Mumbai, India. A surgical checklist was also included in it.

A critical review of the WHO checklist is in order nine years after the original document was published. There are three sections in the checklist - before induction of anesthesia, before skin incision, and before the patient leaves the operation theater (OT).

As per the checklist in its existing form, before induction of anesthesia, at least a nurse and anesthetist have to see that the patient confirms his/her identity, procedure, surgical site and consent. Actually the surgeon has to be the principal person, and all three of them have to be a part of the procedure. Marking the site is a little superfluous, as an error can be committed at this stage just as the stage of operating without prior marking. Check of anesthesia machine should also include disposable kits, drugs and anesthetic gases. Checking functionality of pulse oximeter alone is not adequate. All equipment needs to be checked, including mulipara monitors, electrocautery, special surgical instruments (based on nature of the operation, such as endoscopes, monitors, microscopes, and suction units). The estimation of expected blood loss is always a matter of dispute between anesthetists and surgeons when it has already occurred. Preoperative estimate needs to be determined during the planning stage of the operation and not before induction of anesthesia. It should be based on statistics and not opinion of the surgical team. The checklist should not be to see if the estimated figure is entered in the case paper, but to confirm that blood compatible with the patient's blood is available when the estimated blood loss is more than 500 ml.

Prior to making the skin incision, the checklist states all team members have introduced themselves by name and role. This is perhaps necessary when OT slots are given by prior booking to different teams. But it is superfluous when the team is fixed at least for the day, when all team members know one another. Confirming the patient's name at this stage is bordering on ridiculous, as anesthesia should never been given unless the patient has been identified first. Discovering that a wrong person lies anesthetized on the operation table implies that it is still OK to back out. This stage should never be reached.
Medicolegal negligence lawsuits cannot be prevented even if the patient is taken out of anesthesia. Checking how long the operation will last needs to be checked before administration of anesthesia, so that the anesthesiologist can plan accordingly. Checking it afetr induction of anesthesia serves no purpose. A nurse checking that all equipment required is available, properly functional and sterile at this stage is too late. She has to do it before the patient enters the OT. Recommendations for before patient leaves operating room also leave much to be desired. The nurse verbally confirming the name of the procedure after is complete does not help anyone. God forbid, but if it discovered at this stage that a wrong procedure has been performed, imagine the consequences. Completion of instrument, sponge and needle counts needs to be done before the patient's operative area is closed, such as the abdomen and thorax. If anything is found missing after closure of the surgical incision, one has to open the patient again. That not only increases the patient's morbidity but also will lead to litigation for negligence, which the surgical team will lose.

I hope WHO notes the need for a newer version of the original checklist. I also hope that it involves in this venture more surgeons and anesthetists rather than preventive medicine or public health specialists.