Anjali Soni

Angioleiomyoma Uterus in an Adolescent Girl: A Highly Unusual Presentation

BACKGROUND Uterine angioleiomyoma is a very rare gynecologic tumor; only a few such cases have been reported to date and we have found no such tumor reported in an adolescent girl. CASE We report the case of a uterine angioleiomyoma in an adolescent girl. It presented as a huge abdomino-pelvic mass. The girl had severe menorrhagia and severe anemia. Intra-operatively no distinct planes were found between myoma and myometrium. Due to severe hemorrhage, she underwent sub-total abdominal hysterectomy. SUMMARY AND CONCLUSION Uterine angioleiomyoma is an extremely rare tumor since only 16 such cases have been reported to date. Its appearance in an adolescent girl seems to be the first case of its kind. So it is being reported not only to familiarize the managing physicians with the possibility of such a tumor and its variable presentation, but also to highlight the need for inclusion of this tumor in WHO classification of tumors of the female genital tract.

A prospective observational study of trial of labor after cesarean in rural India

To determine the success rate of trial of labor after cesarean (TOLAC) in rural India.

Hydralazine vs nifedipine for acute hypertensive emergency in pregnancy: a randomized controlled trial

Background There is a paucity of good quality evidence regarding the best therapeutic option for acute control of blood pressure during acute hypertensive emergency of pregnancy. Objective We sought to compare the efficacy of intravenously administered hydralazine and oral nifedipine for acute blood pressure control in acute hypertensive emergency of pregnancy. Study Design In this double‐blind, randomized, controlled trial, pregnant women (≥24 weeks period of gestation) with sustained increase in systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg were randomized to receive intravenous hydralazine injection in doses of 5, 10, 10, and 10 mg and a placebo tablet or oral nifedipine (10 mg tablet up to 4 doses) and intravenous saline injection every 20 minutes until the target blood pressure of 150 mm Hg systolic and ≤100 mm Hg diastolic was achieved. Crossover treatment was administered if the initial treatment failed. The primary outcome of the study was time necessary to achieve target blood pressure. The secondary outcomes were the number of dosages required, adverse maternal and neonatal effects, and perinatal outcome. Results From December 2014 through September 2015, we enrolled 60 patients. The median time to achieve target blood pressure was 40 minutes in both groups (intravenous hydralazine and oral nifedipine) (interquartile interval 5 and 40 minutes, respectively, P = .809). The median dose requirement in both groups was 2 (intravenous hydralazine and oral nifedipine) (interquartile range 1 and 2 doses, respectively, P = .625). Intravenous hydralazine was associated with statistically significantly higher occurrence of vomiting (9/30 vs 2/30, respectively, P = .042). No serious adverse maternal or perinatal side effects were witnessed in either group. Conclusion Both intravenous hydralazine and oral nifedipine are equally effective in lowering of blood pressure in acute hypertensive emergency of pregnancy.

Rupture of Uterus in Mid Trimester of Pregnancy: A Case Series & Review of Literature

With the increasing rates of cesarean section (CS) worldwide, pregnant women with previous CS are also rising at an alarming rate. This is leading to increase in previously rare complications of pregnancy e.g. cesarean scar pregnancy, placenta accreta and rupture uterus. One such complication is mid trimester rupture of uterus, which previously used to be a rare possibility. Now a day’s more and more pregnant women are presenting in shock in mid trimester of pregnancy. Hence, this case series is being reported to highlight this complication of pregnancy and to remind managing obstetricians and sonologists regarding these rare possibilities which should be kept in mind while doing routine sonographic assessment of pregnant women, so as to prevent catastrophe of rupture uterus.

Gynecological diseases in rural India: A critical appraisal of indications and route of surgery along with histopathology correlation of 922 women undergoing major gynecological surgery

Objective: The aim of the study was to generate baseline data for indications of gynecological surgeries, and to assess route of surgery and histopathology correlation in women undergoing major gynecological surgery in a rural tertiary level teaching hospital in India. Materials and Methods: Surgical indications, route of surgery and histopathology findings were reviewed and analyzed retrospectively, in 922 patients (≥35 years age) who underwent gynecological surgery at Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India from January 1, 2011 to May 31, 2013. Results: Of 922 surgeries, 65 had malignancy (7%). Pelvic organ prolapse (POP) (32.3%) and leiomyoma uterus (29%) were two most common benign indications for hysterectomy. Ovarian tumors were present in 13% (25% of these were malignant). Postmenopausal bleeding (PMB) was seen in 5.5% (55% of these were malignant). Conclusions: All except 10% surgeries were done in the absence of definite histopathology diagnosis that is dysfunctional uterine bleeding (n = 42 [45%]), chronic pelvic pain/severe dysmenorrhea (n = 34 [36%]) and recurrent PMB (n = 17 [19%]). Majority of surgeries had histopathological correlation except for six cases (0.6%) of malignancy, which were missed on initial work-up. Majority of the surgeries were done abdominally. In rural areas of developing countries poverty, lack of regular follow-up, resource constraints and lack of technical skills (with respect to laparoscopic/robotic surgeries) pose major challenge in providing quality health care.

Pelvic Organ Prolapse during Pregnancy: A Case Series and Review of Literature

Pelvic organ prolapse during pregnancy is extremely rare. Limited cases (less than 30) have been reported since 1980. From a very benign presentation of heaviness in perineum, it can present as uterine rupture with fetal and maternal mortality. No standard guidelines of care have been established for this rare presentation. There is gross variation in management ranging from conservative measures, laparoscopic surgery to cesarean section followed by peri-partum hysterectomy and abdominal sacral colpopexy. This case series report five cases of pelvic organ prolapse during pregnancy and outlines an approach of watchful expectancy with favorable maternal & fetal outcomes.

Unusual lower genital tract injury caused by bull’s horn: prolapse of small intestine through vagina—first case report in literature

A 90-year-old multiparous post menopausal lady presented to the emergency department in shock with history of injury to perineum by a bull’s horn. She was a known case of utero-vaginal prolapse and was not on any treatment. She was hit by a bull and presented to us 48 h later. The woman had poor health, asthenic build, and senile atrophic vagina. On examination, whole of the small intestine was lying outside introitus as shown in Fig. 1. Immediately the patient was prepared for surgery. Intraoperatively she was found to have laceration of cervix and anterior vaginal wall, around 6 cm in length. There was no vulvar haematoma and no injury to bladder or bowel. After reposition of bowel into abdomen, she was found to have complete utero-vaginal prolapse. Decision to only repair the laceration was taken as the patient was already in septic shock. Cervix and vagina were repaired and the patient was shifted back to emergency ward.

Herlyn-Werner-Wunderlich Syndrome /OHVIRA Syndrome; A Rare UrogenitalAnomaly with Unusual Presentation in Two Cases with Review of Literature

The OHVIRA syndrome classically occurs in the setting of uterine didelphys or more rarely, a septate uterus with incidence in various case series is 0.1-3.8%. Renal agenesis is the most commonly reported urologic anomaly. The typical patient with this rare condition usually presents after menarche with nonspecific symptoms of recurrent pelvic pain or dysmenorrhea but both of our patients had atypical presentation. Sonography is frequently the initial imaging modality for evaluation of suspected Mullerian duct anomalies, MR imaging is an excellent modality for evaluating the frequently complex Mullerian duct anomalies. Treatment invariably requires surgical intervention in the form of excision of vaginal septum to relieve obstruction. In addition to relief of pain due to obstruction, surgery also reduces chances of pelvic endometriosis due to retrograde menstrual seeding. We are reporting these cases being their atypical presentation in adulthood life.

A vaginal foreign body presenting as vesico-vaginal fistulae in a pre-pubertal girl: A case report and review of the literature

Background: A neglected foreign body in a vagina leading to vesico-vaginal fistulae in young girls is a very rare presentation. As such, it poses significant therapeutic challenges in its management. Case presentation: A 10-year old pre-pubertal girl presented with malodorous vaginal discharge and continuous dribbling of urine per vaginum. Two separate stones, one each in the vagina and the urinary bladder, with concomitant vesico-vaginal fistulae (VVF) were diagnosed. The history of a foreign body (the cap of a nail paint bottle) inserted into the vagina, while playing, about two years back was elicited. She underwent abdomino-vaginal repair with satisfactory outcome. Conclusion: Vaginal foreign bodies leading to stone formation and subsequent VVF are a rare presentation. Till date 12 such cases have been reported. This case is being reported to highlight this rare cause of VVF in young girls and to develop consensus regarding its management. The procedure of management here involved first removal of the vaginal foreign body and then prolonged catheterization followed by subsequent repair of VVF after 6-8 weeks. However, individualization of such cases may be required depending upon specific characteristics (e.g., large size in index case).