Rajiv Mahendru

A Rare Case of Retroperitoneal Leiomyoma

Introduction. Leiomyoma uteri is one of the most common benign conditions for which women undergo hysterectomy every year. Fibroids found retroperitoneally are a rare entity, especially, primary retroperitoneal fibroid. Case Presentation. We report a case of 42-year-old para 1 who presented to our hospital with recurring retention of urine, lower abdominal and pelvic pain, and dyspareunia . Provisional diagnosis on the basis of examination and imaging was large subserosal fibroid with mild right-sided hydroureteronephrosis, due to pressure effect of the fibroid. Abdominal hysterectomy was done for the patient, and intraoperatively, a bulky uterus was found with multiple small fibroids on anterior and posterior walls, and a large fibroid approx. 10 × 8 cm was found arising from the posterior surface at the level of internal os retroperitoneally, which was confirmed by histopathology as leiomyoma. Conclusion. Retroperitoneal fibroids are rare neoplasms and treatment is surgical removal. Preoperative imaging can only give provisional diagnosis and can be misguiding. Final diagnosis of retroperitoneal fibroid can be made only intraoperatively.

Preservation of fertility following abnormally adherent placenta treated conservatively: a case report

IntroductionOne of the ensuing complications of placenta accreta includes loss of fertility.Case presentationAn Asian origin Indian national patient with history of placenta accreta at the time of previous delivery and had conservative management with injection methotrexate after the failure of surgical intervention, conceives again and has uneventful antenatal period and parturition.ConclusionConservative strategy of leaving the excessively adherent placenta in-situ alongwith adjuvant therapy in the form of injection methotrexate, not only prevents dreadful complications but also retains fertility in haemodynamically stable patients desirous of future pregnancy.

Shortening the second stage of labor

OBJECTIVE To evaluate the benefits and risks of using uterine fundal pressure in shortening the second stage of labor and on the obstetrical outcome. MATERIAL AND METHODS A pilot study comprising 209 primigravidae between 37 and 40 gestational weeks with singleton fetus in cephalic presentation admitted to the delivery suite were considered and were randomly allocated into two groups: I (n=101) and II (n=108), with or without manual fundal pressure, respectively, during the second stage of labor. Main observation measures considered were: duration of the second stage of labor was the primary outcome measure and the secondary outcome measures were severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death. RESULTS There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures. Significant adverse findings having no mention in the earlier literature, were noticed which were: one case each of retained placenta and uterine prolapse besides increased evidence of maternal exhaustion and perineal injuries (including one case of complete perineal tear) in the group where fundal pressure was exercised. CONCLUSION Application of uterine fundal pressure in a delivering woman was not only ineffective in shortening the second stage of labor but added to the risks during parturition.

At times, myomectomy is mandatory to effect delivery

BackgroundExcision of a leiomyoma has never been a choice during caesarean section.MethodMyomectomy of a massive fibroid was necessitated prior to delivering the baby.ResultsDelivery of a healthy was effected by Classical caesarean section.ConclusionLeiomyoma in pregnancy is not an unknown entity and is a cause of concern for being a source of excruciating pain, at times, during the ongoing gestation.Although performed rarely, it is sometimes necessary to remove a large myoma to effect delivery of the baby during Cesarean section as is depicted in the case being presented hereunder.

Fertility following morbidly adherent placenta treated conservatively.

Placenta that is morbidly adherent is considered as an abnormality in placentation leading to its abnormally firm attachment to the myometrium because of the absence of deciduas basalis leading to its incomplete separation at the time of delivery. One of the potentially catastrophic obstetric complications, placenta accreta is alarmingly on the rise with high maternal morbidity and mortality rate being as high as 7% [1]. The untoward complications may include severe postpartum hemorrhage with its resultant coagulopathy, postpartum curettage, uterine perforation, shock, infection, loss of fertility, and even death [2]. A patient aged 33 years reported overshooting her periods by 10 days and tested positive for pregnancy. Her obstetric history readsdthird gravida and parity two with one alive issue. The last time she was pregnant she had retained placenta following full-term vaginal delivery at home, complicated by postpartum hemorrhage (Fig. 1). Thereafter, taken to a private hospital, she underwent three unsuccessful attempts of manual removal/uterine dilatation and curettages and five units of blood transfusion interspersed with repeated episodes of excessive bleeding per vaginally. Failing to manage by this surgical approach, she was referred for hysterectomy. Her first gestation period and vaginal delivery was uneventful. On admission at Maharishi Markandeshwar Institute of Medical Sciences and Research after 18 days of parturition, she was conscious, cooperative having stable general condition with normal vitals but significant pallor, no cyanosis, and no abnormality detected in cardiovascular or respiratory system. On abdominal examination, her uterus was felt enlarged to 20 weeks size, well contracted with pelvic examination showing moderate amount of bleeding per vaginum, and patulous but closed os of 20e22 weeks sized uterus.

Minilaparotomy hysterectomy: a worthwhile alternative.

Aim:  To report the clinical merits and usefulness of minilaparotomy hysterectomy in comparison to the traditional abdominal approach.

An effective and safe innovation for the management of vault prolapse

ObjectiveConsidering the great variety of techniques and disagreement about the ideal route, there is a need for a simple, safe and effective method for the management of vault prolapse.Study Design51 cases of post- hysterectomy vault prolapse: 45 following vaginal and 6 after total abdominal hysterectomy were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips.ResultsExcept for minor complaints like vomiting, fever and urinary retention in 3.92% cases each (n = 2 each), no major complications were encountered. Moreover, no recurrence, thus far, on follow-up.ConclusionUsing autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only simple, cheap and effective method of treating apical prolapse but is also devoid of any serious complications as described with other techniques.

A rare case of Endometriosis in vaginal hysterectomy scar

Presented hereunder is probably the first reported case of endometriosis at the vaginal apex following vaginal hysterectomy. No other similar case could be traced in the review of the literature.

Shortening the induction delivery interval with prostaglandins: a randomized controlled trial of solo or in combination

OBJECTIVE To compare the efficacy and safety of misoprostol alone with dinoprostone followed by misoprostol, all inserted intravaginally in induction of labor at term and the obstetrical outcome. MATERIAL AND METHODS A pilot study comprising 111 primigravidae, >37 gestational weeks with singleton pregnancy in cephalic presentation having an unfavorable Bishop score admitted for labor induction, were considered and randomly allocated into two groups. In group I (n=55) with intravaginal 25mcg misoprostol 4 hourly (six doses at the most) and and group II (n=56), with dinoprostone 0.5mg followed eight hours later by 25mcg misoprostol induction to vaginal delivery time was found to be significantly different, being 14.8 h in group-I and shorter in group-II with a mean of 11.6 h. Vaginal delivery rates within 12 h (groups-I and -II: 47.2%, as compared to 60.7%, respectively) were found to be higher with dinoprostone-misoprostol induction, as well as vaginal delivery rates in 24 h, 80.0% and 91.1%. The need for oxytocin augmentation was more frequent in the misoprostol than in the dinoprostone-misoprostol group, (61.8%, and 39.3%), and all these observations were statistically significant. Abnormal foetal heart rate pattern occurred more frequently (18.2%) in group-I in contrast to 5.3% in group-II, as was the incidence rate of (18.2%) who had passage of meconium in group-I, this rate being significantly different from group-II having meconium passage in 3 cases, a rate of 5.3%. CONCLUSION Using dinoprostone followed by vaginal misoprostol is safe and effective for induction of labor with less need for oxytocin augmentation and shorter induction delivery interval.

Rectus fascia colpopexy for post-hysterectomy vault prolapse: a valid option.

OBJECTIVE Considering the great variety of techniques and disagreement about the ideal route, there is a need for a safe, simple and effective method for the management of apical prolapse. MATERIAL AND METHODS Twenty seven cases of post- hysterectomy vault prolapse (twenty four following vaginal and three after total abdominal hysterectomy) were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips. RESULT Except for minor complaints like- vomiting, fever and urinary retention in 3.7% cases each (n=1), no major complications were encountered. Moreover, no recurrence, on follow-up thus far. CONCLUSION Using autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only a simple, cheap and effective method of treating vault prolapse but is also devoid of any serious complications such as described with other techniques.