Sanjoy Kumar Bhattacharyya

Consequences of unsafe abortion in India—a case report

Unsafe abortion represents a preventable yet major cause for maternal mortality in India. A majority of these abortions are performed confidentially. Complications occur in a large portion of these cases and ultimately require tertiary care. However, patients and their relatives often fail to disclose the abortion despite the critical state of the patients. This scenario creates considerable confusion for diagnosis and treatment and can lead to further complications. This case report of complications associated with an unsafe abortion in India highlights the need for clinicians to consider the possibility of an undisclosed abortion when treating any morbid woman of reproductive age.

Dilemmas encountered while dealing a pregnancy complicated by pelvic Hydatid disease

Hydatid disease is a zoonosis, caused by Echinococcus granulosus, a parasite, transmitted from canines to humans through faeco-oral route [1]. It is prevalent in Argentina, Australia, India and a few Mediterranean and middle-east countries [2, 3]. The disease manifests itself as multicystic fluid-filled spaces anywhere in the body. Though liver and lung involvement in pregnancy is reported as commonest; brain, bone and abdominal cavity are other affected sites. Till date, there is no generalized consensus regarding the management of pregnancies complicated with this zoonosis [1–3]. This causes confusion among clinicians. We hereby discuss the dilemmas that we have encountered while managing an antenatal woman with coexisting Hydatid disease. Whether medical or surgical approach in the antenatal period would be ideal, intrigued us primarily. The second cause of concern was the choice of the route of delivery. A primigravid Indian woman of 28 years, with 29 weeks of gestation, was admitted with lower abdominal pain. Ultrasonography (USG) of abdomen revealed a single live fetus and few multiseptate cysts in the pouch of Douglas (POD). A suspicion of Hydatid disease arose in mind, which was subsequently confirmed by indirect ELISA testing of woman’s serum by commercially available Echinococcus IgG ELISA kit. Albendazole was started with 400 mg twice a day orally. A favorable clinical response, along with decreasing cysts’ size, was evidenced in repeat scan. She was discharged subsequently and was admitted at term with labor pain. An emergency cesarean section was required due to nonprogress of second stage of labor. She delivered a healthy neonate. Enucleation and partial cystectomy was done in the same sitting as shown in the following figures. 10 % povidine-iodine was instilled in the left-out cyst-remnants.

Metastatic vulvo-vaginal choriocarcinoma mimicking a Bartholin cyst and vulvar hematoma-two unusual presentations.

Metastatic choriocarcinoma may present solely as a vulvo-vaginal growth. It may pose initial diagnostic dilemmas and thus treatment delay. Two cases of metastatic choriocarcinoma which presented as vulvo-vaginal swelling are described here. Both the cases were initially misdiagnosed. Later, unresponsiveness to treatment alerted us to the possibility of metastatic choriocarcinoma. Combination chemotherapy was started following diagnosis by serum β-HCG titer. In spite of initial responsiveness in both cases, one could not be saved due to poor compliance. Suspicion of metastatic choriocarcinoma should be kept in mind while dealing with any recent onset vulvovaginal swelling following a pregnancy. It may initially mislead the clinician due to its apparent benign appearance.

Rape among women and girls presenting at a gynecological emergency department, North Bengal Medical College, Darjeeling, India.

doi:10.1016/j.ijgo.2011.12.018 born in 75 different countries, with 466 (46.6%) born in Canada; 415 (41.5%) self-identified their ethnicity as white, 256 (25.6%) as East Asian, 183 (18.3%) as South Asian, and the rest as “other.” Of the total questionnaires distributed, 888 (67.5%) women answered the questions about anal sex and 54 (6.1%) reported they had used anal sex for birth control. Of these 54 women, 41 (75.9%) had been born in Canada and only 5 had lived in Canada for less than 5 years. They were younger and had undergone more previous abortions than the other women (Table 1). Eleven (20.4%) of the 54 reported that they disliked anal sex. Although all women are asked about previous use of contraception when they present to the clinic for abortion, until this specific question was asked, none of the staff was aware of patients who had used anal sex for birth control. The impression that this was a traditional practice used by certain immigrant groups was not confirmed since it was mostly younger, nonimmigrant women who reported that they had used anal sex for birth control. It is possible that these women were more comfortable revealing this information on the questionnaire.

A randomized comparative study on modified Joel-Cohen incision versus Pfannenstiel incision for cesarean section

OBJECTIVE Pfanennstiel incision is the most commonly used incision for cesarean section, but may not be the best. This study compared the modified Joel-Cohen incision with the Pfannenstiel incision to evaluate whether techniques to open the abdomen might influence operative time, and maternal and neonatal outcomes. MATERIAL AND METHODS In a randomized comparative trial, 302 women with gestational age >34 weeks, requiring cesarean section, were randomly assigned to either modified Joel-Cohen incision or Pfannenstiel incision for entry into the peritoneal cavity. The primary outcome measure was total time required for performing operation and secondary outcome measures were baby extraction time, number of haemostatic procedures used in the abdominal wall, postoperative morbidity, postoperative hospital stay and neonatal outcome. RESULTS Mean total operative time was significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group (29.81 vs 32.67 min, p<0.0001, 95%CI=2.253 to 3.467). Time taken to deliver the baby and haemostatic procedures required during operation were also significantly less in the modified Joel-Cohen group as compared to the Pfannenstiel group. Requirement of strong analgesics was higher in the Pfannenstiel group (53.64% vs 21.85%, p<0.0001). There was no statically significant difference in the incidence of postoperative wound complications but postoperative stay in hospital was significantly less in the modified Joel-Cohen group (p=0.002). Neonatal outcomes were similar in both groups. CONCLUSION The modified Joel-Cohen incision for entry into peritoneal cavity during cesarean section is associated with reduced mean total operative and baby extraction times with less postoperative pain and shorter hospital stay, which may be beneficial and cost effective.

A mysterious growth from vulva mimicking scrotum leading to abandonment by her husband.

Benign vulvar growths are rare. Initially these growths remain small and asymtomatic. Due to social stigma, young women in this stage often prefer to conceal the pathology. With considerable growth, apart from physical complaints, they might cause psychological problems of the subjects and even social withdrawal. Urgent detection and subsequent removal of the growth along with counselling is warranted to improve the patient’s self-esteem.

PREGNANCY IN A WOMAN WITH WILSON'S DISEASE TREATED WITH ZINC: A CASE REPORT

Wilson’s disease is a rare hereditary disorder of copper metabolism affecting 30 per million populations. Copper get deposited in liver, brain and kidney due to decreased hepato-cellular excretion and leading to diverse clinical manifestations. Patient may remain apparently asymptomatic or may present with fulminant liver disease or neuropsychiatric illness. Reproductive outcome in untreated Wilson’s disease is poor. Women remaining untreated either suffer from infertility or experience recurrent pregnancy losses. Invention of copper chelating agents and their usage in these women resulted in successful pregnancy outcome. Penicillamine or zinc salts can be used as copper chelator in pregnancy with Wilson’s disease with equal effectiveness in respect to pregnancy outcome. We report a case of previously undiagnosed Wilson’s disease with three consecutive pregnancy losses who achieved a live birth after successfully treated with zinc salts. The several points regarding antenatal care, drug therapy and optimum time and mode of delivery for the woman with Wilson’s disease are discussed here.

Lesson learnt following diagnostic failure of a case of acute abdomen in pregnancy

Acute abdomen in pregnancy is a problem often encountered in clinical practice. Apart from a few exceptions, most of the underlying causes can be delineated. We are here presenting a case of acute abdomen in pregnancy which initially remained undiagnosed despite efforts and later created an obstetrical catastrophe. This case is being reported due to its uniqueness, diagnostic difficulties and the maternal morbidity associated with it. Mrs S.D., a 25-year-old primigravida at 18 weeks of gestation was admitted with complaints of respiratory distress, abdominal pain and bleeding per vagina. She was previously admitted with abdominal pain at 13 and 16 weeks of gestation, respectively. On those occasions, no identifiable pathology was revealed and she was subsequently discharged. Abdominal sonogram, done twice, featured intrauterine gestation corresponding to the period of amenorrhea without any findings to account for the pain. This time, she was dyspnoeic with distended abdomen and features of hypovolemic shock. She underwent laparotomy, which revealed a dead fetus within the hemoperitoneum (Fig. 1), and a bulky uterus with a hypertrophied left rudimentary horn, which actually harvested the pregnancy (Fig. 2) and ruptured posteriorly. The horn was excised along with ipsilateral adnexa. The patient later recovered well. Pregnancy growing in a rudimentary horn is a rarity. Thin myometrium of rudimentary horn is not suitable anatomically for a growing fetus. Thus the majority of them rupture, creating obstetrical emergencies. Due to the rarity of this phenomenon, we never considered this possibility. Ultrasonography could not detect it. This can be explained by the fact that an enlarging horn may often appear as a normally growing pregnant uterus. A bicornuate uterus, interstitial pregnancy and abdominal pregnancy are other sonographic misdiagnoses of rudimentary-horn gestation. So the point of discussion is how to proceed for a pre-rupture diagnosis of rudimentary-horn pregnancy.