Volume 2 Issue 11, November 2015

Editorial

Gupta AS

Cesarean delivery rates are rising globally. WHO recommends the optimal incidence to remain between 10 to 15% or extended to 20% for adequate prevention of the mother and the child and to prevent severe maternal morbidity and improve neonatal outcome. However, facts indicate a much higher incidence of cesarean births. In private sectors incidence has touched almost 70% and in some hospitals in Brazil the incidence has touched 100%. On an average 1 out of 3 or 1 out of 2 women give birth by cesarean section.
Current pregnancy cesarean births are associated with post operative postpartum hemorrhage, hollow organ injuries, anesthesia complications, infectious morbidity that includes superficial and deep wound infections, thromboembolic phenomena and even mortality.
Post cesarean section wound infection can cause severe morbidity and even mortality. Obese women, women in prolonged labor, PROM, poor aseptic techniques, uncontrolled diabetes, increased operative time and excessive blood loss, are all factors that predispose to cesarean section infectious morbidity. Nosocomial infections, cross infections lead to serious infections. E. Coli and staphylococcus aureus are the commonest organisms isolated. Reported incidence of post operative sepsis after cesarean section that includes major causes like pelvic infections, deep incision sepsis, or minor like superficial wound sepsis, febrile morbidity or catheter associated urinary tract infection ranges from 3.15% to 35.7%.
Superficial wound infections are commonly seen. Deep incision sepsis is not a common feature. However, if the uterine incision gets infected and breaks down then it can lead to pelvic or generalized peritonitis and severe abdominal signs. Many times these patients come back after discharge from the hospital with signs of peritonitis and fever. These patients are morbidly sick and an optimal treatment plan is required. Evaluation with ultrasonography (3D), CT scan and MRI usually indicate the extent of the infection and soft tissue injuries like uterine incision dehiscence or breakdown. Broad spectrum parenteral antibiotics after sample collection for cultures are started. Fluid electrolyte imbalances are corrected. Blood gas analysis and their correction is required. Correction of anemia by transfusion of packed red blood cellss may also be needed. Large abdominal generalized collections usually require drainage. In a very moribund patient ultrasonography guided drains may be inserted. However, it is more prudent to perform an exploratory laparotomy, drain the collection, perform peritoneal lavage, insert drains. If the uterine incision has broken down it may not be possible to repair it in the presence of overwhelming infection. Loose hanging, broken sutures should be excised and the edges freshened. It may be a difficult decision to defer closure of the uterine wound. However, if the tissue is not friable which it usually is then uterine incision may be closed with interrupted sutures as continuous sutures may cut through the friable tissue. Choice of suture material should be a non reactive, mono-filament, delayed absorbable suture like PDS. However, if the tissue is very friable then a decision for closure of the abdomen without suturing the uterus with placement of intra-peritoneal drains or a hysterectomy may have to be considered (a preoperative counseling and consent should be obtained). Hysterectomy would further add to the morbidity as it would open up tissue planes and provide a path for the spread of the infection. Once the patient stabilizes then the uterine incision may be seen to have healed by secondary intention by imaging techniques. In these cases of deep wound infection the integrity of the scar is suspect and the patient should be warned against future pregnancies or counseled regarding the grave but a real risk of scar rupture or dehiscence and its associated consequences for self and for her baby. Such advise and counseling should be properly documented in her case record for future reference.
Overuse of cesarean deliveries, lifestyle changes resulting in obesity, diabetes, casual attitude towards aseptic precautions, poor infection control surveillance all form a perfect recipe for postoperative cesarean sepsis.

We bring the eagerly awaited November issue with a collection of interesting cases for our discerning readers.

Surgical Scar Endometriosis

Author Information

Madhva Prasad S*, Puri J**, Gupta AS***.
(* Assistant professor, ** Third Year Postgraduate Student, ***Professor; Department of Obstetrics and Gynecology, Seth GS Medical college & KEM Hospital, Mumbai, India.)

Abstract

Surgical scar endometriosis is defined as the presence of functional endometrial tissue at a scar site, usually following a previous surgery. Our case is a patient of scar endometriosis presenting after a previous lower segment cesarean section (LSCS).

Introduction

Presence of endometrial glands and stroma ( tissue) outside the uterus is endometriosis. While endometriosis is common in pelvic viscera and peritoneal sites, extrapelvic endometriosis is also described. Extrapelvic endometriosis, although often asymptomatic, should be suspected when symptoms of pain or a palpable mass occur outside the pelvis in a cyclic pattern. Though endometriosis involving the intestinal tract is the most common site of extrapelvic disease, it has been reported in other locations also. A case of surgical scar endometriosis is being reported here.

Case Report

A gravida para 1 living 1 patient with previous LSCS presented to the out patient department with complaints of lump and pain at the left side of the lower abdomen, close to the previous cesarean scar, for which the patient had undergone fine needle aspiration cytology, which was suggestive of scar endometriosis. She had undergone a LSCS 2 years prior in view of meconium stained amniotic fluid. Operative notes showed that the cesarean section was uneventful.  The patient had developed symptoms of cyclical pain and increasing size of the mass during menstruation.
On local examination, a healthy Pfannenstiel scar of LSCS was noted. There was a firm, minimally tender lump of around 1.5x2 cm close to the left angle of the Pfannenstiel scar, which was subcutaneous in origin. On speculum examination, cervix and vagina were healthy, and bimanually uterus was anteverted, normal sized, with clear fornices. The patient was to be posted for excision of scar endometrioma. 
However, the patient conceived spontaneously and had an uneventful regular follow-up in the antenatal OPD. At term gestation, in view of a breech presentation, the patient was taken up for a repeat LSCS. A Pfannenstiel incision was taken and the previous scar was excised. There were no adhesions and no difficulty in opening the layers of the abdomen. A thin flimsy band of adhesion was present between the omentum and serosa of the uterus. (figure 1).
The uterus was eventrated and examined to note that the pouch of Douglas and posterior surface of the uterus had spots that were bluish and engorged which appeared endometriotic. It was decided not to cauterize the endometriotic spots, in view of the possibility of hemorrhage, due to the pregnant state. The ovaries were found to be normal. 
Abdominal closure was done in layers. After closure of the rectus sheath, the subcutaeneous tissue above the left edge of the incision was palpated to find, a single nodular 2x1x1 cm irregular, firm, lobulated, glistening, grey-white colored tissue, which was delineated en-mass by blunt and sharp dissection (figure 2) A simple wide excision was done, that is; a small amount of normal tissue around the mass was removed so as to ensure complete removal. The tissue was sent for histopathological examination.  Delayed absorbable sutures were taken to achieve hemostasis and obliterate the space from which the mass was excised. Skin was approximated with polyamide No 2-0 sutures. Postoperative period was uneventful. The histopathology report showed fibromuscular adipose tissue with nests of cells having abundant glassy cytoplasm with vesicular nuclei, with cyst-like spaces lined by flattened epithelium, which was reported to be consistent with “subcutaneous endometriosis with decidualization”.


Figure 1. Flimsy band of adhesion (A) in the anterior surface of the uterus, which was left undisturbed. 


Figure 2.  Endometriotic mass (A) being held with Babcock forceps, prior to excision.

Discussion

Scar endometriosis occurs as a result of direct inoculation of endometriotic tissue at the scar site during previous surgery. In clinical practice, the occurrence of scar endometrisois has been observed at scars following cesarean section, appendicectomy, hysterectomy, tubectomy and other procedures. [2] Among these, cesarean section appears to be the most common associated operative procedure, even if done by vertical midline incisions.[3,4] Endometriosis following laparoscopic surgery has also been described.[5]  Coexistence with perineal endometriosis has also been described.[6] As yet, it is a rare entity and no reliable estimate about incidence is found in the literature. The mean age of presentation is reported as 32 years, and the commonest symptoms are abdominal lump and pain. It is commonly described to occur as a single mass, and just beneath the previous scar.[3] The classically described symptoms, which were actually present in our patient, of cyclical pain and increase in size of the tissue mass perimenstrually, are reported to be found in only about 20% of the patients.[7] Lipomas, sebaceous cysts, lymphangiomas and desmoid tumors are common differential diagnosis. Occasionally, it can also be mistaken for an incisional hernia or a stitch granuloma.[8,9,10,11] 
Among the imaging techniques, while ultrasonography is the most commonly used modality, MRI has a superior role.[3,9] Very few reports have described the use of fine needle aspiration cytology (FNAC) for the diagnosis of scar endometriosis.[12,13] However, FNAC is not diagnostic , and suspicion of malignancy might require further diagnostic modalities.[14] Though malignant transformation is a possibility, it a very rare event which needs to be kept in mind.[15,16].  However, the gold standard to the diagnosis of endometriosis is the histopathological report.[3] Due to these reasons, excision of the mass should always be considered as the definitive management of the condition. A small case series has demonstrated that the use of percutaneous cryoablation to be effective in treatment of scar endometriosis.[17] High intensity focused ultrasound (HIFU) and ultrasound-guided sclerotherapy with ethanol also appear to be options in the management of this rare condition.[18,19] However, wide local excision continues to be the recommended procedure,[3] as was done in our patient. 

References
  1. D’Hooghe TM. Endometriosis. In: Berek JS, editor. Berek & Novak’s Gynecology.15th edn. Philadelphia: Lippincott Williams & Wilkins; 2012. pp: 505-546. 
  2. Zhu Z, Al-Beiti MA, Tang L, Liu X, Lu X. Clinical characteristic analysis of 32 patients with abdominal incision endometriosis. J Obstet Gynaecol. 2008 Oct; 28(7):742-5.
  3. Khamechian T, Alizargar J, Mazoochi T.5-Year data analysis of patients following abdominal wall endometrioma surgery.BMC Womens Health. 2014 Dec 5;14:151 
  4. Menon M, Sridevi TA , Chandrika PN, Selvakumar SA. Skin to serosa: scar endometrioma. J Clin Diagn Res. 2014 Oct;8(10):OD04–5.
  5. Chmaj-Wierzchowska K, Pieta B, Czerniak T, Opala T.Endometriosis in a post-laparoscopic scar--case report and literature review. Ginekol Pol. 2014 May;85(5):386-9.
  6. Li J, Shi Y, Zhou C, Lin J. Diagnosis and treatment of perineal endometriosis: review of 17 cases. Arch Gynecol Obstet [Internet]. 2015 Jun 4 [cited 2015 Sep 21]; PMID: 26041323
  7. Danielpour PJ, Layke JC, Durie N, Glickman LT.Scar endometriosis - a rare cause for a painful scar: A case report and review of the literature.Can J Plast Surg. 2010 Spring;18(1):19-20.
  8.  Çöl C, Yilmaz EE. Cesarean scar endometrioma: Case series.World J Clin Cases. 2014 May 16; 2(5): 133–136
  9. Oh EM, Lee W-S, Kang JM, Choi ST, Kim KK, Lee WK. A Surgeon’s Perspective of Abdominal Wall Endometriosis at a Caesarean Section Incision: Nine Cases in a Single Institution. Surg Res Pract [Internet]. 2014 Jan [cited 2015 Sep 21]; PMID: 25379559
  10. Patil NJ, Kumar V, Gupta A. Scar endometriosis-a sequel of caesarean section.J Clin Diagn Res. 2014 Apr;8(4):FD09-10
  11. Al-Jabri K. Endometriosis at Caesarean Section scar. Oman Medical Journal. 2009 October;24(4):294-295
  12. Dash S, Panda S, Rout N, Samantaray S. Role of fine needle aspiration cytology and cell block in diagnosis of scar endometriosis: A case report J Cytol. 2015 Jan-Mar; 32(1): 71–73. 
  13. Pachori G, Sharma R, Sunaria RK, Bayla T. Scar endometriosis: Diagnosis by fine needle aspiration. J Cytol. Jan 2015;32(1):65–7
  14. Rekhi B, Sugoor P, Patil A, Shylasree TS, Kerkar R, Maheshwari A. Cytopathological features of scar endometriosis mimicking an adenocarcinoma: A diagnostic pitfall.J Cytol. 2013 Oct;30(4):280-3.
  15. Dobrosz Z, Paleń P, Stojko R, Właszczuk P, Niesłuchowska-Hoxha A, Piechuta-Kośmider I.Clear cell carcinoma derived from an endometriosis focus in a scar after a caesarean section--a case report and literature review.Ginekol Pol. 2014 Oct;85(10):792-5.  Available from: http://www.ncbi.nlm.nih.gov/pubmed/25546933
  16. Jiang M, Chen P, Sun L, Huang Q, Wu H. 18F-FDG PET/CT findings of a recurrent adenocarcinoma arising from malignant transformation of abdominal wall endometriosis. Clin Nucl Med. 2015 Feb;40(2):184–5.
  17. Cornelis F, Petitpierre F, Lasserre AS, Tricaud E, Dallaudière B, Stoeckle E, et al. Percutaneous cryoablation of symptomatic abdominal scar endometrioma: initial reports. Cardiovasc Intervent Radiol 2014 ; 37 : 1575-9 
  18. Zhang L, Zhang W, Orsi F, Chen W, Wang Z.Ultrasound-guided high intensity focused ultrasound for the treatment of gynaecological diseases: A review of safety and efficacy.Int J Hyperthermia. 2015 May;31(3):280-4.
  19. Bozkurt M, Çil AS, Bozkurt DK. Intramuscular abdominal wall endometriosis treated by ultrasound-guided ethanol injection. Clin Med Res . 2014 Dec ;12(3-4):160–5.
Citation

Madhva Prasad S, Puri J, Gupta AS. Surgical scar endometriosis. JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/surgical-scar-endometriosis.html

Post Operative (LSCS) Uterine Scar Dehiscence

Author Information

Dwivedi JS, Gupta AS.
(* Third Year Resident, ** Professor; Department of Obstetrics and Gynecology, G.S.Medical college & KEM Hospital, Mumbai, India.)

Abstract

Puerperal sepsis is an avoidable morbidity. Post operative LSCS uterine scar dehiscence is not common. We would like to present a case of puerperal sepsis with post operative lower uterine segment scar dehiscence following an event of intra-operative atonic post-postpartum haemorrhage managed by B-Lynch compression sutures. The uterine segment scar dehiscence was managed conservatively with broad spectrum antibiotics.

Introduction

Puerperal infection is a general term used to describe any bacterial infection of the genital tract post-delivery upto 42 days. Proper asepsis can prevent puerperal sepsis.[1] If asepsis chain is broken at any point the presentation is in varied forms. The percentage of cesarean section has increased drastically as compared to yester years. Post operative LSCS uterine scar dehiscence is one of the rare presentations.[2] Infection was fifth leading cause of maternal death in a survey done in U.S. from 1991 to 1997.[3] In India sepsis is the second cause after haemorrhage leading to maternal mortality. Preeclampsia, obstetric hemorrhage and puerperal infections formed the lethal triad of causes for maternal deaths in the previous century.

Case Report

A 28 year old woman, para 1, fresh still birth 1, day 13 of emergency lower segment cesarean section (LSCS) with vaginal exploration and episiotomy suturing done at a private medical college was referred to us from a private practitioner in view of ultrasonography (USG) done outside suggestive of ?pyometra, and peritonitis with sub-hepatic and sub-phrenic collections. Review of her operative notes suggested that the indication for emergency LSCS was second stage arrest of descent after 2 hours of vaginal trial of labor, fetal distress and repeated unsuccessful attempts at instrumental delivery. Her pre-operative hemoglobin was 9.5gm%. Intra-operatively the patient had atonic PPH for which uterotonics, and two units packed cell transfusion was given. B-Lynch compression suture was taken with polyglactin 910 no 1 as the uterus remained atonic. Vaginal exploration with episiotomy suturing was done. Total duration of surgery was approximately 3 hours. Patient had repeated episodes of temperature elevations from post operative day 3 onwards. She was investigated and sent home on day 5 after an afebrile period of 24 hours and after excluding wound site infection. She again became febrile from the 7th postoperative day wherein she took treatment from a private practitioner. As oral antibiotics did not work the patient was admitted for injectable antibiotics and had received parenteral Cefoperazone, Piperaciliin and Tazobactam combination, Metronidazole and Gentamycin. At the time of admission to our institution on 13th post operative day , the patient was afebrile, had bradycardia and was pale. On abdominal examination the patient did not have guarding, rigidity or tenderness. There was ascites, and the cesarean section Pfannensteil incision was healed and healthy, uterus was palpable, and 14-16 weeks in size. On local examination there was purulent discharge at the episiotomy site; wound swab for culture was sent. On vaginal examination the vagina was hot, uterus was 14-16 weeks size and foul smelling lochia was present. High vaginal swab was sent for culture sensitivity. Patient was admitted, broad spectrum parenteral antibiotics (Piperaciliin and Tazobactam combination, Metronidazole and Gentamycin) were started, and daily dressing for the episiotomy wound was done. USG repeated from our institution showed a rent in the anterior wall of the myometrium at the LSCS incision site, with anterior wall collection of 4cm*2.5cm*2.5cm size. One of the suture material appeared to extend from the site of the rent to the posterior uterine wall. There was no clinical as well as radiological signs of peritonitis. To confirm the diagnosis, a CT-scan and MRI pelvis was done for the patient and both investigations confirmed the uterine scar dehiscence as shown in the figure.


Figure 1. CT-scan showing the rent in anterior wall of uterus. Blue Arrow shows the uterine rent. Red hollow arrow marks the collection, Yellow hollow arrow shows the uterus and Bl is the bladder.

As the patient did not have any episodes of bleeding, or severe abdominal tenderness and vital parameters were stable, decision to defer exploration was taken. Decison for conservative treatment was based on literature review.[1] Her high vaginal swab grew E.coli and Klebsiella pneumonia. They both were sensitive to piperacillin and tazobactam. Gentamicin and metronidazole were stopped after 10 days but Piperaciliin and Tazobactam combination was continued. She became and remained afebrile for 13 days after starting antibiotics however on the 14th day while on Piperaciliin and Tazobactam combination the patient developed again repeated fever spikes and hence her blood culture was sent which was negative for growth. All possible causes of fever were ruled out and patient was started on parenteral cefoperazone and sulbactam for 21 days. Anemia was corrected by oral and parenteral hematinics. Patient responded well and was discharged on day 45 post-postpartum after an afebrile period of 48 hours. Patient came for follow up on day 62 of LSCS . On vaginal examination the uterus had become a normal sized pelvic organ and no forniceal tenderness was elicited. Repeat USG showed a healed intact scar of LSCS and there were no collections.

Discussion

Puerperal sepsis is an infection of the genital tract which occurs as a complication of delivery. There has been a marked decline in the incidences of puerperal sepsis due to stress on the maintenance of asepsis in labor room and operation theaters. Endometritis, endo-myometritis and endoparametritis are the various names given to postpartum uterine infection [3]. There have been various predisposing factors for puerperal infections. Route of delivery being the most important factor. As compared to cesarean section the metritis related to vaginal delivery is very uncommon. In case of vaginal delivery the duration of rupture of membranes, repeated vaginal examinations, presence of vaginitis, anemia and prolonged labor pose a risk for puerperal sepsis. Our patient was anemic in the antenatal period and was in second stage of labor for almost two hours with an episiotomy and multiple attempts at instrumental delivery; all factors favored infection. Besides, the duration of operation was prolonged and the patient had atonic PPH which further increased anemia and her susceptibility for puerperal sepsis. Most common pathogens involved in the puerperal sepsis are bacteria from the female genital tract [3]. Puerperal infection following vaginal delivery involves the placental implantation site where as the cause of uterine infection in cesarean section is the infected surgical incision. Fever is the most important presenting feature in puerperium and should not be taken lightly. Cesarean section scar dehiscence is a rare form of presentation of puerperal sepsis and occurs due to severe cellulitis and necrosis at the incision site. Incidence of uterine scar dehiscence in immediate post operative period is not documented in literature. In the immediate post-postpartum period it can present as a cause of secondary hemorrhage. If associated with pyometra then it may also lead to peritonitis. Identification of the cause requires high index of suspicion and confirmation using radiological modalities. MRI has been considered to be the most definitive modality for evaluating the uterine incision healing after cesarean section [4]. During surgery B-Lynch compression sutures were taken for atonic PPH. This procedure has been widely recommended to control PPH. Sutures were taken with polyglactin 910. B Lynch recommended the use of chromic catgut No 2 for these compression sutures.[5] Polyglactin 910 sutures are braided, have more tensile strength than chromic catgut and also remain longer prior to absorption. Certain complications of this surgical technique have been reported till date. Erosion of B-lynch through the uterine wall at 6 weeks postpartum was reported by Groetgul et al [6]. Also a case of total uterine necrosis as a complication of B-lynch suture has been reported by Somalwar et al [7]. We do not know whether the B Lynch suture was the cause or the contributory factor along with infection of the post operative scar dehiscence. But we do feel that the use of polyglactin could have resulted in the suture line ischemia by local compression or cutting into the soft infected tissues of the atonic uterus. In cases with post operative LSCS scar dehiscence exploratory laparotomy with repair was considered to be the treatment in the past. However due to fragile nature of the infected tissue and excessive bleeding most of the cases landed up with subtotal/total hysterectomy [8]. Recently microsurgical, laparoscopic repair have been reported [4]. There are reports wherein the scar dehiscence have been managed conservatively using only antibiotics for treating the infection and the uterine incision is allowed to heal by secondary intention [1]. Our patient was reluctant for surgical management as she understood the need and the risk of hysterectomy. She desired childbearing. In our case with good infection control and correction of anemia the LSCS wound gape healed by secondary intention. The consequence of this complication for future pregnancies is unknown, however the chance of rupture in future pregnancy is considered to be high [1] [4]. Such patients should undergo close monitoring of all her future pregnancies and should be delivered by an elective LSCS.

Conclusion

Thus it can be concluded that to prevent is better than to cure. Proper aseptic measures taken will help us reduce the rate of maternal morbidity and mortality. We feel B-lynch sutures at times are taken hastily. However the complications related to B lynch compression sutures needs to be studied in detail and should be kept in mind before taking the sutures. It is also essential to use the recommended suture materials.

References
  1. Parulekar SV, Hira P. Postcesarean Anterior Preperitoneal Abscess. JPGO 2015 Volume 2 Number 8. Available from: http://www.jpgo.org/2015/08/postcesarean-anterior-preperitoneal.html
  2. Mahajan D, Kang M, Sandhu MS, Jain V, Kalra N, Khandelwal N. Rare complications of cesarean scar. Indian J Radiol Imaging [serial online] 2013 [cited 2015 Oct 13];23:258-61. Available from: http://www.ijri.org/text.asp?2013/23/3/258/120265
  3. Puerperal complications. In Cunningham FG, Leveno KJ, Bloom Sl, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS editors. Williams Obstetrics. 24th ed. New York: Mc Graw Hill Education books 2014; pp. 682- 688
  4. Bharatam KK. Cesarean section uterine scar dehiscence-A review. Uterus & Ovary 2015; 2: e751.
  5. B-Lynch CA, Lawal AH R,Abu J, Cowen MJ.The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. British Journal of Obstetrics and Gynaecology March 1997, Vol. 104,pp. 372-375
  6. Grotegut CA, Larsen FW, Jones MR, Livingston E. Erosion of B-lynch suture through the uterine wall: A case report. J Reprod Med Oct. 2004;49(10):849-52
  7. Somalwar SA, Joshi SA, Bhalerao AV, Kawthalkar AS, Jain S, Mahore S. Total Uterine Necrosis: A Complication of B-lynch suture. J South Asian Feder Obst Gynae 2012; 4(1):61-63.
  8. Wagner MS, Bedard MJ. Post postpartum uterine wound dehiscence: a case report. J Obstet Gynecol Can. 2006;28(8):713-5.
Citation

Dwivedi JS, Gupta AS. Postoperative (LSCS) Uterine Scar Dehiscence. JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/post-operative-lscs-uterine-scar.html

Actinomycosis of Ovary - Resurgence

Author Information

Shah NH*, Khambati B** , Paranjpe SH***, Shah VN****..
(* Hon. Endosopic Surgeon Wadia Hospital & Railway Hospital (Byculla), ** Director Asha Nursing Home,***  Director: Velankar Hospital &Paranjpe Maternity Home, **** Anesthetist, Mumbai, India.)

Abstract

Female genital organs are comparatively a rare site for pelvic actinomycosis and detection is extremely low too. Here we present a case of resurgence of pelvic actinomycosis. This patient was operated 4 years back for tubo-ovarian (TO) mass, histopathology confirming actinomycosis and 4 years later she presented with the same symptoms with ultrasonography (USG) showing possibility of chocolate cyst/ TO mass. Actinomyces usually gets a delayed treatment due to its specific and non-specific nature.  Actinomyces species are usually found in the vagina, the most frequent site being the cervico-facial region and grow slowly in conditions of reduced oxygen. The radiological findings are that of a solid mass simulating gynecological malignancies or ovarian and cervical inflammatory conditions. Therefore, the gynecologist should consider the possibility of this infection to spare the patient from morbidity of radical surgical procedure.

Introduction

Actinomycosis is a chronic suppurative granulomatous bacterial infection caused by Actinomyces israelii, which is a slow growing, filamentous, gram positive, non-spore forming anaerobic, or microaerophilic bacteria. Actinomyces species are usually found in human oropharynx, gastrointestinal tract, vagina, and they grow slowly with conditions of reduced oxygen. Actinomyces is an opportunistic pathogen causing infection after disruption of the mucus membrane and spreads into surrounding tissue irrespective of tissue planes. The most common site of human infection is the cervico-facial region, accounting for 40 to 50% of cases. Approximately 15% cases occur in thorax, 20% of the cases occur in the abdomen and pelvis. Pelvic actinomycosis is an uncommon condition accounting for 3% of all human actinomycotic infections. Ovarian actinomycosis is rarer because structure of an ovary is resistant to surrounding inflammatory disease. It has been speculated that bacteria enter the ovary when its surface epithelium is broken during the process of ovulation.

Case Report

A 36 years old female para 2 came with chief complaints of dysmenorrhea and vague, mild, dragging type of pain in abdomen for past 6 months.  This patient was previously operated 4 years back for same complaints with ultrasonography showing a tubo-ovarian mass. A diagnostic laparoscopy was done 4 years ago which revealed a cystic mass on the right ovary and tube. Adhesions were present over the tube, ovary and the mesentery mimicking pelvic tuberculosis. The cyst was drained showing bright yellow fluid with granules.  The cyst wall and fluid were sent for histopathological examination which revealed active actinomycosis. After a month or so of antibiotic treatment she stopped taking treatment despite doctor’s advice, as she found herself to be asymptomatic. Four years later she came with similar symptoms with ultrasonography again showing  tubo-ovarian mass/chocolate cyst of the left ovary. Again a diagnostic laparoscopy was done, showing dense adhesions between the tubes, ovaries and the bowel. The tubes were enlarged showing a hydrosalpinx like picture with cyst of 2 by 2 cm present on both the ovaries. A separate cystic mass was found away from the uterus in the mesentery measuring 5 by 5 cm.


Figure 1. Laparoscopic view of tubo-ovarian mass.


Figure 2.  Ruptured mass showing sulfur granules.

Her blood picture showed Hb – 8.5g/dl, total leukocyte count – 7200/cmm, WBC – 4.39 mil/cmm, HIV  non reactive, random blood sugar – 80 mg/dl.
The mesenteric cyst was removed completely laparoscopically in an endo bag. Both the cysts in each ovary were drained with the cyst wall resected and fluid in the tubes was drained and the left sided tube was partially removed. The fluid was similar bright yellow colored with granules. Removal of the ovary and other tube was not possible due to dense adhesions between the bowel and mesentery. The cystic fluid and the cyst wall and the mesenteric cyst were sent for histopathological examination. Histopathological report confirmed actinomycosis and the patient is planned for post-operative antibiotic therapy with crystalline penicillin 24,000,000 IU per day intravenously for 4 weeks, followed by continued therapy with ampicillin for another 6 months.
Treatment is carried in 2 stages: 1st stage includes  i.v. crystalline penicillin for 2 to 6 weeks for killing the rapidly multiplying bacteria and 2nd stage is continuous oral antibiotics for 6 months to 1 year to prevent recurrence. A thorough interrogation revealed that patient had not taken the correct treatment previously which possibly was the cause of recurrence.

Discussion

Actinomycosis is a low prevalent disease. Its different anatomical locations create a diagnostic challenge to various medical specialties[1]  Due to the general circumstances with  internal immunological environment of the body, it changes the behavior of this organism. The spectrum of behavior varies from commensal to pathogenic type.[2] The first human case of Actinomycosis was reported by James Israel in 1878.[3] The organism per se cannot penetrate an intact epithelium or mucosa. The infection spreads contiguously crossing the anatomic barriers when there is a failure in the integrity of mucosa. Hematogenous spread is less common.[4] There has been increasing number of reports of Actinomycosis in the female genital tract, especially in women using an intrauterine contraceptive devices. The metallic devices have been particularly incriminated, possibly as they provide a focus for infection together with a chemical reducing action favorable for an opportunistic anaerobe such as A. israelii. The present reports are in contrast to old ones, where A. israelii was seen in 1.6-11.6% of intrauterine contraceptive device (IUCD)  users worldwide. Astonishingly the newer trend studies show that, the increasing rate of the  infection related to plastic IUCD without metal or hormonal load.[5] This patient did not have any history of any intrauterine device use. She was however previously operated for tubal ligation surgery. Diagnosis of actinomycosis can be difficult preoperatively because of the insidious nature of the infection with non-specific signs and symptoms and unsure radiological findings of solid masses often giving the impression of gynecological or gastrointestinal malignancies. Koshiyama et al. have reported cases of actinomycotic pelvic inflammatory disease showing advanced cervical and ovarian carcinomas. Hence “final diagnosis mostly rests on post-operative examination of the specimen, histopathology, and culture” as was in this case.[6] The complications associated with IUCD use include dissemination of actinomycosis, hepatic abscess, intracranial abscess and even death.[7] Thus, a conclusive diagnosis has to be obtained by histopathological examination and culture of the pus/fluid material. It is very difficult and time taking to obtain a positive culture for Actinomycosis. Thus, histopathological examination played a major role in the present case in deriving the accurate diagnosis.

In conclusion, we would like to suggest that women presenting clinically with nonspecific abdominal symptoms, backache and vaginal discharge, actinomycosis should be considered and ruled out with cytological and microbial culture methods. Once the diagnosis is established, the infection can be treated with good results with long term penicillin.[1,4] It is also important to look at other sites for actinomycosis, in the absence of which the possibility of existence of foreign bodies in the genital tract should be considered.

References
  1. Westhoff C. IUDs and colonization or an infection with Actinomyces. Contraception. 2007;75 6 Suppl:S48–50.
  2. Simms I, Stephenson JM. Pelvic inflammatory disease epidemiology: what do we know and what do we need to know? Sex Transm Infect 2000;76:80–87.
  3. Brown JR. Human Actinomycosis for Pathological Anatomy 1978; 74:15Suppl:S-53.7.
  4. Al-Kadhi S, Venkiteswaran KP, Al-Ansari, Shamsudini A, Al-Bozomm I, Kiliyanni AS. Primary vesical actinomycosis: a case report and literature review. Int J Urol. 2007;14(10):969–971.
  5. Chatwani A, Amin-Hanjani S: Incidence of actinomycosis associated with intrauterine devices. J ReprodMed 1994;39:585 – 587.
  6. Koshiyama M, Yashida M, Fujii H, Nanno H, Hayashi M, Tauchi K, et al. Ovarian actinomycosis complicated by diabetes mellitus simulating an advanced ovarian carcinoma. Eur J ObstetGynaecolReprodBiol 1999;87:95-9.
  7. Gupta PK, Erozan YS, Frost JK. Actinomycetes and the IUD: an update. Acta Cytol 1978;22:281-282.12. Hager WD, Majmudar B. Pelvic actinomycosis in women using intrauterine contraceptive devices.Am J Obstet Gynecol.
Citation

Shah NH, Khambati B, Paranjpe SH, Shah VN. Actinomycosis of Ovary - Resurgence JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/actinomycosis-of-ovary-resurgence.html

Laparoscopic Excision Of A Large Paraovarian Cyst In Pregnancy

Author Information

Borse M*, Latkar P**, Prasad R***
(* Consultant Obstetrician and Gynecologist , Deenanath Mangeshkar Hospital, Pune; India ** Consultant Obstetrician and Gynaecologist, Yashashri Hospital, Pune, India; Clinical attache to Dr. Mahindra Borse.)

Abstract

Adnexal masses are seen in 1-2% of pregnant women and paraovarian cysts account for the third most common type. They can be of various sizes ranging from 1-20 cm are often diagnosed incidentally on an ultrasound, during physical examination or when a Woman experiences symptoms related to them. Small cysts can be closely observed during the course of pregnancy but large ones, even if asymptomatic, should be excised in order to prevent complications like torsion, rupture, hemorrhage, infection and dystocia. Excision of large cysts can be done in pregnancy, safely, using laparoscopy and here we report one such case.

Introduction

Adnexal masses are seen in 1-2% of pregnant women1 and paraovarian cysts account for the third most common type after serous cystadenomas and mature cystic teratomas.[2] They are epithelium - lined extra-peritoneal cysts arising from the remnants of the mesonephric or paramesonephric ducts.[3] Though they are often seen in women in the 3rd or 4th decade of life, they have been reported in pre – menarchal girls with an incidence of 4%.[4]  Here, we report a case of a large paraovarian cyst diagnosed during routine physical examination at 11 weeks of gestation that was excised laparoscopically.

Case Report

A 22 year old, primigravida registered for antenatal care at 11 weeks of gestation. She was otherwise asymptomatic and had no past medical or surgical complaints. On examination, a cystic mass was palpable per abdomen, arising from the pelvis corresponding to an 18-week size uterus. On per vaginal examination, a 12 – week size uterus deviated to the left was felt. In the right fornix a 12x10x10 cm, cystic, mobile, non-tender mass was felt separately from the uterus. The left fornix was empty. A provisional diagnosis of a right ovarian cyst was made. The woman underwent an ultrasound examination which confirmed the presence of a large 12*15 cm right ovarian cyst without internal septae or solid component. CA -125 was 8 IU/ml. The rest of the obstetric scan was normal. After discussing the pros and cons with the couple, a decision for laparoscopic cyst excision was taken in view of its large size.
At 14 completed weeks of gestation, the procedure was performed under general anesthesia. At the time of surgery the cyst along with the gravid uterus corresponded to a 20-week size pelvic mass. The patient was put in low lithotomy position and the operating table was given a 300 left lateral tilt. A 10 mm central port was put along the midline mid-way between the xiphisterum and umbilicus using Hasson’s technique. Pneumoperitoneum was created using air insufflation and pressure was maintained at 14 mm of Hg. A unilocular 15x12x10 cm cyst was seen within the leaves of the right broad ligament and the right ovary was seen separately from the cyst (Figure 1). The left ovary and both fallopian tubes were normal. A 14 week gravid uterus with an arcuate fundus was seen. The broad ligament over the cyst was opened and a small nick was made on the cyst so as to drain the 800ml of straw-coloured fluid, thus decompressing the cyst (Figure 2). The redundant cyst wall was peeled off from the surrounding tissue (Figure 3) and removed through one of the additional ports. After ensuring hemostasis (Figure 4) using bipolar energy source, the pneumoperitoneum was deflated (Figure 5). Post – operative ultrasound showed a live fetus with a fetal heart rate of 150 beats per minute with adequate liquor and a normal placenta. There was no evidence of retro placental hemorrhage. The total operative time was 20 minutes. She had an uneventful recovery and was sent home in 24 hours. She received a single shot of intravenous third generation cephalosporin and was put on oral third generation cephalosporin for the next 5 days. She did not receive any tocolysis. Sutures were removed after a week and she made an uneventful recovery. At 2 week follow- up visit, there was adequate fetal growth. The histopathological report of the cyst wall showed that it was lined with flattened cells and fibro collagenous stroma with no solid areas or signs of malignancy. Her further antenatal course was uneventful and she delivered vaginally at term.


Figure 1: Right paraovarian cyst seen separately from the right ovary.


Figure 2: Decompression of the cyst using a suction tip.


Figure 3: Peeling of cyst wall.


Figure 4: Cauterized base of cyst.


Figure 5: Redundant broad ligament peritoneum with right ovary.

Discussion

Paraovarian cysts tend to grow in pregnancy as they are hormone – dependent. They are detected incidentally on routine ultrasound, during physical examination or when the patient becomes symptomatic. These cysts can be either managed conservatively or surgically via laparotomy or laparoscopy. However, there are several concerns with conservative management. Firstly, a paraovarian cyst cannot always be differentiated from an ovarian cyst on an ultrasound scan.[5,6] A large study conducted in Egypt on 1853 women, concluded that paraovarian cysts could be detected only in 44% of women with these cysts.[7] Secondly, the concern of malignancy – the risk though  small i.e. 2%[8]cannot be completely ruled out as tumor markers for ovarian malignancy are not very reliable in pregnancy and thus one has to rely only on sonographic markers (25-30%).[9] Thirdly, being hormone dependent these cysts continue to grow during pregnancy thus putting the woman at a higher risk of complications like torsion, rupture, hemorrhage, infection.[10] dystocia and increased incidence of operative delivery. Lastly, large paraovarian cysts rarely resolve spontaneously.[11] Several studies in recent times have demonstrated the safety of laparoscopic surgery in pregnancy12. Though initially procedures were electively scheduled in the second trimester in order to reduce the rates of spontaneous abortions and preterm labor, recent studies have reported that surgery can be safely performed in all trimesters.[12] The patient can be made to lie in the supine position or in low lithotomy with a left lateral tilt to the operating table of 15-300 in order to prevent vascular compression by the gravid uterus. In case of a smaller cyst the primary port can be placed along the midline. However, large cysts can occupy the entire abdomen, necessitating a lateral port. Rouzi was the first to report laparoscopic excision of a large paraovarian cyst containing 2.5litres of fluid at 20 weeks of gestation in 2011[13]using a left subcostal port for entry. Abdominal entry can be achieved using a Verre’s needle or by Hasson’s technique. CO2 gas is preferred for creation of pneumoperitoneum as it is cheap, easily available and has rapid blood solubility. However, there have been concerns of fetal hypoxia with its use, though fetal acidosis has not been reported.[14] A study followed up children, whose mothers underwent laparoscopic surgery when pregnant, with CO2 as distension medium, up to 8 years of age and found no developmental delay in them.[15] Also, the functional residual capacity that is already compromised is pregnant women further reduces due to gas insufflation. Hence, it is recommended to keep insufflation pressures between 12-15 mm of Hg and monitor end tidal CO2 ( EtCO2) in order to gauge maternal acid-base status.[12] Alternatively, air insufflation can be used. However, if the operative time is prolonged, due to poor solubility of air there is a small risk of air embolism.
The cyst can be decompressed by making a small nick on the surface and introducing a suction tip through it. In order to prevent intraperitoneal spillage, a closed drainage system can be created by direct puncture of the cyst using a 5 mm trocar – canula inserted through the ipsilateral iliac fossa. A suction tube can be directly attached to the side channel of the canula or alternatively a suction tip can be put into the cyst through the canula in order to drain the cyst fluid. This helps to achieve a clean operative field and reduces operative time. The cyst wall after dissection can be removed through an ipsilateral side port using an endobag.
Laparoscopic surgery has other advantages to conventional laparotomy which include lesser post-operative pain and post – operative ileus, shorter hospital stay and early recovery. Moreover, long term studies have shown no difference in maternal or fetal outcome with either surgical modality.[16] Prophylactic tocolysis also has no role to play.[17]

Conclusion

Minimally invasive surgery is safe and effective for management of large paraovarian cysts in pregnancy.

References
  1. Dede M, Yenen MC, Yilmaz A, Goktolga U, Baser I. Treatment of incidental adnexal masses at cesarean section: a retrospective study. Int J Gynecol Cancer 2007; 17: 339-341.
  2. Bignardi T, Condous G. The management of ovarian pathology pregnancy. Best Prac Resear Clin Obstet Gynecol. 2009; 23: 539-548.
  3. Athey PA, Cooper NB. Sonographic features of paraovarian cysts. AJR. 1985; 144: 83–86.
  4. Samaha M, Woodruff JD. Paratubal cysts: frequency, histogenesis, and associated clinical features. Obstet Gynecol. 1985; 65: 691–694.
  5. Kiseli M, Caglar GS, Cengiz SD, Karadag D, Yilmaz MB. Clinical diagnosis and complications of paratubal cysts: Review of the literature and report of uncommon cases. Arch Gynecol Obstet 2012;285: 1563–69.
  6. Barloon TJ, Brown BP, Abu-Yousef MM, Warnock NG. Paraovarian and paratubal cysts: preoperative diagnosis using transabdominal and transvaginal sonography. J Clin Ultrasound. 1996; 24(3): 117–122.
  7. Darwish A, Amin A, Safwat AM. Laparoscopic Management of Paratubal and Paraovarian Cysts. JSLS. 2003 Apr-Jun; 7(2): 101–106.
  8. Stein AL, Koonings PP, Schlaerth JB, Grimes DA, d'Ablaing G. 3rd.Relative frequency of malignant parovarian tumors: should parovarian tumors be aspirated? Obstet Gynecol. 1990; 75: 1029–1031.
  9. Savelli L, Ghi T, De Iaco P, Ceccaroni M, Venturoli S, Cacciatore B. Paraovarian/paratubal cysts: comparison of transvaginal sonographic and pathological findings to establish diagnostic criteria. Ultrasound Obstet Gynecol. 2006; 28: 330–334
  10. Janovski NA, Paramanandan TL. Ovarian tumors: tumors and tumor-like conditions of the ovaries, fallopian tubes, and ligaments of the uterus. Philadelphia: W. B. Saunders. 1973:191-194.
  11. Levine D et al. Management of asymptomatic ovarian and other adnexal cysts imaged at ultrasound. Society of Radiologists in Ultrasound Consenses Conference statement. 2010; 256(3): 943-954. 
  12. SAGES - Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for Diagnosis, Treatment, and Use of Laparoscopy for Surgical Problems during Pregnancy.2007. Publication #23 Jan 2011.
  13. Rouzi AA.Operative laparoscopy in pregnancy for a large paraovarian cyst. Saudi Med J. 2011; 32(7):735–7
  14. Comitalo JB, Lynch D. Laparoscopic cholecystectomy in pregnant patient. Surg Laparoscopic Endoscopy. 1994. 4; 268-271.
  15. Rizzo AG. Laparoscopic surgery in pregnancy: long -term follow- up. Journal of laparoendoscopic and advanced surgical techniques. 2003. 13; 11-15.
  16. Soriano D, Yefet Y, Seidman DS, Goldenberg M, Mashiach S, Oelsner G. Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril 1991.71;955-960.
  17. Katz VL, Farmer RM. Controversies in tocolytic therapy. Clinical obstetrics and gynecology. 1999. 42;802-819.
Citation

Borse M, Latkar P, Prasad R. Laparoscopic Excision Of A Large Paraovarian Cyst In Pregnancy. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/laparoscopic-excision-of-large.html

Adult Granulosa Cell Tumor of the Ovary

Author Information

Shilotri M*, Panchbudhe  S**, Satia MN***, Kothari K****.
(* Second Year Resident, ** Assistant Professor, *** Professor, Department of Obstetrics and Gynaecology; **** Associate Professor, Department of Pathology, Seth G S Medical College and KEM Hospital, Mumbai, India.)

Abstract

Adult granulosa cell tumors (AGCTs) accountfor 95% of all granular cell tumors and 1 - 2% of all ovarian tumors.[1] Prognosis mainly depends on the stage of the tumor and its mitotic index. These tumors have a propensity to recur many years after the initial diagnosis. We present a case of a 26 year old nulligravida havinga large adnexal mass with hemorrhage within for which she underwentan emergency exploratory laparotomy with right salpingo-oophorectomywhich on histopathology was diagnosed to be an AGCT of the right ovary.

Introduction

Granulosa cell tumors (GCTs) of the ovaries originate from sex cord stromal cells. Based on histological appearances they are further classified as adult cell granulosa cell tumor and juvenile granulosa cell tumors (JGCTs). AGCT is the more common variety and seen in women in the reproductive age group or postmenopausal period. They have a peak incidence at 50 - 55 years of age and are more common in postmenopausal women than premenopausal. AGCT is primarily treated surgically while radiotherapy and chemotherapy are mainly used for recurrent tumors. GCTs are usually diagnosed at an early stage and have a favorable prognosis.

Case Report

A 26 years old woman, married since 4 years, known case of primary infertility was referred to our institutionwith possible ongoing hemorrhage within an ovarian tumor, with a sudden fall in hemoglobin from 8g% to 6 g%, for emergency exploratory laparotomy. At the time of admission, she was pale but her vital parameters were normal. On per abdominal examination, there was a 32 weeks size mass arising from the pelvis with a firm to cystic consistency and generalized tendernessall over the abdomen. On per vaginal examination, the cervix was high up, pushed anteriorly and the uterus could not be felt separately from the mass. The mass occupied both the lateral and posterior fornices. On per rectal examination, the rectal mucosa was free from the mass. The rest of the systemic examination was unremarkable.
The patient complained of a lump in abdomen, first noticed two months ago, which was gradually increasing in size and initially painless. USG done two months ago was suggestive of a 15 x 6cm enlarged ovary with multiple enlarged follicles, the largest measuring 7cm and appearing to be a complex cyst, with suspicion of ovarian hyper stimulation syndrome in view of history of ovulation induction for one cycle by clomiphene citrate two months prior to the onset of symptoms. She also had a history of irregular menses since attaining menarche, menstruating every 1.5 to 2 months for which she intermittently took oral contraceptive pills. She was admitted at the referring hospital for evaluation in view of the above report. Her serum levels of CA-125, alpha-fetoprotein and carcinoembryonic antigen were normal. As her vital parameters were stable and a repeat USG after one week showed no change in the size of the ovarian mass, she was discharged, asked to undergo a CT scan and follow up for an elective surgical resection of the mass. CT scan of the abdomen and pelvis done a month later was suggestive of a large right ovarian mass measuring 19.8 x 16.6 x 8.5cm with a possibility of ovarian torsion and less likelihood of ovarian hyperstimulation syndrome. There was a mild left pleural effusion and minimal free fluid in the abdomen and pelvis. However, she did not have any fresh complaints and hence did not follow up at the hospital.A month later,she was re-admitted at the referring hospital with complaints of increasing size of the mass, persistent pain in abdomen and fever. In view of a sudden fall in the hemoglobin from 8g%, as on admission, to 6g% overnight and an increase in the height of the mass per abdominally, hemorrhage within the tumor was suspected and she was referred to our institution for emergency exploratory laparotomy. On admission at our institution, USG pelvis with Doppler studiesshowed a 27x18x14cm multicystic, midline ovarian mass likely to be a hemorrhagic cyst with no evidence of torsion. CT scan of the abdomen and pelvis was suggestive of a 25x20x11cm solid-cystic lesion with enhancing septae and hemorrhagic areas within.
After transfusing two units of packed red cells pre-operatively and intra-operatively, an emergency exploratory laparotomy was undertaken under general with epidural anesthesia through a midline vertical incision which had to be extended from the xiphisternum up to the symphysis pubis in view of the large size of the mass. Intra-operatively, a large cyst of 24x21x10cm with the right fallopian tube stretched over itwas seen extending into the epigastrium while the left fallopian tube, left ovary and the uterus were normal. No evident metastatic deposits or lymphadenopathy were seen. A right salpingo-oophorectomy was done and the specimen along with a peritoneal fluid sample was sent for histopathological and cytological examination respectively. Grossly, the capsule of the mass looked intact. On cut section, the cyst was biloculated, containing hemorrhagic fluid and gelatinous areas within with solid areas present focally. On microscopy, the tumor cells were round to oval and focal spindle shaped cells having vesicular nuclei with undulating margins and nuclear grooves were seen. Call Exner bodies were noted. Areas of hemorrhage and necrosis were present. Capsule was intact. The peritoneal fluid did not contain any malignant cells. Thus, a diagnosis of adult granulosa cell tumor with stage I was made. She was referred to a specialized cancer institute for further management where the diagnosis of adult granulosa cell tumor of the ovary was confirmed on histopathology. She was advised to avoid conception for one year and to follow up regularly at the institute.


Figure 1. CT scan showing 25x20x11 cm solid-cystic lesion with enhancing septae and hemorrhagic areas within.


Figure 2. Large right hemorrhagic ovarian cyst with right fallopian tube stretched over it.


Figure 3. Right hemorrhagic ovarian cyst measuring 24x21x10 cm.


Figure 4. High power showing cells with scant cytoplasm and oval vesicular, grooved nuclei. HEx400.


Figure 5. Solid, micro follicular arrangement of tumor cells. HEx100.


Figure 6. Long cords of tumor cells amidst extensive hemorrhage. HEx100.

Discussion

Granulosa cell tumors are sex-cord stromal tumors of the ovary with malignant potential that can occur in women of all age groups. The juvenile granulosa cell tumors are usually seen in pre-pubertal girls while adult granulosa cell tumors are more commonly found in postmenopausal women than those in the reproductive age group. These patients may present with abdominal mass, abdominal distension or menstrual irregularities. As GCTs are often hormone producing, they may present with manifestations of hyper-estrogenemia such as precocious puberty in pre-pubertal girls and abnormal uterine bleeding or postmenopausal bleeding in older women. There may be a concomitant endometrial pathology like endometrial hyperplasia in 25 -50% or endometrial adenocarcinoma in up to 5-10% of the patients.[2] AGCTs may also be virilizing presenting with hirsutism, clitoromegaly, amenorrhea and deepening of voice. On examination, a pelvic mass is almost always present. On imaging they appear as round to ovoid masses that are multicystic, occasionally with solid components or less often as unilocular simple or complex cysts or even homogenous solid masses. Tumor markers such as serum inhibin levels and serum antimullerian hormone (AMH) levels are being studied and used for diagnosis and follow up of patients.[3,4]
Prognosis largely depends on the surgical stage of the tumor, mitotic index and nuclear atypia. Due to its relatively early manifestation, 80-90% are diagnosed at stage I and hence have a better prognosis than most other ovarian tumors.[5] Primary treatment modality for GCTs is surgical and choice of the surgery is determined by the age of the patient and need for fertility preservation. For patients in the pre-pubertal and reproductive age group with stage I disease, a unilateral salpingo-oophorectomy is preferred, as in our case. In cases of a higher stage of disease and post-menopausal women, a total abdominal hysterectomy with bilateral salpingo-oophorectomy is undertaken.
These tumors have a tendency to recur many years after the primary diagnosis, thus regular follow-up with physical examination and tumor markers like inhibin, AMH and estradiol is essential.
In conclusion, adult granulosa cell tumors have a better prognosis than most other ovarian malignancies, stage of disease being the most important prognostic factor. Surgical clearance of the tumor is the main-stay of treatment. Emphasis must be laid on the need for long term follow-up in view of recurrences that occur several years after the initial disease.

References
  1. Ukah C, Ikpeze O, Eleje G, Eke A. Adult granulosa cell tumor associated with endometrial carcinoma: a case report. J Med Case Rep. 2011;5(1):340.
  2. Khosla D, Dimri K, Pandey AK, Mahajan R, Trehan R. Ovarian granulosa cell tumor: clinical features, treatment, outcome, and prognostic factors. N Am J Med Sci. 2014 Mar;6(3):133-8. doi: 10.4103/1947-2714.128475. PubMed PMID: 24741552;PubMed Central PMCID: PMC3978936.
  3. Boggess JF, Soules MR, Goff BA, Greer BE, Cain JM, Tamimi HK. Serum inhibin and disease status in women with ovarian granulosa cell tumors. Gynecol Oncol.1997 Jan;64(1):64-9. PubMed PMID: 8995549.
  4. Lane AH, Lee MM, Fuller AF Jr, Kehas DJ, Donahoe PK, MacLaughlin DT. Diagnostic utility of Müllerian inhibiting substance determination in patients with primary and recurrent granulosa cell tumors. GynecolOncol. 1999 Apr;73(1):51-5. PubMed PMID: 10094880.
  5. Stuart GC, Dawson LM. Update on granulosa cell tumours of the ovary. CurrOpinObstet Gynecol. 2003;15:33–7.
Citation

Shilotri M, Panchbudhe,  S, Satia MN, Kothari K.  Adult Granulosa Cell Tumor of the Ovary. JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/adult-granulosa-cell-tumor-of-ovary.html

Advanced Carcinoma Cervix In Pregnancy: A Case Report

Author Information

Fernandes S*, Cardoso M**. 
(* Assistant Professor, Department of Obstetrics and Gynaecology, Father Muller Medical College, Mangalore; ** Associate Professor, Department of Obstetrics and Gynaecology, Goa Medical College, Goa, India.)

Abstract

Cervical cancer is the most common malignancy diagnosed during pregnancy; its incidence however, is low. The case of a pregnant lady at 37 weeks of gestational age is presented who came with abdominal pain and intermittent bleeding per vaginum. By pelvic examination the cervix was replaced by a growth 6x6 cm which bled on touch. Cesarean section was done. Intra operative findings revealed involvement of right parametrium upto lateral pelvic wall, left parametrium just short of lateral pelvic wall. A cervix biopsy was taken on 9th postoperative day which revealed non keratinising squamous cell carcinoma. A FIGO stage 3b was established. Postoperative period was uneventful. Patient was referred for radiotherapy. Most cases present in the preinvasive or early stage. The case reported has presented in an advanced stage of malignancy in labor. 

Introduction

Cervical cancer is the most common malignancy in pregnancy, with an incidence of 0.8 to 1.5 cases per 10 000 births. [1,2]  One third of cases occur during the reproductive period[.3,4] About one-half of these cases are diagnosed prenatally and the rest within 12 months following delivery.[1]
Most patients are diagnosed at an early stage of disease,[5,6]  probably a result of routine prenatal screening, but it is also possible that advanced stage disease interferes with conception. 
Studies have shown that 76% of lesions diagnosed during pregnancy are in stage 1b[5,6].  Several reports have been identified in literature of preinvasive or early stage carcinoma in pregnancy. However, there is noticeable absence of literature which mentions presentation of an advanced stage of ca cervix in labor. Hence, this case is reported. 
The presenting symptoms of cervical carcinoma in pregnancy are dependent upon the clinical stage and lesion size. The diagnosis is often delayed in pregnant women since many of the symptoms are similar to those associated with normal pregnancy.

Case Report

A 30 year old female, gravida 4 para 3, presented at 37 weeks period of gestation with complaints of abdominal pain and intermittent bleeding per vaginum since 1 day. She gave no prior history of bleeding or discharge per vaginum. Her previous pregnancies were uneventful full term normal deliveries. She had no ongoing medical problems.
On examination, the patient had mild uterine contractions. Pelvic examination revealed the cervix being replaced by a large mass of around 6x6 cm, indurated, which bled on touch. The right parametrium was indurated up to the lateral pelvic wall. The left parametrium was indurated just short of the lateral pelvic wall. On rectovaginal examination, the rectal mucosa was free. General investigations showed no abnormality.
As the patient was in labor, an emergency cesarean section was done with bilateral tubal ligation. A male, 2.9 kg baby was delivered with an Apgar of 7/9. Intraoperative findings revealed the cervix being completely replaced by a large indurated mass of around 6x6cm extending posteriorly up to the junction of the body of the uterus and cervix. Right parametrium was involved upto the lateral pelvic wall. There was no ascites and no lymph nodes involvement. Postoperative course was uneventful. On the 9th postoperative day, a cervical biopsy was taken. Histopathological examination revealed non keratinizing squamous cell carcinoma. A CT scan was done revealed an irregular polypoidal mass replacing the cervix superiorly involving the body of uterus and inferiorly involving the vagina. Fat planes between the mass and rectum and bladder were indistinct in places. Iliac lymph nodes and a few mesenteric were enlarged. A FIGO stage 3b was established. The patient was referred for radiotherapy.


Figure 1. Intraoperative findings: there is a mass arising from the cervix.


Figure 2. MRI of the pelvis.

Discussion

Advanced cervical cancer despite being the most commonly diagnosed carcinoma in pregnancy, is a rarity. Cesarean section followed by radical hysterectomy and chemoradiation is the treatment of choice.[7] However, in this case as the patient came directly in labor with no prior clinical staging or biopsy report, the decision to go ahead with the definitive treatment was deferred at that time. MRI is the diagnostic method of choice which enables to identify tumor dimensions,stromal invasion ,vaginal and parametrial invasion and lymph node infiltration. [8] There however, exists no protocol for management of such cases.[2]

References
  1. Smith LH, Dalrymple JL, Leiserowitz GS, Danielsen B.,Gilbert WM. “Obstetrical deliveries associated with maternal malignancy in California, 1992 through 1997,” Am J Obstet Gynecol 2001;184(7):1504–22.
  2. Duggan B, Muderspach LI, Roman LD, Curtin JP,G. d’Ablaing, Morrow CP. Cervical cancer in pregnancy: reporting on planned delay in therapy. Obstet Gynecol 1993;82(4):598–601.
  3. Lishner M.Cancer in pregnancy.Ann Oncol. 2003;14(Suppl 3):iii31-6
  4. Pavlidis NA.Coexistence of pregnancy and malignancy.Oncologist.2002;7(4):279-87 
  5. Van Calsteren K, Vergote I, Amant F. Cervical neoplasia during pregnancy: diagnosis, management and prognosis. Best Pract Res Clin Obstet Gynaecol 2005;19(4):611–30.
  6. Zemlickis D, Lishner M, Degendorfer P, Panzarella T, Sutcliffe SB,Koren G. Maternal and fetal outcome after invasive cervical cancer in pregnancy. J Clin Oncol 1991;9:1956–61.
  7. M Takushi,H. Moromizato.K. Sakumoto,K .Kanazawa,”Management of invasive carcinoma of the uterine cervix associated with pregnancy:outcome of intentional delay in treatment,” Gynecologic Oncology, vol.87,no. 2,pp. 185-189,2002.
  8. Nicolet V., Carigan L., Bourdon F., Prosmanne O.(2000) MR imaging of cervical carcinoma: a practical staging approach. Radiographics 20: 1529-1549.
Citation

Fernandes S, Cardoso M.  Advanced Carcinoma Cervix In Pregnancy: A Case Report.  JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/advanced-carcinoma-cervix-in-pregnancy.html

Location of Opening In Membranes After Vaginal Delivery in A Case Of Placenta Previa

Image
Author Information

Parulekar SV
(Professor and Head. Department of Obstetrics and Gynecology, G.S.Medical college & KEM Hospital, Mumbai, India.)

Abstract

The concepts in the management of placenta previa are changing. But the pathology does not change much. If a patient with placenta previa delivers vaginally, examination of the placenta and membranes helps confirm the diagnosis was correct. An image of the same would help graduate and postgraduate students make this diagnosis during their examinations. Such an image is presented here.

Introduction

The definition of placenta previa keeps changing. It was location of the placenta within 3 inches (7.5 cm) of the internal os in 1969.[1] Now it is within 2 cm of the internal os.[2,3] However vaginal delivery can still be allowed depending on the clinical circumstances. The diagnosis is mad by ultrasonography (USG). It is more accurate when transvaginal USG is used. The diagnosis is rarely made by actual clinical examination. A case is presented in which a preterm patient with placental abruption diagnosed on USG was detected to have a marginal placenta previa on clinical examination. The image of her placenta and membranes is presented here for educational purpose.

Case Report

A 34 year old woman, gravida 5 para 4, presented at 32 weeks of gestation with preterm labor. She had 4 full term normal deliveries in the past. Her antenatal course had been uneventful, and hematological, biochemical, serological investigations and obstetric USG reports were normal. The placenta was diagnosed to be in the upper segment on the left side. Her general consition was good and systemic examination revealed no abnormality. There was a sigle fetus in vertex presentation and fetal heart rate was 144 bpm.  She was administered tocolysis and betamethasone. She developed premature rupture of membranes and acute pain in abdomen after 24 hours. A clinical diagnosis of concealed placental abruption was made. It was confirmed by USG. Labor was induced with oxytocin infusion. During the course of labor, the placental edge was felt at the left edge of the internal os at 4 cm dilatation of the cervix. There was no vaginal bleeding. Oxytocin infusion was continued and she was delivered vaginally uneventfully after  six hours. The appearance of the placenta and membranes is shown in figure 1.


Figure 1. Maternal surface of the placenta and fetal membranes. The opening in the fetal membranes is seen to be next to the edge of the placenta (arrow).

The placenta and membranes were normal. The opening in the fetal membranes through which the fetus delivered was found to be next to the edge of the placenta. The patient made an uneventful recovery.

Discussion

During the process of childbirth, the membranes rupture spontaneously or are ruptured artificially early or late depending on prevailing obstetric practices and also depending on the obstetric condition. Since this is done above the cervix, it is away from the placenta implanted in the upper segment. This becomes evident when the placenta and membranes are examined after childbirth. If the placenta is implanted in the lower segment, the opening the fetal membranes will be near the placenta, the distance from it being equal to the distance between the placental edge and the internal os. If the placenta is marginal i.e. it reaches the internal os, this opening will be right next to the placenta,[4,5] as was found in the case presented. This does not hold true in a case delivered by cesarean section, as the opening in the membranes is under the anterior part of the lower uterine segment and the location of the placenta is variable.

Conclusion

Except in cases delivered by a cesarean section, location of the opening in fetal membranes near the placental edge indicates placenta previa.

Acknowledgment

I thank Dr Jagtap V for taking and providing a picture of the specimen.

References
  1. Donald IT. Practical Obstetric Problems. Lippincott. Philadelphia. 1969p. 365
  2. Diagnosis and Management of Placenta Previa. SOGC CLINICAL PRACTICE GUIDELINE. No. 189, March 2007. Available from: http://sogc.org/wp-content/uploads/2013/01/189E-CPG-March2007.pdf
  3. Oppenheimer L; Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can 2007 Mar;29(3):261-73.
  4. Manual of Pathology of the Human Placenta: Second Edition. Rebecca N Baergen Springer Science & Business Media, 06-Jan-2011 - Medical pages 216.
  5. Kaplan CG, Altshuler GP. The placenta. In Mills SE ed. Sternberg's Diagnostic Surgical Pathology, 5th Edition. Philadelphia Lippincott Williams & Wilkins 2010; p 2074.
Citation

Parulekar SV. Location of Opening In Membranes After Vaginal Delivery in A Case Of Placenta Previa JPGO JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/location-of-opening-in-membranes-after.html

Rupture Of Hydrosalpinx Into Broad Ligament During Hysterosalpingography

 Image
Author Information

Parulekar SV
(Professor and Head. Department of Obstetrics and Gynecology, G.S.Medical college & KEM Hospital, Mumbai, India.)

Abstract

Hysteroslpingography is one of the most commonly used methods of assessment of the uterus and fallopian tubes in evaluation of female infertility. Though considered safe, there are some complications of the procedure. Rupture of the hydrosalpinx into the broad ligament is a complication that is described here for the first time in the world literature.

Introduction

Hysterosalpingography has been used for years in the assessment of female infertility.[1,2] It gives useful information on the uterine cavity and fallopian tubes. It is best carried out under image intensified fluoroscopic control, so that irradiation is minimized, and excessive injection of radiopaque dye or use of excessive force during injection can be avoided.[3] Either or both of these factors can lead to a rupture of a hydrosalpinx, in cases with bilateral tubal block. Radiologic appearance of a rupture of a hydrosalpinx into the broad ligament is presented here.

Case Report

A 30 year old woman, married for 9 years, presented for management of her infertility. She had suffered from abdominal tuberculosis in the past, and had received antituberculous therapy. After completion of her treatment, she started undergoing valuation of her infertility. She presented to us with reports of her various tests, including hemogram, urinalysis, liver and renal function tests, serology for syphilis and HIV, and chest radiogram. These reports were normal. Hysterosalpingography was done by a radiologist. Its appearance is shown in figure 1.


Figure 1. Hysterosalpingography. The cervical canal and uterine cavity are normal in size and shape. Right fallopian tube is blocked in the ampullary portion. The left fallopian tube is convoluted and has a hydrosalpinx. There is loculated spill of the dye above and below the fallopian tube, around the hydrosalpinx.

The patient was explained that the tubes were most probably damaged due to tuberculosis as an extension of her abdominal tuberculosis. The poor prognosis of a tubal reconstructive surgery was explained to her. She was counselled to undergo either in vitro fertilization and embryo transfer, or to adopt a child.

Discussion

A hydrosalpinx is a distension of a fallopian tube due to block at its lateral end. That produces a retort-shaped swelling. A hysterosalpingography shows a retort-shaped shadow in such cases.[4,5] Since the fluid inside the hydrosalpinx is in an enclosed, space, forceful injection of any fluid into the uterine cavity and from there into the fallopian tube would result in excessive distension of the hydrosalpinx, if the other fallopian tube is blocked too. Such overdistension can be avoided by observing the uterus and fallopian tubes during the performance of the procedure under fluoroscopy. In the case presented, the right fallopian tube was blocked in the ampullary portion. The left fallopian tube had formed a moderate sized hydrosalpinx. Thus its walls were much thinner than tose of a normal tube. Forceful injection of the dye probably caused a rupture of the hydrosalpinx. If the rupture had occurred into the peritoneal cavity, the radiopaque dye would have escaped into the peritoneal cavity and would have spread, covering serosal surface of bowel. If it had ruptured intraperitoneally and peritubal adhesions were present, it would have produced a localized irregular shadow, the dye spreading into nonadherent parts between adherent surfaces. The localized shadow surrounding the hydrosalpinx is rounded, smooth surfaced and unilocular. Though a lateral film was not available, which would have shown forward and backward bulging of the shadow, it appears that it would have been so, since such a bulging would be unlikely to be confined only to the coronal plane. Actually such a phenomenon has been witnessed during laparoscopy and chromopertubation too (personal unplublished data), in which a spherical distension of the broad ligament by methylene blue had been seen. Since the dye had spread over a larger area (between two leaves of the broad ligament) and was probably mixed with the fluid in the hydrosalpinx which escaped along with the dye into the hydrosalpinx, the shadow cast by the loculated spill was less dense as compared to that cast by the hydrosalpinx. The site of the rupture must have been small, so that all contents of the hydrosalpinx did not escape into the broad ligament. Since the plates were obtained within a short time of the previous plates, the dye which had escaped into the broad ligament did not have time to spread out retroperitoneally.

Conclusion

Hysterosalpingography can cause rupture of a hydrosalpinx into the broad ligament due to force of injection of the dye. The radiological appearance of this complication is unique.

References
  1. Albeṙt Mathieu. Hydrosalpinx—Its Visualization By Hysterosalpingography. Cal West Med 1931 Aug; 35(2): 73–78.
  2. Simpson WL, Beitia LG, Mester J. Hysterosalpingography: a reemerging study. Radiographics. 2006;26 (2): 419-31.
  3. Chalazonitis A, Tzovara I, Laspas F et-al. Hysterosalpingography: technique and applications. Curr Probl Diagn Radiol 2009;38 (5): 199-205.
  4. Ubeda B, Paraira M, Alert E et-al. Hysterosalpingography: spectrum of normal variants and nonpathologic findings. AJR Am J Roentgenol. 2001;177 (1): 131-5.
  5. Rezvani M, Shaaban AM. Fallopian tube disease in the nonpregnant patient. Radiographics 2011;31 (2): 527-48.
Citation

Parulekar SV. Rupture Of Hydrosalpinx Into Broad Ligament During Hysterosalpingography. JPGO JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/rupture-of-hydrosalpinx-into-broad.html

An Unusual Case of Vomiting in Pregnancy and Fetal Loss

Author Information

Kiran S*, Gupta D**, Jain A*, Shukla A***.
(* Resident, ** Assistant Professor, ***Additional Professor. Department of Gastroenterology, G.S.Medical college and KEM Hospital, Mumbai, India.)

Abstract

Intestinal malrotation is a congenital condition that rarely may present in adults with intestinal obstruction. We report here a case of pregnant lady with 3 previous abortions in 2nd trimester who presented with symptoms of small bowel obstruction. Imaging by MRI enterography revealed that the duodenojejunal (DJ) junction was on the right of midline, jejunal loops on right side and cecum in midline. Superior mesenteric vein (SMV) was to the left of Superior mesenteric artery (SMA) suggestive of nonrotation of midgut. Corrective surgery was done (Ladd procedure) uneventfully after an MTP. Patient had a subsequent successful pregnancy.

Introduction

Intestinal malrotation is a rare congenital condition caused by absence or incomplete rotation of small bowel during the embryonic development.[1] It affects approximately 1 in 500 live births with 90% complications within first year of life.[2] Intestinal malrotation in adults is often incidentally detected.[3] Rarely, adults may present acutely with bowel obstruction, intestinal ischemia or abdominal pain.[4] Volvulus without malrotation can occur during pregnancy and rarely congenital intestinal malrotation may cause intestinal obstruction.[5-7]  We report here a case of pregnant lady who presented with repeated symptoms of small bowel obstruction during 2nd trimester of each pregnancy resulting from intestinal malrotation followed by abortion.

Case Report

30-year-old lady, 4th time pregnant with 3 previous abortions presented to us in the 5th month of gestation with large quantity bilious vomiting since 1 month. She also had 2 kg weight loss during present pregnancy. She was treated with ondansetron, doxylamine, metoclopramide and domperidone without any relief. She had similar complaints in all her previous pregnancies and each time had abortion during 2nd or 3rd trimester. The weight lost during each pregnancy was regained after abortion. She was dehydrated and hypotensive this time on admission. On Investigations, there was iron deficiency anemia, raised blood urea and nitrogen. Her serum amylase, lipase, liver function tests, fundoscopy, βhCG, TSH, prothrombin and autoimmune workup were normal. Ultrasound of abdomen showed dilated duodenum and stomach with excessive peristalsis of bowel loops in right iliac fossa. Endoscopy showed dilated stomach and duodenum till D3.
MRI enterography was done to evaluate the bowel and it showed that the duodenojejunal (DJ) junction was on the right of midline, jejunal loops on right side and cecum in midline (Figure 1). Superior mesenteric vein (SMV) was to the left of Superior mesenteric artery (SMA) suggestive of nonrotation of midgut (Figure 2). Incidentally seen was intraventricular with intraparenchymal hemorrhage in the fetus (Figure 3).
Medical Termination of Pregnancy (MTP) was done in view of major fetal abnormalities. Post MTP symptoms improved within a day. Corrective surgery was done (Ladd procedure) uneventfully (Figure 4). A year later the patient conceived, remained asymptomatic throughout pregnancy and successfully delivered a baby.



Figure 1. MR enterography showing DJ junction on right of midline and jejunal loops on right side of abdominal cavity.


Figure 2. MR enterography showing SMV (small arrow) to the left of SMA (long arrow).


Figure 3. MR enterography showing incidentally detected intracerebral bleed in the fetus.


Figure 4. Surgery showed cecum (small arrow) in the midline and jejunal loops (long arrow) on the right side of abdominal cavity.

Discussion

Intestinal rotation and positioning occur in the fetus during early gestation. By the fifth week, the intestine is outside the abdomen and completes a full 2700 rotation with return into the abdominal cavity by the end of the first trimester. If any step of this process gets arrested, then it results in intestinal anomalies which can result in marked morbidity and mortality.[8]
Most patients are symptomatic early in life, and rarely present later in life.[9] Vomiting is a common presenting complaint, but chronic or intermittent abdominal pain, malabsorption, diarrhea, food intolerance, common bile duct obstruction or chylous ascites may also occur.[10]
Like in our patient, symptoms from malrotation may occur during pregnancy due to enlarging uterus pushing the non-fixed, mobile portions of the bowel into the upper abdomen.[ 8 ] The symptoms are likely to be more frequent and severe in the last trimester of pregnancy.[11] In a study of volvulus occurring during pregnancy, two patients presented during the first trimester, nine during the second trimester, and 25 in the third trimester, including eight at term; while five women presented postpartum.[12]
The diagnosis of malrotation often is not considered in the pregnant patient as symptoms are often nonspecific and abdominal findings may be difficult to interpret because of the size of the gravid uterus. In addition, intestinal obstruction is infrequent during pregnancy, occurring in one of 30,000-60,000 deliveries and is usually due to adhesions rather than malrotation . Avoidance of radiology studies during pregnancy may also contribute to delayed diagnosis. 
Ultrasound or magnetic resonance imaging like in our patient may be useful during pregnancy in demonstrating abnormal positioning of the mesenteric vessels suggesting midgut malrotation, or fluid-filled, dilated duodenum and should be considered in presence of unexplained GI symptoms. Treatment of this abnormality is surgical – Ladd procedure, which involves division of Ladd's bands followed by widening of the small intestinal mesentery, performing an appendectomy and correct placement of the cecum and colon and should be recommended even in patients who are asymptomatic and in whom the malrotation is serendipitously discovered.[8]
Pregnancy can induce volvulus/obstruction in an asymptomatic patient with intestinal malrotation. Intestinal malrotation may by itself lead to recurrent pregnancy losses since our patient conceived successfully post-surgery.
In our patient intestinal malrotation was the cause of recurrent vomiting and pregnancy loss during previous pregnancies and correction of which lead to an uneventful pregnancy and successful delivery.

Conclusion

This case emphasizes the need to search for intestinal malrotation in patients with unexplained vomiting during pregnancy.

References
  1. Berrocal T, Lamas M, Gutiérrez J, Torres I, Prieto C, del Hoyo ML. Congenital Anomalies of the Small Intestine, Colon, and Rectum 1. Radiographics 1999;19:1219-36.
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  5. Pellerin D, Bertin P. [Primary postnatal volvulus of the small intestine]. Annales de chirurgie infantile 1972;13:83-94.
  6. Usmani SS, Kenigsberg K. Intrauterine volvulus without malrotation. Journal of pediatric surgery 1991;26:1409-10.
  7. De Felice C, Massafra C, Centini G, Di Maggio G, Tota G, Bracci R. Relationship between intrauterine midgut volvulus without malrotation and preterm delivery. Acta obstetricia et gynecologica Scandinavica 1997;76:386.
  8. Rothstein RD, Rombeau JL. Intestinal malrotation during pregnancy. Obstetrics and gynecology 1993;81:817-9.
  9. Gilbert HW, Armstrong CP, Thompson MH. The presentation of malrotation of the intestine in adults. Ann R Coll Surg Engl 1990;72:239-42.
  10. Andrassy RJ, Mahour GH. Malrotation of the midgut in infants and children: a 25-year review. Archives of surgery 1981;116:158-60.
  11. Hamlin CH, Palermino DA. Volvulus associated with pregnancy: report of 5 cases. American journal of obstetrics and gynecology 1966;94:1147-8.
  12. Malkasian GD, Jr., Welch JS, Hallenbeck GA. Volvulus associated with pregnancy; a review and a report of 3 cases. American journal of obstetrics and gynecology 1959;78:112-24.
Citation

Kiran S, Gupta D, Jain A, Shukla A. An Unusual Case Of Vomiting In Pregnancy And Fetal Loss. JPGO JPGO 2015. Volume 2 Number 11. Available from: http://www.jpgo.org/2015/11/an-unusual-case-of-vomiting-in.html