Volume 3 Issue 12, December 2016

Editorial

Chauhan AR

Intrauterine contraceptive device (IUCD) like the copper T (CuT) is an ideal spacing method for women. It is safe, effective, reversible, easy to insert, does not interfere with intercourse and does not require any action on the part of the woman once inserted. As per WHO Medical Eligibility Criteria (MEC), copper IUCDs are safe in the majority of women; there are very few situations, like active pelvic inflammatory disease, where it is contraindicated. Unlike other reversible methods like oral contraceptive pills or condom which have higher pregnancy rates for typical use compared to correct or ideal use, there is no such difference in IUCD use. In fact, failure rates for most IUCDs are low at < 2%. Over the last few years, with the introduction of the postpartum IUCD programme to increase contraceptive coverage, there has been a resurgence in the number of users. Despite this, according to the National Family Health Survey of 2005- 2006, the commonest method of family planning in India is still tubectomy in about a third of women; IUCDs account for only an estimated 2%. The IUCD which is most often used in the public sector is the CuT 380 and in the private sector, CuT 375 (multiload design). 
Unfortunately, apart from side effects like heavy menstrual bleeding and vaginal discharge, the two most common complications with IUCD are expulsion and displacement/ perforation. Of these, expulsion rate is high; it occurs in approximately 1 in 20 women, typically during the menses within the first 1- 3 months post- insertion. On the other hand, perforation occurs in less than 1 to 2 per 1000 women, and usually at the time of insertion. Acute severe pain or loss of resistance on sounding the uterus, or hemorrhage at the time of insertion are signs that perforation may have occurred and the procedure should be immediately abandoned. Previous cesarean section appears to be a risk factor for increased chance of perforation. There are no real differences in perforation rates among the various types of IUCD, especially the copper bearing ones; levonorgestrel intrauterine system is associated with least perforations, less than 1 per 1000 insertions. 
Irrespective of whether expulsion or perforation has occurred, the patient will present with either pregnancy and contraceptive failure, or inability to feel the threads or tail of the device. If pregnancy has occurred an ultrasound will help to locate the gestation sac relative to the position of the device; patient should be thoroughly counseled about risks of continuation vs termination of pregnancy. Management algorithm for missing threads includes thorough clinical examination along with sounding of the uterus, X-rays in anteroposterior and lateral positions with the uterine sound in situ, and abdominal and pelvic ultrasonography. This should be followed mandatorily by removal of the device, either by minimally invasive technique or laparotomy. If embedded in the intestine and ignored, patients can present with perforation or obstruction of small or large bowel.
Perforation may displace or dislodge the IUCD partially or completely; if incomplete, it may be embedded within the myometrium and some part may be in outside the uterus. If completely expelled, the IUCD may be in any part of the pelvis and abdomen, and terms such as "wandering" and "migrating" are used to describe unusual locations when it is found. Migration of the IUCD may in some cases be due to faulty training and insertion wherein perforation occurs at the time of insertion, or secondarily due to a chronic inflammatory process with slow erosion of the uterine wall. Areas where the IUCD is found are the omentum, large and small intestine, and bladder, where it may also form a calculus. Though a rarity, literature is full of case reports of retrieval of IUCD from these unusual locations, usually with laparoscopic surgery. This issue carries an unusual case report of displaced IUCD with concomitant intrauterine viable pregnancy which we hope will be of interest to our readers.

Inclusion Of Posterior Cervical Lip In Lower Segment Closure During LSCS

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Author Information

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

Abstract

Lower segment cesarean section is the commonest operation in obstetrics. The operative steps are not complex, and usually no complication occurs due to anatomical confusion. A case is presented in which the posterior cervical lip was accidentally sutured between the upper and lower cut edges of the lower segment during a lower segment cesarean section.

Introduction

Lower segment cesarean section (LSCS) is the  is the commonest operation in obstetrics today. The percentage of women who had LSCS in India was 2.9%, 7.1% and 10.6% in the years 1992-93, 1998-99 and 2005-06 respectively.[1,2,3] Its technique has evolved over a number of years, but the current technique has been the same, albeit a few minor variations, over a number of decades. The operative steps are well established, the anatomy is easy to understand, and usually there is no error in performance of the operation related to the anatomy of the operative area. A case is presented in which the posterior lip of the cervix was sutured inadvertently between the upper and lower cut edges of the lower uterine segment during performance of an LSCS. This is the first case of this type in the world literature.

Case Report

A 21 year old primigravida presented in labor at term. She had regular antenatal care. Her past medical, surgical and gynecological history was normal. General and systemic examination revealed no abnormality. Obstetric examination showed a single fetus in vertex presentation. She was in active phase of labor, the cervical dilatation being 4 cm, effacement 60%, station +2, occiput at 2 o’clock position, membranes intact and pelvis adequate. She made good progress and was fully dilated after 4.5 hours. Her second stage of labor was prolonged for 2 hours. A junior consultant attempted obstetric vacuum extraction, which failed. Then a trial of obstetric forceps delivery was done, which also failed. So a decision to perform a cesarean section was taken. The cesarean section was performed by two other junior consultants. A male child weighing 2.8 kg was delivered uneventfully. Its Apgar scores at 1 and 5 minutes were 8 and 10 respectively. The lower segment incision was closed with a continuous interlocking suture of No. 1 polyglactin. The abdomen was closed. At the time of suturing the episiotomy which had been made for the attempted vacuum and forceps delivery, cervix was traced. The anterior lip of the cervix was seen well, but the posterior lip and the sides of the rim of cervix were not seen as they were drawn up (figure 1). There was no communication with the uterine cavity, the roof of the vagina being totally closed by the posterior aspect of the posterior wall of the portio vaginalis.


Figure 1. Speculum examination showing anterior lip of the cervix (held with sponge holding forceps) and closed roof of the vagina by the posterior surface of the posterior wall of the cervix (yellow arrow).

A diagnosis of inadvertent inclusion of the posterior lip of the cervix in the lower segment closure was made. The abdomen was opened again. The lower segment suture line was opened by removing the polyglactin suture. The posterior lip of the cervix was found to be sutured between the upper and lower edges of the lower segment. The cervix was pushed down to its normal position after confirming that it was not traumatized and bleeding. Then the lower segment was sutured again with a continuous suture of No. 1 polyglactin. The occurrence was explained to the patient and her relatives, who accepted it as an error that did not lead to any adverse consequences. The patient made an uneventful recovery. The uterus and cervix were found to be normal at the time of a follow up examination after 15 days.


Figure 2. Lower segment suture line. The edge of the cervix is seen (black arrows) protruding between the upper (yellow arrows) and lower edges (green arrows) of the lower segment incision at two sites.


Figure 3. Appearance of the lower segment incision after removal of the suture. The upper edge of the lower segment incision (yellow arrow), posterior lip of the cervix (black arrow), lower edge of the lower segment incision (green arrow), and smooth posterior wall of the posterior wall of the cervix (white arrow) are seen.


Figure 4. Appearance of the lower segment incision after removal of the suture. The upper edge of the lower segment incision (yellow arrow), posterior lip of the cervix (black arrows), lower edge of the lower segment incision (green arrow), and smooth posterior wall of the posterior wall of the cervix (white arrow) are seen.


Figure 5. Appearance of the lower segment incision after removal of the suture. A hemostat (yellow arrow) is passed into the cervical canal after drawing the posterior cervical lip (black arrows) backwards and upwards, to demonstrate the location of the cervical canal. Lower edge of the lower uterine segment incision is shown by white arrows.


Figure 6. Abdominal appearance of the posterior vagina prior to releasing the posterior cervical lip from the lower segment suture line: the vagina is drawn forward and upward due to traction on the cervix attached to it.

Discussion

Normally the cervix hangs down after childbirth, following vaginal delivery as well as cesarean section. In the case presented, the posterior lip of the cervix hanging down was somehow drawn up and reached the level of the lower uterine segment incision. It might have occurred while a hand was passed below the presenting part to deliver it. With full cervical dilatation, there is no cervix to get caught between the hand and vertex of the baby. Thus there is reason to beieve that the cervix was not actually fully dilated at the time of the cesarean section. That was probably the reason for  failure of the vacuum and forceps delivery. Then it was inadevrtently sutured to the cut edges of the lower segment incision, believing it to be decidua detached from the myometrium. As a result the uterine cavity got walled off from the vagina. Had the condition not been diagnosed in time, the blood coming from the uterine cavity and lochia would have been retained above the cervix. It could have led to development of a pyometra too.
The reason for publishing this case report is to create awareness of the possibility of such an occurrence, which would lead to serious health consequences for the patient, and medicolegal trouble for the treating obstetrician.

Acknowledgment

I thank Dr Neha Shah for taking operative photographs.

References
  1. Gosh S. Increasing trend in Caesarean Section Delivery in India: Role of Medicalisation of Maternal Health. 1st ed. Bangalore: The Institute for Social and Economic Change; 2010. p 6.
  2. Kambo I, N Bedi, B S Dhillon, N C Saxena (2002). A critical appraisal of cesarean section rates at teaching hospitals in India, International Journal of Gynecological and Obstetrics, 79.
  3. Mishra U S and M Ramanathan (2002). Delivery-related complications and determinants of cesarean section rates in India, Health Policy and Planning, 17 (1): 90-98.
Citation

Parulekar SV. Inclusion Of Posterior Cervical Lip In Lower Segment Closure During LSCS. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/inclusion-of-posterior-cervical-lip-in.html

Juxtaposition Of Urethral And Microperforate Hymenal Openings

Author Information

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

Abstract

Microperforate hymen is an uncommon congenital malformation of the female genital tract. It usually is an isolated anomaly, but may occur associated with other anomalies. A case of microperforate hymen, with opening juxtaposed to the external urinary meatus is presented. 

Introduction

Congenital anomalies of the hymen include imperforate, microperforate, cribriform, and septate types.[1,2] A microperforate hymen allows some menstrual flow, but may cause partial obstruction and stasis. That may lead to infection ascending up the genital tract.[3] It also causes dyspareunia. The opening is usually at or near the center of the hymen. A case is presented where it was juxtaposed to external urinary meatus. This is the first case of this type in the world literature.

Case Report

A 21 year old woman, married for 2 years, presented with apreunia. She had menarche at the age of 13 years. Her past menstrual cycles were regular, painless, and with moderate flow. Her last menstrual period had been 3 weeks ago. She had apareunia. She had never been able to have penetrative sexual intercourse. Her general and systemic examination revealed no abnormality. Her breast development was of Tanner’s stage 5. Her axillary and pubic hair development was normal. Local examination showed an apparently intact hymen, normal clitoris, labia minora and majora, and external urinary meatus. Rectal examination showed a normal sized uterus, and no pelvic tenderness or mass. Since she claimed to have regular menses, she was asked to report during a menstrual flow. She presented a week later. There was flow of menstrual blood from a spot near 6 o’clock position of the external urinary meatus. Careful local examination showed a small opening outside the urinary meatus, closely related to it, from which the menstrual blood was escaping. A radiological study was done after a week, in which radiopaque dye was injected through a catheter passed through that opening into the cavity beyond and radiograph was obtained (figure 1). It showed a vagina of normal dimensions. A diagnosis of a microperforate hymen was done. She was investigated and was found to be fit for anesthesia. A week following her next menstrual period, surgical correction of the microperforate hymen was done under spinal anesthesia. the hymen was split longitudinally from its perforation site to the fourchette. Interrupted sutures of No. 2-0 polyglactin were put over the cut edges to approximate the lining epithelium on both sides of the cuts, for achieving hemostasis as well as better healing across the edges so that opposite cut edges would not approximate in the midline (figures 2 to 8). Two fingers could be easily passed into the vagina at the end of the operation. The patient made an uneventful recovery. She was advised to apply an antiseptic cream locally for one week and maintain menstrual hygiene. She was well at the first follow up after 15 days, and had successfully stated sexual intercourse 2 months after the surgery.


Figure 1. Radiograph showing normal vagina (black arrow) filled with radiopaque dye instilled through a catheter.  A gauze swab (yellow arrow) is seen around the introitus, held around the microperforation of the hymen to prevent leakage of the dye during the procedure.


Figure 2. Local examination showing absence of any hymenal opening. The external urinary meatus is pointed out by yellow arrow. The position of hymen is pointed out by black arrows.


Figure 3. The microperforation is enlarged by putting it on stretch with the tip of a curved hemostat. The thinness of the hymen is made evident by its fold elevated by the hemostat.


Figure 4. The hymen is slit longitudinally from its opening towards the fourchette.


Figure 5. Approximation of epithelium on inner and outer surface of the cut hymen over the cut edges. Sutures have already been placed at 3, 6, and 9 o’clock positions. A suture is being placed between 7 and 8 o’clock positions.


Figure 6. Normal vagina and cervix are seen after insertion of a Sims’ speculum and a right angled retractor to retract the posterior and anterior vaginal walls respectively.


Figure 7. The end result. External urinary meatus is shown by yellow arrow. Sutures are seen along the rim of the new hymenal opening. Normal vagina is seen within.


Figure 8. The end result. The external urinary meatus is shown by passing the tip of a curved hemostat into it.

Discussion

A microperforate hymen is almost always an isolated finding. But an association with bifid clitoris,  hypoplastic kidney with ectopic ureter, duplication of the ureter, polydactyly and vascular anomalies has been reported.[4] Familial occurrence has also been reported.[5] A microperforate hymen can cause ascending pelvic infections and recurrent urinary tract infections.  Microorganisms ascend through microperforations in the hymen, infect collected discharge behind the hymen and can cause formation of a pelvic abscess.. Recurrent urinary tract infections can occur because of pooling of urine in the functional urogenital sinus and invasion into the urethra.  They can then infect any accumulated material in the vagina, uterus, tubes, and abdomen.[3] In case of a married woman, if efforts at sexual intercourse are continued in presence of a microperforate hymen,  urethral coitus may take place, resulting in urethral dilatation and urinary symptoms.[6] Coitus interfemora with deposition of semen over the external genitals can lead to a pregnancy, the sperm entering the vagina through the microperforation.[7] 
In our case the hymenal opening was large enough to permit drainage of menstrual blood and vaginal discharge without collecting behind the hymen. So there was no occurrence of ascending pelvic infection or urinary tract infection. Fortunately there was no urethral dilataion caused by urethral coitus. The surgical treatment was satisfactory, and the patient had normal sexual activity  two months after the operation.
Microperforate hymen can escape detection if the menstrual flow is not obstructed. Thus it sometimes comes to light much later than an imperforate hymen. A careful genital examination at birth can detect the condition and will prevent a number of complications reducing morbidity considerably.

Acknowledgment

I than Dr Sana Bijapur for recording operative video.

References
  1. DiVastaad, Grace e. Normal hymen and hymenal variations. In Practical Pediatric and Adolescent Gynecology, First Edition. Edited by Paula J. Adams Hillard. 2013 John Wiley & Sons, Ltd. New Jersey. Pp 45-48. available from: http://sci-hub.cc/10.1002/9781118538555.ch9
  2. Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3 to 9 years of age. . J Pediatr 2002; 140(5):600–607.
  3. Sanfilippo AM, Mansuria SM. Microperforate Hymen Resulting in Pelvic Abscess. J Pediatr Adolesc Gynecol (2006) 19:95–98.
  4. Winderl L, Silverman R: Prenatal diagnosis of congenital imperforate hymen. Obstet Gynecol 1995; 85:857.
  5. Liang CC, Chang SD, Soong YK: Long-term follow-up of women who underwent surgical correction for imperforate hymen. Arch Gynecol Obstet 2003; 269:5.
  6. Di Donato V, Manci N, Palaia I, Bellati F, Perniola G, Panici PB. Urethral coitus in a patient with a microperforate hymen. J Minim Invasive Gynecol. 2008 Sep-Oct;15(5):642-3. doi: 10.1016/j.jmig.2008.05.002.
  7. Goto K, Yoshinari H, Tajima K, Kotsuji F. Microperforate hymen in a primigravida in active labor: a case report. J Reprod Med. 2006 Jul;51(7):584-6.
Citation

Parulekar SV. Juxtaposition Of Urethral And Microperforate Hymenal Openings. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/juxtaposition-of-urethral-and.html

Left Ventricular Diverticulum

Author Information

Bandekar P*, Athavle U**
(*Additional Professor, Department of Obstetrics and Gynecology, Seth G S Medical College & N. Wadia Maternity Hospital, ** Consultant Radiologist, N. Wadia Maternity Hospital, Mumbai, India)

Abstract

Fetal cardiac anomalies such as ventricular and atrial septal defects, those involving outflow tracts, chambers, and valves are often encountered in routine screening. However, fetal left ventricular diverticulum rarely gets diagnosed prenatally. We present a case report of a fetal left ventricular diverticulum, diagnosed at 20 weeks of gestation. The diagnosis was confirmed by neonatal echocardiography. A well timed prenatal imaging and diagnosis helps in prognostication and in counseling of the couple.

Introduction

We report a case of left ventricular diverticulum with fetal bradyarrhythmia and persistent ectopic beats diagnosed antenatally at 20 weeks of gestation. The diagnosis was eventually confirmed on neonatal echocardiography.

Case Report

A 33 year old primigravida had a routine fetal anomaly scan at 20 weeks gestation which showed an out pouching from the left ventricle of the fetal heart, as seen in Figure 1. This was also visible with color Doppler as seen in Figure 2.


Figure 1: Fetal Bradyarrythmia.


Figure 2: Communicating Diverticulum.

Fetal 2 D echocardiogram showed a large ventricular diverticulum approximately 14 x 7 mm arising from the left wall of the fetal left ventricle. Normal cardiac connection and a left sided aortic arch were noted. The diverticulum was wide mouthed and contractile. There was no evidence of intra-cardiac thrombus. Ventricular function was normal. Also evidence of fetal arrhythmia and persistent ectopic beats was noted. Fetal heart rate was between 80-100 beats per minute. The heart rate showed bradyarrhythmia (bradycardia with irregular rhythm). No pericardial effusion was seen; thorax showed normal appearance. In the absence of hydrops or any other identifiable abnormality in the fetus, the overall prognosis was considered to be good without any intervention. A combined test previously done at 12 weeks confirmed low risk for trisomy 13, 18 and 21. TORCH screening and antibodies SSA-Ro and SSB-La were negative.
Regular ultrasound scans showed normal fetal growth, liquor and Doppler studies for umbilical and middle cerebral artery. The patient underwent a cesarean section for obstetric indication, delivered a male baby weighing 3 kg and had normal Apgar at birth. Mother and baby were discharged after a complete pediatric review. The newborn had regular pediatric echocardiography scan and a detailed CT cardiac angiogram. The diagnosis was left ventricular diverticulum (muscular) with normal outflow tracts. The baby is doing well with conservative management and at present is nine months of age.

Discussion

Diagnosis of congenital left ventricular diverticulum can be made by fetal ultrasound and can be further confirmed by prenatal echocardiography and MRI. Management depends on the clinical correlation and associated abnormalities, maternal and fetal. If asymptomatic, the diverticula can be managed with a conservative approach. Treatment options for high-risk cases include conservative, medical or surgical approach and management of arrhythmias in symptomatic babies after birth. 
Fetal echocardiography has become a very practical and proficient aid. The rates at which cardiac anomalies are detected are on an increase.[1] The overall prevalence of cardiac anomalies at birth is 7.8/1000.[2] A recent addition to the list of antenatally diagnosed cardiac anomalies is ventricular diverticulum; the first case was reported in 1990 [3] and approximately 20 cases have been reported after that.[4] The incidence is 0.5 per 100,000 live births. A ventricular diverticulum originates from either septum, wall, or apex. Such diverticula are only rarely associated with other anomalies.[5]
An important differential diagnosis of ventricular diverticulum is an aneurysm. A diverticulum is a small finger-like, synchronously contracting, narrow projection, with the same thickness and layers as the rest of the myocardium.[6] Fetuses with an isolated diverticulum alone have a good prognosis [7,8]. Cardiomyopathy, Ebstein's anomaly, outflow tract obstruction, and atrioventricular regurgitation may all be identified as a right ventricular diverticulum.[9] Other important differential diagnosis of ventricular aneurysm are post-ischemic aneurysm and intra- thoracic cystic lesions.
The prognosis of ventricular diverticulum depends on the time of detection, the size and the progression, the association and grade of compression of the fetal lungs, involvement of the mitral opening, reversal of atrial shunt, associated cardiac failure, and the presence of connective tissue disorders which may cause myocardial damage.[5,10,11]
This baby was delivered by a cesarean section for purely obstetric indications, and detailed echocardiography after birth confirmed the antenatal diagnosis.

References 

  1. Russo MG, Paladini D, Pacileo G, Ricci C, Di Salvo G, Felicetti M, et al. Changing spectrum and outcome of 705 fetal congenital heart disease cases: 12 years, experience in a third-level center. J Cardiovasc Med (Hagerstown) 2008; 9(9):910–5.  
  2. Chew C, Halliday JL, Riley MM, Penny DJ. Population-based study of antenatal detection of congenital heart disease by ultrasound examination. Ultrasound Obstet Gynecol. 2007; 29(6): 619–24.  
  3. Gembruch U, Steil E, Redel DA, Hansmann M. Prenatal diagnosis of a left ventricular aneurysm. Prenat Diagn. 1990;10(3): 203–9.
  4. El Kady D, Gerscovich EO, Moon-Grady A, Towner D, McGahan JP, Rhee-Morris L, et al. Congenital cardiac left ventricular aneurysm with pericardial effusion: early prenatal diagnosis and intervention. J Ultrasound Med. 2005; 24(7):1011–5. 
  5. Chaubal N, Dighe M, Shah M, Chaubal J, Raghavan J. Congenital left ventricular aneurysm: prenatal sonographic diagnosis. J Ultrasound Med. 2004; 23(1):125–8. 
  6. Wax JR, Moran A, Pinette MG, Reyes A, Cartin A, Blackstone J. Prenatal sonographic diagnosis of fetal right ventricular diverticulum. J Ultrasound Med. 2007; 26(2):267–70.  
  7. Del Rio M, Martinez JM, Bennasar M, Palacio M, Figueras F, Puerto B, et al. Prenatal diagnosis of a right ventricular diverticulum complicated by pericardial effusion in the first trimester. Ultrasound Obstet Gynecol. 2005; 25(4):409–11.  
  8. McAuliffe FM, Hornberger LK, Johnson J, Chitayat D, Ryan G. Cardiac diverticulum with pericardial effusion: report of two cases treated by in-utero pericardiocentesis and a review of the literature. Ultrasound Obstet Gynecol. 2005; 25(4):401–4.  
  9. Hornberger LK, Dalvi B, Benacerraf BR. Prenatal sonographic detection of cardiac aneurysms and diverticula. J Ultrasound Med. 1994;13(12): 967–70.  
  10. Matias A, Fredouille C, Nesmann C, Azancot A. Prenatal diagnosis of left ventricular aneurysm: A report of three cases and a review. Cardiol Young. 1999; 9(2):175–84.
  11. Pipitone S, Sperandeo V, Mongiovi M, Roberto G, Centineo G. Prenatal diagnosis of ventricular aneurysm: A report of two cases and a review. Prenat Diagn. 2002; 22(2):131–6.
Citation

Bandekar P, Athavle U. Left Ventricular Diverticulum. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/left-ventricular-diverticulum.html


Intrauterine Contraceptive Device (IUCD) Perforating Bowel Managed Laparoscopically

Author Information

Shah NH*, Paranjpe S**, Shah VN*** 
(* Director, Vardann Multispeciality Hospital, ** Director, Velankar Hospital & Paranjpe Maternity Home, *** Consulting Anesthesiologist, Vardann Multispeciality Hospital, Mumbai, India.)

Abstract

Intrauterine contraceptive device IUCD migration in to the small bowel after uterine perforation is a rare but serious event.  Removal of the IUCD in such cases is mandatory because of the risk of complication such as fistula formation and colonic perforation. We present the case of a 28 year-old female with a Copper T 380A IUCD embedded in the small bowel, along with an intrauterine pregnancy of 6 weeks, which was removed with minimally invasive techniques.

Case Report

A 28 year old female (Gravida 2, Para 1, Living 1) with previous 1 LSCS 5 years ago presented to our hospital with history of one and a half months of amenorrhea with history of intrauterine contraceptive device (Copper T 380A) inserted 5 years back. Patient had a regular follow up for the copper T threads till 6 months, after which she had not visited the hospital. Patient had regular periods without any menstrual dysfunction until last 6 weeks. Her last menstrual date was 50 days prior to admission. There was no history of any medical co morbidities. On per speculum examination, copper T tail was not visible.
Ultrasonography was done which was suggestive of a live intrauterine pregnancy of 6 weeks. The sonogram also revealed the presence of extrauterine IUCD, in the left adnexa closer to the fundus of the uterus.
An exploratory laparoscopy was undertaken during which the uterus and adnexae appeared normal with no evidence of inflammation or any site of perforation. The copper T was seen to be perforating the small bowel and embedded within it. The embedded copper T was gently removed from the 5 mm port.


Figure 1. Peritoneum covering the copper T seen.


Figure 2. Copper T seen perforating the bowel.

A small 2 inch laparotomy incision was taken through which the perforated small bowel was removed and sutured in 2 layers. An intraperitoneal drain was kept.  After explaining the prognosis and risks to the patient, the pregnancy was continued as per patient’s decision.


Figure 3. Bowel sutured.


Figure 4. Bowel inserted back into the abdomen.

Discussion

Most of the uterine perforations are asymptomatic and are unrecognized at the time of insertion.[1] No operative management had been recommended in the past for a migrating IUCD because of the increased morbidity associated with its removal. [1] However, the complication of a migrating IUCD can lead to pain, fibrosis, adhesions and in some cases, can result in penetration into surrounding organs like urinary bladder, sigmoid colon, appendix, and small bowel.[1,2] A perforation in the bowel can cause an abscess formation, intestinal ischemia, or volvulus.[2] Therefore, it has been suggested that exploration and IUCD retrieval should be the primary therapeutic approach for patients with a missing IUCD.[2]
Arslan et al in a review of the literature identified 47 such cases of uterine perforation in which a complication occurred of intestinal penetration. Half the reported cases of intestinal perforation in the literature were that of Copper-7 and copper-T IUCD. Intestinal perforations caused by IUCDs  primarily involved, in order, the sigmoid colon, followed by the small intestine and rectum.[3]
With advances in minimally invasive techniques, these situations can be safely managed with laparoscopy, which has the advantage of less morbidity and faster recovery. Chi et al removed an IUCD which had been completely perforated into the sigmoid colon by performing a laparoscopic assisted resection of the involved sigmoid colon segment. Some authors recommend that partial penetration of an IUCD into the colon wall can be removed laparoscopically with intracorporeal repair of the colon defect.[4] They also suggested that a full-thickness perforation by an IUCD into the colon wall should be repaired by resection of the involved colon with primary anastomosis. In our case, a small 2 inch laparotomy incision was taken to repair the bowel. 
Potential complication during removal such as organ perforation (e.g. bowel, bladder) and possible surgical repair surgery such as resection of bowel and colostomy insertion should be discussed in advance. Thus, all diagnosis and treatment can be performed at the same setting as seen in our case.

Conclusion
  1. Proper technique of IUCD insertion should be followed to avoid primary perforation. However, spontaneous perforation and migration can occur in rare instances such as this, and is often quite unpredictable. Removal of the IUCD is indicated in asymptomatic patients also, and the use of minimally invasive techniques is possible in selected patients.
  2. References
  3. Mederos R, Humaran L, Minervini D. Surgical removal of an intrauterine device perforating the sigmoid colon: a case report. Int J Surg. 2008; 6(6):e60-2.
  4. Chi E, Rosenfeld D, Sokol TP. Laparoscopic removal of an intrauterine device perforating the sigmoid colon: a case report and review of the literature. Am Surg. 2005; 71(12):1055-7.
  5. Arslan A, Kanat-Pektas M, Yesilyurt H, Bilge U. Colon penetration by a copper intrauterine device: a case report with literature review. Arch Gynecol Obstet. 2009; 279(3):395-7.
  6. Zeino MY, Wietfeldt ED, Advani V, Ahad S, Younkin C, Hassan I. Laparoscopic removal of a copper intrauterine device from the sigmoid colon. JSLS 2011; 15(4): 568- 70.
Citation

Shah NH, Paranjpe S, Shah VN. Intrauterine Contraceptive Device (IUCD) Perforating Bowel Managed Laparoscopically. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/intrauterine-contraceptive-device-iucd.html

Ectopic Pregnancy With Myomectomy Managed Laparoscopically

Author Information

Shah NH*, Paranjpe S**, Shah VN*** 
(* Director, Vardann Multispeciality Hospital, ** Director, Velankar Hospital & Paranjpe Maternity Home, *** Consulting Anesthesiologist, Vardann Multispeciality Hospital, Mumbai, India.)

Abstract

Incidence of uterine leiomyoma is approximately 2% in pregnant women.[1] Traditionally obstetricians are trained to avoid myomectomy during pregnancy or cesarean section due to fear of severe bleeding often necessitating hysterectomy. Here we present a case of ectopic pregnancy managed laparoscopically along with laparoscopic removal of an intramural fundal fibroid of about 5 x 6 cm in the same sitting.

Introduction

The classical clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding. Unfortunately, of that, only 50% of patients present with all the 3 symptoms. About 50% of patients with ectopic pregnancy have vaginal bleeding, 50% of patients have an adnexal palpable mass, and 75% of patients have pain and abdominal tenderness. In one of the case series published, that of ectopic pregnancies, abdominal tenderness and pain was presented in 98.6% of patients, amenorrhea in 74.1% of patients, and vaginal bleeding in only 56.4% of the patients.[2]
The blood loss during a myomectomy is usually severe during pregnancy as the size and blood supply of the myoma are increased in pregnancy. In most cases it is wise to defer myomectomy for preferably 6 months after pregnancy. Pedunculated fibroids on the other hand can be easily removed, and are an exception.[3]

Case Report

A 35 year old female came to our outpatient department with chief complaints of pain in abdomen with 6 weeks amenorrhea. She had previous one normal delivery 8 years back. A urine pregnancy was done which was positive and an ultrasonogram showed an ectopic pregnancy on the left side with an empty uterine cavity along with an intramural fibroid on the right uterine wall of about 5 by 5 cm in size. On asking about the past history, she had also complained about severe dysmenorrhea since 1 year for which she was on some medications since 2 months.  
A decision for laparoscopic exploration was taken. A left tubal ectopic pregnancy was seen; left side salpingectomy was done. 


Figure 1. Left tubal ectopic pregnancy and fibroid arising from right lateral wall.


Figure 2. Fibroid capsule opened.

A fibroid of about 5 by 5 cm was seen jutting from the right sided uterine wall. Injection vasopressin was injected around the fibroid and removed with a myoma screw; minimal bleeding was encountered.  Myoma cavity was sutured in 2 layers and haemostasis was achieved.  Peritoneal wash was given.


Figure 3. Fibroid removed with myoma screw.


Figure 4. Fibroid and left tube with ectopic after its removal.

Discussion

Uterine myomas are observed along with pregnancy more frequently nowadays than in the past because many women are delaying pregnancy until they are in their late thirties, which is the time for an increased risk of myoma growth. Also, the use of sonography has improved the diagnostic capability of detection of even smaller myomas and has increased our knowledge of myomas in pregnancy. Enucleation of the fibroid is technically easier in gravid uterus owing to greater looseness of the capsule.[4] There are very few reports of intramural myomectomy with management of ectopic pregnancy done at the same sitting. Davison et al in 2013 have reported a case of hemoperitoneum secondary to bleeding from a pedunculated fibroid along with concomitant tubal abortion; they performed an uncomplicated laparoscopic myomectomy and concluded that minimally invasive surgery was safe and feasible for pedunculated fibroids even in the presence of hemoperitoneum.[5]

References
  1. Katz VL, Dotters DJ, Droegemeuller W. Complications of uterine leiomyomas in pregnancy. Obstet Gynecol 1989;73(4):593-6.
  2. Alsuleiman SA, Grimes EM. Ectopic pregnancy: a review of 147 cases. J Reprod Med. 1982; 27(2):101-6. 
  3. Davis JL, Ray-Mazumder S, Hobel CJ, Baley K, Sassoon D. Uterine leiomyomas in pregnancy: a prospective study. Obstet Gynecol 1990; 75(1): 41-4.
  4. Kwawukume EY. Myomectomy during cesarean section. Int J Gynecol Obstet 2002; 76: 183-4.
  5. Davison JZ, Bennett TA, Jaffe IM. Laparoscopic myomectomy for hemoperitoneum from a uterine leiomyoma with concomitant tubal abortion: a case report. J Reprod Med. 2013; 58(9-10): 438-40.
Citation

Shah NH, Paranjpe S, Shah VN. Ectopic Pregnancy With Myomectomy Managed Laparoscopically. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/ectopic-pregnancy-with-myomectomy.html

Pregnancy Outcome In Previous Posterior Uterine Rupture

Author Information

Desai D*, Prasad M**, Gupta AS***.
(*Second Year Resident, *Assistant Professor, ***Professor, Department of Obstetrics and Gynecology, Seth G S Medical College & K.E.M. Hospital, Mumbai, India)

Abstract

We come across several cases of previous cesarean sections. The risk of scar dehiscence and uterine rupture in subsequent pregnancies is known. But in modern times, uterine rupture in an unscarred uterus is a rare phenomenon. The successful management and its favorable outcome of a patient who had a previous posterior uterine wall rupture, is presented here.
Introduction
Previous posterior uterine wall rupture with subsequent conception is a high risk pregnancy. A fine balance to achieve adequate fetal maturity, timely delivery to circumvent an antepartum uterine rupture and achieve a favorable maternal and fetal outcome with minimal morbidities and no mortalities is a challenge to the obstetrician. Here we present a rare case of previous posterior uterine wall rupture of unknown etiology and its successful pregnancy outcome.

Case Report

A 26 year old gravida two, para one with no living issue, registered at 13 weeks of gestation at our center, as no medical center around her place of residence was willing to manage her high risk pregnancy. Her previous pregnancy records were reviewed.  Intraoperative posterior uterine wall rupture was documented in those records. In that pregnancy, she had registered at 26 weeks and had 5 antenatal follow up visits. It was an induced labor for postdatism. Labor induction had failed and as labor had not progressed cesarean section was done. Labor record, duration of labor prior to cesarean section and methods of induction or labor augmentation were not mentioned in that document. The record also mentioned that during that cesarean section a posterior wall uterine rupture was found and it was sutured. The baby was stillborn.  Details regarding how the baby was delivered, whether fetus was lying intraperitoneally, extent of uterine injury, whether a uterine incision was required, and suture materials used to repair the posterior rent were not mentioned. It was not possible to obtain records and more clarifications from her previous treating doctor. One unit blood transfusion was required, and there were no other postoperative problems. 
In this pregnancy, she followed up regularly. She was admitted at 24 weeks as she was at a very high risk of rupture of previous posterior wall uterine scar of unknown dimensions and site. Scar strength and integrity also could not be predicted and she was also not a local resident. All high risks and associated morbidities were explained to her and her husband. Hemoglobin was 11.5 gm% with normal leucocyte count. Her platelet count was 1.8 lakh /cu mm and normal blood sugar values. Urine examination was within normal limits and serum TSH was 4.9 IU/ml. She was started on tablet levothyroxine 50 µgm once a day in view of gestational hypothyroidism. 
An ultrasound suggestive of single live intrauterine pregnancy of 18 weeks 4 days was available; placenta was anterior not low lying, non adherent. No malformations were seen in the fetus, liquor was adequate. Injectable steroids were given at 26 weeks for fetal lung maturity in anticipation of the need to deliver her prematurely. At around 31 weeks, gestational thrombocytopenia was diagnosed (platelet count was 90000/cu mm) and she was started on multivitamin injection once a day as per hematologists’ advise. Daily monitoring of platelet count was done. It increased to 1.2 lakh/ cu mm in a week. She was scheduled for lower segment cesarean section (LSCS) at 32 weeks after confirming availability of adequate blood and platelets. LSCS was done under spinal anesthesia. 
Intraoperatively, there were no adhesions present between bladder and anterior lower segment. Sharp dissection was done to separate bladder, and there was no obvious previous anterior uterine scar seen. A female fetus weighing 2.3 kg was delivered, who cried immediately and had Apgar score of 9/10. She was admitted in the neonatal intensive care unit (NICU) as she had a grunt and was a premature neonate. After expulsion of placenta, uterine cavity was inspected. There was no evidence of scarring, thinning or focal sub decidual hemorrhages in the posterior wall. The uterus was not eventrated and the uterine closure was done in two layers with polyglactin No. 1 suture material. Lastly, after ensuring no evidence of adhesions in pouch of Douglas and near rectosigmoid region, posterior uterine wall was inspected. There was a well healed irregular, broad, midline, vertical, ragged previous rupture scar seen extending from just below the fundus to just above the cervix at the level of insertion of uterosacral ligaments. It was thick, intact in its entire length. Bilateral fallopian tubes and ovaries appeared normal. 


Figure 1. Image showing posterior surface with arrow pointing at the scar.

Postoperative period was uneventful and she was discharged on day 5. Suture removal was done and wound was healthy. Healthy neonate was discharged from the NICU on day 15 of birth. She was counseled against future pregnancies and various contraceptive choices were discussed with her.

Discussion

Uterine rupture is a rare occurrence. In a 6 year period of study by Revicky et al in the UK, there were only 12 cases of uterine rupture noted, with a rate of 1 in 3000 deliveries.[1] However, in a 5 year study series conducted in Ethiopia by Berhe et al, the rate was 1 in 110 deliveries.[2] A similar study done by Ashimi et al in Northern Nigeria reported it to be 15 per 1000 deliveries.[3] In India, the rate is reported to be around 1 in 360, and as concluded by Singh et al, uterine rupture continues to be a harsh reality.[4, 5]  These statistics clearly highlight the disproportionate occurrence of uterine rupture in the developing world. A cross- sectional study in Chattisgarh, India studied the factors associated with rupture uterus. It is more common in scarred uterus, multiparous women, unbooked pregnancies and induced labor. Obstructed labor, injudicious use of oxytocics, prior history of suction evacuation, poor intrapartum management and lack of referral facilities were all factors associated with uterine rupture .[5]
This association with induced labor has been confirmed by Chibber et al in a 25 year review of cases.  Interestingly 48% of the cases were in patients with no prior uterine scar.[6] In our case also an unscarred uterus had ruptured during an induced labor. As reported by Chibber, when uterine rupture occurs, it occurs in the lower segment in 78 % and near the fundus in 22%. Rathod et al have reported that common site of rupture is the anterior wall.[4,6] According to retrospective analysis done in Nigeria, it was found that lateral wall tear is more common around 39% in unscarred uterus.[7] However, posterior uterine wall rupture (as in our case) has not been mentioned as a common location. Perinatal mortality is high when uterine rupture occurs. In the study by Rathod et al, the perinatal mortality was as high as 90%. In our case too, the previous pregnancy resulted in a stillbirth. A case series of 27 women with previous uterine rupture also demonstrated good maternal-fetal outcomes, in which there was only one case of repeat uterine rupture. [8]
Previous history of uterine rupture is considered a contraindication for VBAC (Evidence level “D”).[9] However, no specific recommendation regarding the timing of the planned cesarean section is mentioned. Our patient was fortunate, as the placenta had not implanted on the rupture site as that would have probably weakened the scar or could have resulted in an adherent placenta. Our patient underwent planned LSCS at 32 weeks of gestation. This gestational age was chosen based on multiple factors, wherein a balance was reached between chances of scar giving way and prematurity. The decision was based on the fact that estimated baby weight was more than 2 kg, fetal lung maturity had been relatively ensured by antenatal steroid administration and our NICU statistics had a good survival outcome at this gestational age. Our decision to deliver at 32 weeks was validated by the fact that the mother went home with a live born neonate of reasonable maturity and without the tragedy of a uterine rupture. 

Conclusion

Posterior uterine wall ruptures, that too involving almost the entire length of the posterior wall are not common.  It is not possible to predict the recurrence of rupture and loss of fetal or maternal life, or the uterus. Women without living children despite proper counseling risk their lives by getting pregnant. This will result in obstetricians having to face the challenge of managing such patients with the aim of ensuring a good maternal and fetal outcome without a repeat rupture. The route of delivery will undoubtedly have to be abdominal. The main challenge is the timing of the delivery so that a reasonably mature neonate is delivered out before the upper segment or unknown site uterine scars have to prove their integrity.

References
  1. Revicky V, Muralidhar A, Mukhopadhyay S, Mahmood T. A Case Series of Uterine Rupture: Lessons to be Learned for Future Clinical Practice. J Obstet Gynaecol India. 2012;62 (6):665–73. 
  2. Berhe Y, Gidey H, Wall LL. Uterine rupture in Mekelle, northern Ethiopia, between 2009 and 2013. Int J Gynaecol Obstet. 2015;130 (2):153–6. 
  3. Ashimi AO, Omole-Ohonsi A, Uqwa AE, Amole TG. A prospective surveillance of ruptured uterus in a rural tertiary health facility in northwest Nigeria. J Matern Fetal Neonatal Med. 2014; 27 (16):1684–7. 
  4. Rathod S, Samal SK, Swain S. A Three Year Clinicopathological Study of Cases of Rupture Uterus. J Clin Diagn Res. 2015; 9(11):QC04-6.
  5. Singh A, Shrivastava C. Uterine Rupture: Still a Harsh Reality! J Obstet Gynaecol India. 2015; 65(3):158–61. 
  6. Chibber R, El-Saleh E, Al Fadhli R, Al Jassar W, Al Harmi J. Uterine rupture and subsequent pregnancy outcome-how safe is it? A 25-year study. J Matern Fetal Neonatal Med. 2010; 23(5):421–4. 
  7. Eguzo KN, Lawal AK, Ali F, Umezurike CC. Patterns of uterine rupture in Nigeria: a comparative study of scarred and unscarred uterus. Int J Reprod Contracept Obstet Gynecol. 2015; 4(4):1094–9
  8. Al Qahtani NH, Al Hajeri F. Pregnancy outcome and fertility after complete uterine rupture: a report of 20 pregnancies and a review of literature. Arch Gynecol Obstet. 2011; 284 (5):1123–6. 
  9. Green-top Guideline No. 45 Birth after previous caesarean birth. Royal college of Obstetricians and Gynecologists. October 2015.
Citation

Desai D*, Prasad M**, Gupta AS. Pregnancy Outcome In Previous Posterior Uterine Rupture. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/pregnancy-outcome-in-previous-posterior.html

Adnexal Fibroid/Ovarian Tumor – An Obstetrician’s Dilemma

Author Information

Jassawalla NM*, Shetty S**, Vora P***. 
(*Third Year Resident, **Professor, Department of Obstetrics and Gynaecology, J.J.M. Medical college, Davangere, Karnataka, *** Third year Resident, Department of Obstetrics and Gynaecology, Nowrosjee Wadia Maternity Hospital, Mumbai, India)

Abstract

Ultrasonography helps differentiate between ovarian tumors and fibroids. Large cystic degenerations and leiomyomas located in the adnexa can pose a dilemma to both radiologist and operating surgeon. We present a rare case of a large broad ligament leiomyoma with cystic degeneration masquerading as ovarian malignancy.

Introduction

Uterine fibroid tumors are non cancerous growths in the uterus. Extra uterine fibroids are not as common as uterine fibroids.[1] Broad ligament fibroids are rare and primary tumors of the broad ligament are rarer still. They are easily confused with ovarian neoplasms due to their location.

Case Report

A 33 year old nulliparous married lady presented with mass per abdomen and pain in abdomen since last five months. These were insidious in onset with loss of appetite and some episodes of vomiting since last few days. She also complained of easy fatiguability on performing daily chores. She had regular menstrual cycles with normal flow and appeared pale. Per abdomen examination revealed a mass of 22 weeks' gravid uterine size with a non- bosselated surface, soft in consistency, occupying the hypogastric, left iliac and left loin regions with mobility in vertical direction only. The upper and lateral margins were well defined but the lower margin was not felt, appearing to arise from pelvic cavity. Auscultaion revealed no bruit over the mass. Per speculum examination showed pulled up cervix, deviated to right, with a healthy vagina. Bimanual examination confirmed the findings with fullness in all fornices except left fornix; all fornices were non-tender. 
Ultrasound revealed a well encapsulated, thick walled, mixed echogenic mass lesion measuring 20 x 16 x10.5 cm noted in the right adnexa with predominant solid component and few cystic necrotic areas. Color Doppler revealed internal vasularity of low impedance flow in the solid component indicating a malignant right ovarian mass; right ovary was not made out separately. Left ovary was normal. Uterus was normal in size, shape and echopattern and visualized separately. CA- 125 levels were in normal range. 


Figure 1. Ultrasonography mimicking an ovarian neoplasm

Preoperative diagnosis based on history, clinical examination and imaging features was of a malignant ovarian neoplasm. The patient underwent an exploratory laparotomy through a right paramedian infra- umbilical vertical incision. Intraoperatively a normal sized uterus with a broad ligament fibroid 22 x 15 x 10 cm, pedunculated with a stalk arising from the broad ligament was seen on the right side. The fibroid was firm in consistency with cystic pockets, adherent to the omentum and small bowel. After releasing the adhesions carefully, excision of the right broad ligament fibroid was done. Histopathological examination confirmed a pedunculated broad ligament leiomyoma with cystic degeneration.


Figure 2. Intraoperative finding of broad ligament leiomyoma.

Discussion

Benign tumors of the broad ligament are usually asymptomatic. The location of the tumors often determines the various symptoms.[2] Ultrasonography is the primary modality used in diagnosis of leiomyoma and most often typical appearances are seen making the diagnosis easy.[3,4] However, atypical appearances that follow degenerative changes can cause confusion in diagnosis.[3] Thus broad ligament fibroid and cystic degeneration of fibroids with internal septations can mimic an ovarian malignancy.[5] Cystic degeneration is considered an extreme sequel of edema in leiomyomas with degenerative changes and its incidence is as high as 4 %.[6] Thus a distinction between benign and malignant adnexal masses done preoperatively helps in optimal case management. Broad ligament fibroids have a potential to grow to large size.[7] A surgical approach is generally preferred for symptomatic large broad ligament fibroids. A multidisciplinary approach to minimize the diagnostic challenges helps optimize the management of such cases and reduces morbidity and mortality.

References
  1. Leelavathi, Roy P, Triveni K, Impana S. Broad ligament fibroid mimicking as ovarian tumor. Open Journal of Obstetrics and Gynecology 2015; 5:665-8.
  2. Stewart EA. Uterine Fibroids. Lancet 2001; 357(9252): 293-8.
  3. Aydin C, Eris S, Yalçin Y, Sen Selim H. A giant cystic leiomyoma mimicking an ovarian malignancy. Int J Surg Case Rep. 2013; 4(11):1010-2.
  4. Pandy D, Priyadarshini P, Feroz MS, Roopa PS, Kudva R, Shetty J, et al. Massive degenerated leiomyomas masquerading as ovarian neoplasm. Sri Lanka J Obstetrics and Gynecology. 2011;33:163-5.
  5. Geeth M, Anuradha G, Vamsi P, Ramkumar V. Leiomyomas masquerading as ovarian neoplasms. IOSR J of Dental and Medical Sciences 2015;14(7):5-9.
  6. Low SC, Chong CL. A case of cystic leiomyoma mimicking an ovarian malignancy. Ann Acad Med Singapore 2004; 33(3): 371-4.
  7. Godbole RR, Lakshmi KS, Vasant K. Rare case of giant broad ligament fibroid with myxoid degeneration. J Sci Soc 2012; 39:144-146.
Citation

Jassawalla NM, Shetty S, Vora P. Adnexal Fibroid/Ovarian Tumor – An Obstetrician’s Dilemma. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/adnexal-fibroidovarian-tumor.html

Possible Underestimation Of The Risk In Case Of Cervical Ectopic

Author Information

Gupta N*, Jain R**, Nigam A***, Rana S****.
(*Associate Professor, **Assistant Professor, ***Professor, Department of Obstetrics and Gynecology, ****Assistant Professor, Department of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India)

Abstract

Cervical ectopic pregnancy is one of the rare sites of presentation, and frequently results in hysterectomy as a life saving procedure. We report a 39 year old female who underwent emergency hysterectomy as a life-saving procedure because she presented in shock following a suction evacuation. Review of literature revealed that early diagnosis by good history and sonography can diagnose cervical ectopic. Such cases are better managed at specialist centers with good surgical or interventional radiology expertise to save the fertility. Mismanagement leads to loss of fertility due to hysterectomy in all cases.

Introduction

Cervical implantation of pregnancy is one of the rare sites for ectopic pregnancy with less than 0.1% incidence.[1,2] Several cases have been reported, guidelines for management formed but still we end up performing hysterectomy in a number of cases reported in the world literature.[3,4,5] Small numbers of cases are successful in preserving fertility, but hysterectomies indicate we still need to learn our lessons well. We report a case of cervical pregnancy which needed hysterectomy as a life- saving procedure and discuss errors that can be corrected to prevent this from happening again.

Case Report

A 39 year old Gravida 10 Para 3 Living 3 Abortion (MTP) 6 was referred to our center in hemorrhagic shock following suction evacuation for 3 months amenorrhea. She had three prior full term deliveries, one of which was a lower segment cesarean section. She had undergone six MTPs, two of which were surgical abortions. She started heavily bleeding during a suction evacuation done to terminate her three months' pregnancy, when she was referred to us. 
On examination, the patient was drowsy and pale. She had a  pulse rate of 124 bpm, her respiratory rate was 18 breaths /min and her blood pressure was 90/60 mm of Hg. Per abdominally there was a previous Pfannensteil scar, no guarding, no rigidity or tenderness. Patient was resuscitated and adequate blood arranged and cross matched. Ultrasound examination was not done as general condition of patient was very poor and valuable time would have been lost. Written informed consent was taken for suction evacuation / laparotomy. A provisional diagnosis of incomplete abortion with perforation of previous cesarean scar was made. In operation theater, per vaginum examination showed that the cervical os was open, cervix was ballooned up and filled with clots, uterus was contracted and bilateral adenexa was not palpable and not tender. A suction evacuation was done assuming incomplete abortion but profuse bleeding started so the decision for laparotomy was taken. Intra operatively the uterus was 10 weeks in size with cervix ballooned up with bluish discoloration. The previous lower segment uterine scar was intact. Now, the diagnosis of cervical ectopic pregnancy was made but by this time the patient’s general condition had further deteriorated so the decision of total abdominal hysterectomy was taken to save her life (Figure 1). She received three red cell concentrates and four fresh frozen plasmas. Her post operative period was uneventful and she was discharged on day 6. Histopathology report confirmed the findings of cervical pregnancy (Figure 2).


Figure 1. Gross photograph of hysterectomy specimen with expanded cervix &  ectopic gestation. 


Figure 2. Low power microphotograph showing endocervical  epithelium below, and chorionic villi with fibrinous exudates above. (H&E,10X)

Discussion

Several methods have been discussed to manage a cervical ectopic pregnancy. Conservative methods include intra-amniotic feticide by using potassium chloride or methotrexate and systemic chemotherapy by using methotrexate.[4,6,7] Curettage can also be used, but commonly results in hemorrhage.[8] Control of bleeding is then done by doing cervical artery ligation and tamponade with Foley catheter. Primary hysterectomy is the treatment of choice in uncontrolled hemorrhage, late presentation of cervical pregnancy beyond 12 weeks and in those women not desirous of further pregnancy.[4,9]
However hysterectomy in a woman who has not completed her family will be traumatizing. This is especially common nowadays in view of multiple attempts at in vitro fertilization. Abortions are managed by dilatation and curettage, and future pregnancy can then adhere to the scar tissue in cervix. Similarly, increased use of lower segment cesarean section has increased the presentation of cervical ectopic like never before.[3]
Commonly, presenting complaints are taken as incomplete abortion with retained products of conception in the cervix by the emergency staff. Further suction evacuation or dilatation curettage can result in profuse hemorrhage that may not be controlled in ill- prepared centers. By the time patient presents to the tertiary level center, the only option is to do a life- saving hysterectomy.
Such pitfalls can be prevented by following several guidelines. Hosni et al in 2014 concluded that early diagnosis is crucial for conservative treatment of cervical ectopic pregnancy.[10] Such pregnancies are best managed at tertiary referral centers where advanced facilities for cervical artery or uterine artery ligation are available, whether surgically or by interventional radiology. 
For early diagnosis we need good radiology support. A study by Crochet concluded that patient’s history or clinical examinations alone are insufficient to indicate or eliminate the possibility of ectopic pregnancy. Presence of lower abdominal pain and vaginal bleeding should prompt a transvaginal ultrasonogram and β hCG levels to confirm the diagnosis. No study to date has established a single β hCG level that is diagnostic of ectopic pregnancy.[11] Presence of sliding sign on transvaginal ultrasound can help differentiate retained products of conception from ectopic pregnancy.[12] Gentle pressure by probe on the cervix will cause gestational sac of abortus to slide, unlike that of ectopic pregnancy, which will be adhered to the wall. 
Hence, when history suggests risk factors for cervical ectopic like previous cesarean or curettage, transvaginal sonogram by an expert radiologist is essential to confirm ectopic. Sliding sign and fetal heart activity can help differentiate it from retained products of conception. Such cases should then be referred to centers having expertise for ligation of vessels either surgical or radiological. Live fetus can be managed by intra-amniotic potassium chloride or methotrexate. Systemic methotrexate can also be given where intra-amniotic delivery expertise is not available. Occasionally curettage of ectopic can be also be done. But all such cases can result in potentially fatal hemorrhage. Initial management of hemorrhage can be done by packing and tamponade using 30 ml saline filled Foley catheter. However, uncontrolled hemorrhage should prompt early cervical or uterine artery ligation in order to preserve the uterus. It can be done surgically by laprotomy or minimally invasive by intervention radiology.
Centers which lack such radiological and surgical expertise end up referring patients late to referral centers when patient is in shock. At those times, only possible life- saving intervention is hysterectomy, with elimination of future possibility of pregnancy.

Conclusion

Early diagnosis and management at a specialist center can be the only option for fertility saving intervention in cervical ectopic pregnancy. Management at primary health centers or late diagnosis commonly lead to hysterectomy in cases of cervical ectopic pregnancy.

References
  1. Petrides A, Dinglas C, Chavez M, Taylor S, Mahboob S. Revisiting ectopic pregnancy: a pictorial essay. J Clin Imaging Sci. 2014; 4:37. 
  2. Chukus A, Tirada N, Restrepo R, Reddy NI. Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass. Radiographics 2015; 35(3): 946-59.
  3. Samal SK, Rathod S. Cervical ectopic pregnancy. J Nat Sci Biol Med. 2015; 6(1):257-60.
  4. Singh S. Diagnosis and management of cervical ectopic pregnancy. J Hum Reprod Sci. 2013; 6(4): 273-6. 
  5. Hwang JH, Lee JK, Oh MJ, Lee NW, Hur JY, Lee KW. Classification and management of cervical ectopic pregnancies: experience at a single institution. J Reprod Med. 2010; 55(11-12): 469-76.
  6. Asante A, Verma U, Coddington CC, Stewart EA. Single-dose intramuscular methotrexate treatment of cervical ectopic pregnancy. A case report. J Reprod Med. 2015; 60(1-2):78-82.
  7. Petousis S, Margioula-Siarkou C, Kalogiannidis I, Karavas G, Palapelas V, Prapas N, Rousso D. Conservative management of cervical pregnancy with intramuscular administration of methotrexate and KCl injection: Case report and review of the literature. World J Clin Cases. 2015; 3(1): 81-4. 
  8. Fylstra DL. Cervical pregnancy: 13 cases treated with suction curettage and balloon tamponade. Am J Obstet Gynecol. 2014; 210(6):581.
  9. Saeng-anan U, Sreshthaputra O, Sukpan K, Tongsong T. Cervical pregnancy with massive bleeding after treatment with methotrexate. BMJ Case Rep. 2013; 2013.
  10. Hosni MM, Herath RP, Mumtaz R. Diagnostic and therapeutic dilemmas of cervical ectopic pregnancy. Obstet Gynecol Surv. 2014; 69(5): 261-76. 
  11. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013; 309(16):1722-9. 
  12. Lin EP, Bhatt S, Dogra VS. Diagnostic clues to ectopic pregnancy. Radiographics. 2008; 28(6):1661-71.

Citation

Gupta N, Jain R, Nigam A, Rana S. Possible Underestimation Of The Risk In Case Of Cervical Ectopic. JPGO 2016. Volume 3 No. 12. Available from: http://www.jpgo.org/2016/12/possible-underestimation-of-risk-in.html