A rare case report of large bilateral vulval elephantiasis

Elephantiasis, the result of chronic lymphedema, is characterized by gross enlargement of the limbs or genitalia. It occurs because of obstructive diseases of the lymphatic system. Genital elephantiasis is a common result of filariasis. Other causes are lymphogranuloma venereum. granuloma inguinale, carcinomas, lymph node dissection, irradiation and tuberculosis. Filarial elephantiasis of the female genitalia is extremely uncommon, about 1-2% of the total cases of filarial elephantiasis. Mrs. X, 25 years old female, P1L1, resident of a village in Bihar presented to gynaecology OPD of ABVIMS and Dr. RML Hospital on 06th January 2020 with complaint of huge progressively increasing vulval swelling since 3 years. Patient had come from Bihar for treatment. She had been showing in her native place for 2 years but now the lump had made her walking difficult. She did not give history of any drug given for treatment for filariasis. She gave history of being treated for pulmonary Koch 10 years back. On examination, there was a non- ulcerative, polypoidal growth of around 20×14×11 cm arising from bilateral labia majora and minora obstructing the vulval cleft. There was no associated lymphadenopathy or limb oedema. All the investigations were within normal limits. Microfilaria antigen testing done at night was negative. Patient was given diethylcarbamazine and excision of the lump was done on 14th February 2020. Histopathological report showed dilated lymphatics with non-caseating granulomas, consistent with filariasis. In endemic countries like India, filariasis is the commonest cause of elephantiasis; however genital filariasis in woman is very rare. Other cause could be tuberculosis which is still rarer. Early diagnosis and treatment of filariasis can eradicate this neglected tropical disease which causes disfigurement and severe morbidity as its sequelae.

Tubercular pyometra in a young unmarried female - dilemma and pitfalls in diagnosis: a rare case report with review of literature

This rare case is the first case being reported as tubercular pyometra in a young unmarried woman. Diagnosis of genital tuberculosis which is a form of EPTB (extra pulmonary TB) can be baffling, compelling a high index of suspicion owing to paucibacillary load in the biological specimens. A negative smear for acid-fast bacilli, lack of granuloma on histopathology and failure to culture mycobacterium tuberculosis do not exclude the diagnosis of EPTB. A 25-year-old unmarried, government employee from Bihar presented to our OPD with secondary amenorrhea for two months carrying with her an USG, CT and MRI done in Bihar suggesting enlarged uterus with fluid collection. CT-also reported few enlarged lymph nodes. Her preoperative investigations revealed an elevated ESR and x-ray chest was normal. Dilatation was done under ultrasonic guidance in OT and 150 cc of thick caseous material was drained A gentle curettage was done on lateral wall near cornea and both the caseous material and endometrial tissue was sent for gram staining, TB-PCR (polymerase chain reaction), NAAT (nucleic acid amplification techniques) and culture. In the post-operative period gram staining for AFB, NAAT, TB-PCR all came negative and it was difficult to convince patient to take ATT. However, on day 10, HPE report came as granuloma suggestive of TB and patient was put on ATT. Culture too was reported negative later.  Paucibacillary female genital TB (FGTB) is difficult to diagnose because of varied presentation and limitations of diagnostic tests A raised ESR is presumptive but non-specific. Other tests are x-ray chest, HSG, endometrial tissue for TB PCR nucleic acid amplification techniques (NAAT, HPE and culture (conventional or Bactec). Patients with EPTB are, however, more likely to have negative sputum smear results and many EPTB cases do not have direct lung involvement.  Currently, there are no standard guidelines or algorithm for the diagnosis of FGTB. Female genital TB has varying presentation and diagnosis is difficult because of the paucibacillary nature.

Successful outcome in a perplexing case of Roberts uterus: a rare uterine anomaly, a rare case report with review of literature

Robert uterus is a rare Mullerian development anomaly with very few cases reports available. It presents with triad of morphologic features of - Blind hemi cavity with or without unilateral hematometra, contralateral unicornuate uterine cavity and normal uterine fundus with or without small external indentation. The major difficulty lies in making the diagnosis of Robert’s uterus. All the reported cases of Robert’s uterus have been managed differently according to patient’s complaints. A 25-year-old married female, resident of Agra presented to gynecology OPD of Dr RML Hospital and associated PGIMER in June 2013, with primary infertility and cyclical left sided dysmenorrhoea since menarche. Patient was consulting at her hometown Agra for 2 years and had an USG and MRI pelvis report of Feb. 2013 with her showing unicornuate uterus with rudimentary horn. Infertility investigations were done in our hospital. HSG report was of localized spill on right with left tubal block. Patient was posted for diagnostic hystero-laproscopy which was further followed by laprotomy, after which we could reach to a diagnosis of Robert uterus with non-communicating left cavity and with severe endometriosis. Patient needed a second hysteroscopy for lysis of septum and subsequently conceived with IVF. She delivered a healthy male baby of 2.65 kg by elective LSCS at 37 weeks with associated breech presentation with gestational hypertension with severe IHCP on 20 June 2019. Paediatric surgeons and gynecologists should be aware of this rare atypical obstructive Mullerian malformation and its management to avoid inappropriate management delays in these patients. A timely diagnosis and definite treatment have a great impact on future reproductive and endocrine function.

Placenta accreta not previa: a rare case report of placenta accreta in an unscarred uterus

Placenta accreta spectrum disorders are usually associated with direct surgical scar such as caesarean delivery, surgical termination of pregnancy, Dilatation and curettage, Myomectomy, Endometrial resection and Asherman’s syndrome. It can also be associated with non-surgical scar and uterine anomalies. Rarely it can be encountered in unscarred uterus. Mrs X, 35-year female, unbooked patient, G7P2L2A4 with nine months of amenorrhoea reported in emergency of RML Hospital on 30/07/2019 with history of labour pains since 2 days. Patient gave history of four dilatation and curettage for incomplete abortion. On examination patient was found to be severely anaemic (Hb -6 gm). 2 Packed RBC were transfused preoperatively. There was no progress in labour beyond 6 cm for 4 hours. Patient was thus taken for LSCS for NPOL, with blood on flow. Intraoperatively, after delivery of the baby placenta which was fundo-posterior did not separate. In view of parity and morbidly adherent placenta (clinical grade III), subtotal hysterectomy was done. Patient was transfused 4 PRBC, 4 FFP and 2 platelets. Uterus with placenta in situ was sent for histopathology. Patient was in ICU for 2 days and recovered well. Post-operative period was uneventful. Placenta accreta is defined as abnormal trophoblast invasion of whole or a part of placenta into myometrium of uterine wall. Caesarean delivery is associated with increased risk of placenta accrete and the risk increases with each caesarean section, from 0.3% in woman with one previous caesarean delivery to 6.47% for woman with five or more caesarean deliveries. Placenta accreta spectrum disorders occur in 3% of woman diagnosed with placenta previa and no prior caesarean. In the developing world, the obstetrician should be prepared to encounter un diagnosed placenta accrete even in absence of previous LSCS. Curretage following MTP is also a risk factor, so vigourous currettage should be avoided to prevent endometrial damage.

Case series of pubic bone diastasis causing severe pelvic girdle pain in pregnancy

Pelvic girdle pain (PGP) is a pregnancy discomfort that causes pain and limitation of mobility and functioning in any of the three pelvic joints. The patient usually presents antenatally with persistent suprapubic pain which is exaggerated during moving, walking or climbing stairs. Intrapartum, this could be associated with disruption of sacroiliac joint, hematuria and bladder dysfunction in severe cases. Pelvic X-rays, ultrasound, and magnetic resonance imaging aid in confirmation of diagnosis by measuring the degree of separation of symphysis. Treatment modalities range from conservative management to orthopedic interventions in form of pelvic strapping, open reduction and internal fixation. Postpartum pain often masks clinicians to make the diagnosis of pubic symphysis diastasis. A case series of three cases which were diagnosed and confirmed with ultrasound and managed with orthopedic consultation. till their delivery and in post-partum period till recovery. Although there is still no specific consensus on treatment guideline, management generally of conservative management to surgical in the form of pelvic bracing or strapping. Awareness of this rare condition can help in management of pain and associated disability which improves post-delivery.

Chronic kidney disease in pregnancy and fetomaternal outcome

Background: Chronic kidney disease is a heterogeneous group of renal dysfunctions with complex and varied presentations in pregnancy. With a long asymptomatic course, timely diagnosis and management is crucial for fetomaternal wellbeing.Methods: A retrospective cohort study over a period of 3 years and 4 months included all obstetric in patients with known or newly diagnosed renal disorders. Maternal outcome was measured with regard to biochemical parameters presence /absence of proteinuria, hypertension, mode of pregnancy termination and complications. Fetal outcome was noted with respect to antenatal complications, weight, Apgar, NICU stay. Computation of results was done using percentages, mean and proportions.Results: Out of 13 women studied, 53.8% were pre-diagnosed cases of renal dysfunction and 46.2% were diagnosed during pregnancy. 38% had proteinuria at first visit and 50% remained so even after delivery. 60% had history of pregnancy induced hypertension in their previous pregnancies. Secondary hypertension and superimposed preeclampsia were seen in 30% and 38% cases respectively, with only one patient requiring magnesium sulphate prophylaxis in post-partum. Cardiac dysfunction was found to be coexisting in 15.3% cases with pre-existing renal leision. Intrauterine growth restriction was seen in 61.5% cases Average fetal weight was 2. 26kg with 30% having NICU stay. 30.6% had preterm delivery. Mode of delivery was caesarean section in 46% cases.Conclusions: Pregnancy with CKD is a high-risk pregnancy with adverse fetomaternal outcomes. For optimal pregnancy outcomes, an expert multidisciplinary team is required. With limited studies in south Asian population, there needs to be an upgradation in registry system.

Hindi translated version of menopausal rating score questionnaire: a method to evaluate post menopausal symptoms in India

Background: There are large number of post menopausal patients in India deserving more care and attention than is given at present.MRS questionnaire in Hindi (MRS-H), a translated and validated version of original MRS Scale (MRS-E), self assessed by patients in their own native language. This tool can be used to assess and document current quality of life as well as improvement with treatment of severe post menopausal symptoms, in Indian population.Methods: 30 bilingual English and Hindi speaking postmenopausal patients were recruited for this study.MRS Questionnaire has 11 questions covering somatic, pschycological and genitourinary symptoms of menopause. The scoring system is simple. Hindi translation of MRS Questionare was done from English (MRS-E) to Hindi (MRS-H) by 4 independent translations using standard protocol. The MRS-H was tested for internal validity and also compared with MRS - E.Results: Quality of life is a subjective perception modified by the cultural habitat in which one lives. MRS-H showed high validity and good co-relation with MRS-E. The MRS-H possessed good convergent and discriminant validity. MRS-H showed anICC (Intraclass coefficient) was more than 0.5 and cronbach alpha more than0.5. There was found to be strong correlation between MRS-E and MRS-H questionnaire with all correlation value above 0.7.Conclusions: The authors recommend the use of the self assessed MRS-H in Hindi should be used to assess menopausal complaints and relief with treatment in India.