Intraoperative complications encountered in patients with repeat cesarean section

Objective: to find out the type and frequency of intraoperative complications encountered in patients who had repeat cesarean section

Study design: observational Study

Place and duration: the Gynaecology and Obstetrics Unit - III in Liaquat University Hospital Hyderabad. The study period was from July 2005 to July 2006

Method: this study included the women who had repeat cesarean section during the period from July 2005 to July 2006. These women were divided into three groups, group I [GI] included the women with previous 1 cesarean section, group II [GII] included the women with previous 2 cesarean section and group III [GIII] included the women with previous 3 or more cesarean sections. Intraopratieve complications were noted in terms of dense adhesion [with omentum, bowel, uterus and bladder], extremely thinned out lower uterine segment, scar dehiscence, ruptured uterus, placenta praevia, bladder injury, adherent placenta and fetal demise

Results: out of 240 repeat cesarean sections, cases included in GI were 114 [47.5%], in GII were 90 [37.5%] and in GIII were 36 [15%]. Dense adhesions were found in 26 patients of group I [22.8%], in 32 patients of Group II [35.5%] and in 7 patients of group III [19.4%]. Extremely thinned out lower uterine segment was found in 10 patients of group I [8.7%], in 15 patients of group II [16.6%] and in 3 patients of group III [8.3%]. Scar dehiscence was observed in 9 patients of group I [7.8%], in 4 patients of group II [4.4%] and in 2 patients of group III [5.5%]. Ruptured uterus was seen in 3 patients of group I [2.6%] and in 1 patient of group II [1.1%]. Bladder was injured in 1 patient of group I [0.8%] and in 1 patient of group II [1.1%]. Cesarean hysterectomy was performed due to morbidly adherent placenta in 1 case of group I [0.8%] and in 1 case of group III [2.7%]. Fetal demise occurred due to ruptured uterus in 3 cases of group I [2.6%] and in 1 case of group II [1.1%]

Conclusion: women with repeat cesarean section are at risk of having multiple intraoperative surgical complications, which may increase the rate of maternal and fetal morbidity and fetal mortality

Risk factors, clinical presentation and management of 62 cases of ectopic pregnancy at tertiary care center

Objective: to observe the risk factors, clinical pattern and management of ectopic pregnancy

Design: descriptive observational study

Place and duration: gynecological Unit II, Liaquat University of Medical and Health Sciences, Hyderabad from January 1st 2006 to April 1st 2008

Patients and methods: all patients with confirmed diagnosis of ectopic pregnancy were included in the study. A pre-formed proforma was used to record the details about the demographic features, pre-existing risk factors for ectopic pregnancy, clinical features at presentation, management and findings at surgery. Data fed to SPSS program version 11 to analyses the results in terms of frequency and percentages

Results: total maternity admissions were 8016 with 62 cases of ectopic pregnancy giving an incidence of 0.8% or 1:129. Mean age was 24 years. Majority of the patients were of low parity [n=34, 54.8%]. Pelvic inflammatory disease [n=22, 35.4%], previous abdominal pelvic surgery [n=16, 26%], previous ectopic [n=4, 6.4%] and infertility [n=22, 35.4%] were seen as the major risk factors. Regarding the clinical pattern; abdominal pain, amenorrhea and collapse appeared as the common clinical presentations. All patients required surgery. Open laparotomy was performed in 56 [90.3%] cases while 6 [9.7%] patients managed laparoscopically. None of the patients found suitable for conservative or medical management. There was no maternal death related to ectopic pregnancy and the postoperative recovery was uneventful

Conclusion: the classic clinical pattern of amenorrhea and abdominal pain was lacking in most of the cases with ectopic pregnancy and there were initial diagnostic difficulties. Pelvic inflammatory disease and history of infertility were the main risk factors. Due to the delay in making diagnosis at early stage, open surgery was required in all cases. This emphasizes the importance of a thorough clinical evaluation and appropriate investigations for patients with high suspicious to benefit our poor patients by the use of recent therapeutic modalities

Key to successful vesico-vaginal fistula repair-an experience of urogenital fistula surgeries and outcome at gynaecological surgical CAMP-2005

Vesico-vaginal fistula is not life threatening medical problem, but the woman face demoralization, social boycott and even divorce and separation. The aetiology of the condition has been changed over the years and in developed countries obstetrical fistula are rare and they are usually result of gynaecological surgeries or radiotherapy. Urogenital fistula surgery doesn't require special or advance technology but needs experienced urogynaecologist with trained team and post operative care which can restore health, hope and sense of dignity to women. This prospective study was carried out to analyze the success rate in patients attending the referral hospital and sent from free gynaecological surgery camps held at interior of Sindh, and included pre-operative evaluation for route of surgery, operative techniques and postoperative care. Total 70 patients were admitted from the patients attending the camp. Out of these, 29 patients had uro-genital fistula. Surgical repair of the fistula was done through vaginal route on 27 patients while 2 required abdominal approach. Out of 29 surgical repairs performed, 27 proved successful. Difficult and complicated fistulae need experienced surgeon. Establishment of separate fistula surgery unit along with appropriate care and expertise accounts for the desired results

Leiomyosarcoma: a rare malignant change in a leiomyoma

A 62 years old post-menopausal lady para l+1 presented with irregular vaginal bleeding and foul smelling vaginal discharge for 3 months. Her past medical and surgical history was unremarkable. Premenopausal menstrual history as well as obstetrical performance was normal. Physical examination revealed a lady of weak built and pale looks. Her abdomen, chest and cardiovascular system were unremarkable. On speculum examination, there was a soft friable necrotic mass of about 6 x 4 cm, with foul smelling discharge, protruding through external cervical os and filling whole of upper vagina. Cervix was normal. Uterine size could not be assessed due to mass filling upper vagina. Both adnaxae were clear. Provisional diagnosis of endometrial polyp with inflammatory or malignant change was made. On blood analysis heamoglobin was 9.5 grams / dl, ESR was 30 m.m. and TLC was 12000. Liver function test, blood urea, blood glucose, ECG and x-ray chest were normal. Ultrasound of abdomen and pelvis showed enlarged uterus with hyper-echoic irregular mass arising from fundus of uterus and occupying whole uterine cavity measuring 8 x 33 cm in size, suggestive of fibroid, polyp or leiomyosarcoma. Considering her age, symptoms and ultrasound report, laparotomy was decided. At laparotomy, in inspection, uterus was enlarged, 12 weeks size with outer smooth surface and partial inversion of uterine fundus. Adnexae and rest of peritoneal cavity was normal. There was no ascites or enlarged pelvic lymph nodes or any evidence of malignancy in peritoneal cavity and liver. Total hysterectomy with bilateral salpingo-ophrectomy was done. Both tubes and ovaries looked normal. On incising uterine cavity, a large polypiodal growth, arising from the left corner of uterus and extending down to the cervix was found. Histopathology report confirmed the diagnosis of leiomyosarcoma