Site of pregnancy obstetrician’s dilemma

A 28-yr-old P2L2 lady, with history of two previous caesarean deliveries and tubal ligation, presented at 6weeks of amenorrhea with pain lower abdomen. The operative notes from her previous caesarean section stated that she had a unicornuate uterus without a rudimentary horn (ASRM Class II D Mullerian anomaly)5 and only right fallopian tube was visualised, which was ligated by Parkland’s method.On workup, she had a positive urine pregnancy test and ultrasound showed a left adnexal mass without any evidence of intraperitoneal collection, possibly an unruptured left ovarian ectopic pregnancy secondary to failed tubal ligation. Further investigation by MRI revealed an entirely new finding. The suspicious left adnexal mass was the left horn of bicornuate uterus which had an intrauterine gestational sac. Hence, her revised diagnosis was G3P2L2, post LSCS, bicornuate uterus (ASRM class IV B) with 6 weeks of intrauterine left horn pregnancy following failed tubal ligation.She underwent a medical followed by surgical evacuation of intrauterine pregnancy as patient was unwilling to continue the pregnancy.This case highlights the importance of a comprehensive evaluation, whenever a lady is diagnosed with a Mullerian anomaly, in order to correctly classify the patient and identify associated anomalies of urogenital tract which would avoid such erroneous diagnosis of site of pregnancy as illustrated in our case.

Vaginal ligation of descending branch of uterine artery in the management of massive secondary post-partum haemorrhage

A 25 year old lady presented on day 22 of an uneventful caesarean delivery, in a state of class IV haemorrhagic shock, secondary to sudden onset of vaginal bleeding without any inciting cause. Immediate resuscitation was initiated and the cause for massive secondary post-partum haemorrhage (PPH) was identified as an actively bleeding vessel at 3 ‘O’ clock position on a visibly healthy cervix with a well contracted uterus. This was the descending branch of left uterine artery, which was ligated after pulling the cervix with a sponge holder towards the introitus and application of Vicryl No 1-0 suture. The bleeding decreased significantly post vascular ligation. Further exploration of vagina and cervix did not reveal any active bleeding or laceration and no retained placental tissue was found inside uterine cavity on ultrasound examination. This is a rare case of Massive Secondary PPH in a post-caesarean patient due to spontaneous giving way of descending branch of uterine artery.

A rare case of Meckel Gruber syndrome

Meckel Gruber syndrome (MGS) is a rare lethal autosomal recessive disorder.  It is characterized by triad of features having occipital meningoencephalocele, polycystic kidneys and post-axial polydactyly. We report an antenatal patient detected with occipital meningoencephalocele in foetus on early anomaly scan at 15 weeks of gestation followed by foetal MRI which revealed the typical triad features strongly suggestive of MGS. The patient opted for medical termination of pregnancy and the abortus was autopsied, with the permission of the patient, for detailed evaluation of anomalies which were consistent with MGS. This case highlights the importance of a detailed foetal evaluation antenatally to detect anomalies which are incompatible with life and proper diagnosis as it has bearing on patient’s future obstetric outcome.