Radical abdomino-pelvic surgery in the management of uterine carcinosarcoma with concomitant para-aortic lymphadenopathy metastasising from anal carcinoma.

Uterine carcinosarcomas are aggressive gynaecological cancers comprising less than 5% of uterine malignancies. We present the case of a woman in her 70s with a complicated history of advanced anal carcinoma treated with pelvic radiotherapy and multiple laparotomies, who was referred to gynae-oncology following MRI surveillance imaging showing evidence of endometrial carcinoma and para-aortic lymphadenopathy. Successful surgical excision required multidisciplinary teamwork between gynae-oncology, colorectal and urology surgeons. The patient underwent midline laparotomy, with adhesiolysis, ileum resection and side to side anastomosis, posterior exenteration, left kidney mobilisation and suspension, para-aortic lymph node debulking and left ureteric stent insertion. Significant challenge was posed by the extensive adhesions from previous laparotomies and the debulking of the para-aortic lymph nodes around the renal vessels. This case demonstrates the importance of a multidisciplinary approach in complex pelvic surgery and the vitality of good communication between colleagues in achieving effective patient care.

Successful management of a pregnant woman with COVID-19 and multiple severe complications.

We report a case of a 36-year-old gravida 2 para 1 woman at 38 weeks of gestation. A caesarean section was performed for severe pre-eclampsia, intrauterine growth restriction and oligohydramnios. The patient suffered postoperative bleeding, and exploratory laparotomy was performed. Uterine atonia, Couvelaire uterus and left adnexal haematoma were found, requiring a supracervical hysterectomy. As COVID-19 pneumonia and superimposed bacterial infection developed, the patient was mechanically ventilated in the intensive care unit. Remdesivir and meropenem were initially administered, but were changed to levofloxacin and ciprofloxacin following antibiotic sensitivity tests. Blood culture grew Enterococcus galinarum Meanwhile, bleeding of the incisional wound occurred, which was controlled by the cessation of heparin therapy and regular wound care. With intensive monitoring and multidisciplinary management, the patient's condition improved, and she was discharged from the hospital on day 25 from admission.

Misoprostol-augmented induction of labour for third trimester fetal demise in a patient with prior hysterotomies.

A 31-year-old G3P2002 with history of two prior caesarean sections presented with influenza-like illness, requiring intubation secondary to acute respiratory distress syndrome. Investigations revealed intrauterine fetal demise at 30-week gestation.She soon deteriorated with sepsis and multiple organs impacted. Risks of the gravid uterus impairing cardiopulmonary function appeared greater than risks of delivery, including that of uterine rupture. Vaginal birth after caesarean was achieved with misoprostol and critical care status rapidly improved.Current guidelines for management of fetal demise in patients with prior hysterotomies are mixed: although the American College of Obstetricians and Gynecologists recommends standard obstetric protocols rather than misoprostol administration for labour augmentation, there is limited published data citing severe maternal morbidity associated with misoprostol use. This case report argues misoprostol-augmented induction of labour can be a reasonable option in a medically complex patient with fetal demise and prior hysterotomies.

Giant nasal granuloma gravidarum.

Nasal granuloma gravidarum usually presents as a small vascular lesion on the septum or turbinates during pregnancy. We present a case of a giant nasal granuloma gravidarum and its management.

Successful management of three cases of interstitial pregnancies with local instillation of potassium chloride: avoiding a potential cornuostomy.

Here, we present three cases of women with interstitial pregnancy who were managed with local instillation of potassium chloride. These women were in their 20s-30s and presented in stable condition. Of them, two had a history of previous ectopic pregnancy. Interstitial pregnancy was diagnosed by transvaginal sonography which showed an empty uterine cavity with a gestational sac 1 cm away from the lateral edge of the uterine cavity, with <5 mm myometrium surrounding it in all planes. Two of the three cases failed to respond to methotrexate injection. Due to the presence of high-end ultrasound machine and technical expertise, local instillation of potassium chloride was offered as an alternative to surgical treatment, which is definitive, and all three patients had a successful outcome. One patient returned with pain in the abdomen, which required inpatient monitoring and was later diagnosed with urinary tract infection and was given appropriate antibiotics.

Vesico-vaginal fistula presenting as overactive bladder in a case of Gellhorn pessary for vault prolapse.

An 81-year-old woman with early dementia was on a regular follow-up for change of Gellhorn pessary every 6 months for vault prolapse. She presented with frequency and urgency for 10 months duration 5 years into conservative management. Her symptoms did not improve on anticholinergics and lifestyle modifications. She underwent an opportunistic change of pessary under general anaesthesia coincidental to scalp wound debridement. On removal of the pessary, a gush of urine was noted followed by confirmation of a large vesico-vaginal fistula (VVF). In the initial period of follow-up, she was reviewed by the urogynaecology team and considered to be a poor surgical candidate for a major surgical procedure and was offered conservative measures with incontinence pads and possible indwelling catheter. Serious complications like fistulae can still occur despite well-managed pessary treatment. Earlier presentation with overactive bladder symptoms masked the VVF resulting in delayed diagnosis.

Imaging as an alternate diagnostic modality in a presumptive case of abdominopelvic TB in a COVID-19 patient.

A 30-year-old, multiparous widow, with postpolio residual paralysis, presented with complaints of dull aching abdominal pain for 15 days. Ultrasound showed a mixed echogenic right adnexal mass with free fluid in the pelvis and abdomen. CT abdomen and pelvis revealed partially defined peripherally enhancing collection in lower abdomen and right adnexa suggestive of tubo-ovarian abscess. There was mild ileal wall thickening and few enlarged mesenteric lymph nodes. Ascitic fluid did not show acid fast bacilli and cultures were sterile. Extensive diagnostic laboratory work was done which was inconclusive. Diagnostic laparoscopy could not be performed due to non-availability of elective operation theatre in the COVID-19 pandemic. Presumptive extrapulmonary tuberculosis was clinically and radiologically diagnosed. She was started on daily anti tuberculosis treatment. This case shows us the importance of imaging as a diagnostic tool and as an alternative for laparoscopy in COVID-19 pandemic to diagnose abdomino-pelvic tuberculosis.

Left gonadal vein thrombosis in a patient with COVID-19-associated coagulopathy.

COVID-19 disease is a viral illness that predominantly causes pneumonia and severe acute respiratory distress syndrome. The endothelial injury and hypercoagulability secondary to the inflammatory response predisposes severely ill patients to venous thromboembolism. The exact mechanism of hypercoagulability is still under investigation, but it is known to be associated with poor prognosis. The most common thrombotic complication reported among these patients is pulmonary embolism. To our knowledge, gonadal vein thrombosis is an uncommon phenomenon that has not been reported in the setting of COVID-19-associated coagulopathy. We report an unusual case of ovarian vein thrombosis and pulmonary embolism associated with COVID-19 presenting with abdominal pain. To our knowledge, this is the first reported case of COVID-19 with absent respiratory symptoms and presentation with venous thrombosis in an unusual location.