Chilaiditi's syndrome associated with colonic volvulus and intestinal malrotation-A rare case.

INTRODUCTION: Chilaiditi's syndrome (symptomatic hepatodiaphragmatic interposition of the colon) is an exceptionally rare cause of bowel obstruction and may present difficulty in diagnosis and management. This is the first reported case of colonic volvulus occurring in Chilaiditi's syndrome in association with intestinal malrotation and this case study describes its successful management. PRESENTATION OF CASE: An 18 year old male presented as an emergency with vague abdominal pain and a past history of gastroschisis repair with intestinal malrotation. CT scanning showed a closed loop obstruction due to a volvulus of the colon herniating under the falciform ligament. The patient was successfully treated by surgical reduction of the hernia, anatomical correction of the malrotation and caecopexy with a tube caecostomy. At six month follow up the patient was well and asymptomatic. DISCUSSION: In nine of the previously reported cases of Chilaiditi's syndrome with colonic volvulus, treatment was by partial colonic resection of which a third underwent stoma formation. One patient died as a consequence of anastomotic leak following primary anastomosis. We therefore suggest an alternative approach to management. CONCLUSION: Chilaiditi's syndrome with colonic volvulus in association with intestinal malrotation has not previously been described. As there is no consensus in the literature as to how to manage such a case we suggest that reduction of the volvulus, anatomical correction of the malrotation and fixation of the caecum by tube caecostomy results in a successful outcome. This approach avoids the need for colonic resection and possible stoma formation.

Role of antenatal care in safe motherhood.

PIP: Implementation of the Safe Motherhood initiative in India calls for the institution of good prenatal care for all women. The first aspect of prenatal care is collecting the patient's history and reviewing the health history of her family. The physical examination should include inspection for reproductive tract diseases, a bimanual examination early in pregnancy to correlate the size of the uterus and the reported last menstrual period, and routine abdominal palpation. Ultrasonography should be performed at least once. Laboratory tests should include analysis of hemoglobin and hematocrit levels, urine analysis, blood grouping and Rh typing, serological tests for syphilis, antibody screening and screening for rubella and hepatitis antigen, and cervical cytology. Additional screening and genetic testing may be necessary in certain cases. Women with no complications should be seen once a month for 28-30 weeks, once every two weeks until 36 weeks, and once a week thereafter. High-risk patients should be seen more frequently. Infections detected during pregnancy must be properly treated with antibiotics, although, in general, women should avoid medications during pregnancy. In India, hematinics and vitamins should be given to all pregnant women. Drugs and substances to be avoided during pregnancy include tetracycline, chloramphenicol, streptomycin, cotrimoxazole, diuretics, alcohol, trimethadone, warfarin, lithium, quinine, sex hormones, anesthetics, tobacco, vitamin D, and all live vaccines except BCG. Common sense should dictate the safe level of activity for a pregnant woman.^ieng

Ectopic pregnancy and fertility control measures.

PIP: A retrospective study of patients admitted for ectopic pregnancy over the 1979-84 period was undertaken at the Kilpauk Medical College and Hospital, Madras to analyze the cases of ectopic pregnancies among women who had attempted to restrict their families. There were 41,785 deliveries and 125 ectopic pregnancies during the study period, giving a ratio of 1 ectopic pregnancy to 334 deliveries. In this study, in 123 cases the age was between 20-38 years, and in 2 cases 40 years. The incidence of nullipara was about 22 cases (17.6%); para 1, 30 cases (24%); para 2, 38 cases (30.4); para 3, 21 cases (16.8%); and para 4 and above, 14 cases (11.2). Among 125 cases, 120 cases (96%) tubal pregnancies, 2 were ovarian pregnancies and 1 was a secondary abdonominal pregnancy. As for the clinical features, 40% (50) cases came with a history of amenorrhea and other associated symptoms and in 60% (75 cases) pain was the most consistent feature. On analyzing the incidence of tubal pregnancy following fertility control measures, the modes of conception also seem to have some influence on the incidence of etopic pregnancy. In 125 cases with dagnosis of ectopic pregnancy, 20 (16%) were found to have tubal pregnancies following temporary or premanent family planning methods. Those women ranged in age from 24 to 35 years, and all were multiparous except 1 nulliparous who had hormones for hypoplastic uterus for 15 days. 8 women with 2-3 children had puerperal sterilization, 6 women with 2-8 children had induced abortion with minilap, 1 woman with 2 children had transvaginal tubectomy, 3 with 0-3 children used oral contraceptives, and 2 with 5 and 8 children had a copper-T IUD. With increasing parity the fertility control measures were associated with increasing numbers of ectopic pregnancy. The mean time interval between last pregnancy and the occurrence of ectopic pregnancy varied greatly in the various fertility control measures.^ieng

A new technique for minilaparotomy.

Female sterilization by minilaparotomy was performed on 500 patients at Kilpauk Medical College Hospital, Madras, India. Access to the Fallopian tubes was achieved by elevating the uterus with the gloved hand of a medical or paramedical assistant. The effectiveness of the fingers for this maneuver in place of various uterine elevators is discussed and its usefulness pointed out in relation to practive in developing countries. The role of paramedical personnel and the hospital's medical staff, in this technique is described.

Non-acceptance of puerperal sterilization. A study.

This is an analysis of reasons given by 800 women who were hospitalized for deliveries at the Government Kilpauk Medical College Hospital in Madras for refusing puerperal sterilization. The cases are analysed by socio-demographic characteristics, age and parity. The most common reasons given were "inability to do manual work after the operation", "husband objects", and "necessity for prolonged rest". The author suggests ways of dealing with these barriers to sterilization.