Assisted breech vaginal delivery of dicephalus dipus dibrachius conjoined twins: a case report.

BACKGROUND: Conjoined twinning is a rare congenital anomaly. Even after significant advancement in the health care delivery system in developing countries, adequate antenatal care of pregnant patients and antenatal diagnosis of congenital malformations by radiological techniques like sonogram need to be emphasized. CASE: A 25-year-old woman (G1P0) at 38 weeks' gestation vaginally delivered stillborn dicephalus male twins with 2 heads, 2 necks, and a common trunk with 2 arms and 2 legs at Kasturba Hospital. The fetuses were in breech presentation and were delivered using assisted breech vaginal delivery. The conjoint nature of the fetuses remained undiagnosed antenatally and was clinically unsuspected during the intrapartum period. It was only confirmed after delivery. The intrapartum and postpartum course was uncomplicated, and the patient was discharged home on postpartum day 2. CONCLUSION: The diagnosis of conjoined twins can be missed without adequate antenatal care, leading to adverse fetomaternal outcome. Antepartum diagnosis of conjoined twins with sonography with or without MRI is essential for optimal obstetric and perinatal management, preoperative surgical planning, and parental counseling. Surgical separation of conjoined twins is possible in select cases and involves a multidisciplinary approach using several specialties.

Evaluation of calcium ion release from apical plugs formed by Biodentine and MTA with and without incorporation of triple antibiotic powder and modified triple antibiotic powder (cefaclor) using atomic absorption spectrophotometry - An in vitro study.

Introduction: Apexification procedure with Mineral trioxide aggregate (MTA) and Biodentine as apical plugs along with the incorporation of medicaments such as silver zeolite, chlorhexidine, and triple antibiotic powder (TAP) is a new area of research that is gradually gaining momentum in dentistry. Aim: The study aimed to evaluate and compare the calcium released from the apical plugs formed by MTA and Biodentine with and without incorporation of 2% TAP and 2% modified triple antibiotic powder (mTAP). Materials and Methods: Ninety single-rooted teeth were randomly divided (n = 15) into two experimental groups with three subgroups (n = 5) each based on the composition of apical plugs (4 mm) as follows: Group A: Biodentine - Subgroup 1: Biodentine, Subgroup 2: Biodentine + 2% TAP, and Subgroup 3: Biodentine + 2% modified TAP and Group B: MTA - Subgroup 1: MTA, Subgroup 2: MTA + 2% TAP, and Subgroup 3: MTA + 2% modified TAP. Each sample tooth was then immersed in 10 mL of deionized water. Evaluation of calcium release was done on days 7, 15, and 30 using an atomic absorption spectrophotometer. Data were analyzed using a one-way analysis of variance and a Tukey's post hoc test. Results: Calcium ion release was maximum for Biodentine compared to MTA and was greater with materials incorporated with TAP and mTAP than materials alone at days 7, 15, and 30. Conclusion: The incorporation of 2% TAP and 2% mTAP resulted in increased calcium ions released from MTA and Biodentine which helps in faster apexification.

Pregnancy increases myometrial artery myogenic tone via NOS- or COX-independent mechanisms.

Myogenic tone (MT) is a primary modulator of blood flow in the resistance vasculature of the brain, kidney, skeletal muscle, and perhaps in other high-flow organs such as the pregnant uterus. MT is known to be regulated by endothelium-derived factors, including products of the nitric oxide synthase (NOS) and/or the cyclooxygenase (COX) pathways. We asked whether pregnancy influenced MT in myometrial arteries (MA), and if so, whether such an effect could be attributed to alterations in NOS and/or COX. MA (200-300 µm internal diameter, 2-3 mm length) were isolated from 10 nonpregnant and 12 pregnant women undergoing elective hysterectomy or cesarean section, respectively. In the absence of NOS and/or COX inhibition, pregnancy was associated with increased MT in endothelium-intact MA compared with MA from nonpregnant women (P < 0.01). The increase in MT was not due to increased Ca(2+) entry via voltage-dependent channels since both groups of MA exhibited similar levels of constriction when exposed to 50 mM KCl. NOS inhibition (N(ω)-nitro-L-arginine methyl ester, L-NAME) or combined NOS/COX inhibition (L-NAME/indomethacin) increased MT in MA from pregnant women (P = 0.001 and P = 0.042, respectively) but was without effect in arteries from nonpregnant women. Indomethacin alone was without effect on MT in MA from either nonpregnant or pregnant women. We concluded that MT increases in MA during human pregnancy and that this effect was partially opposed by enhanced NOS activity.

Intestinal obstruction associated with ovarian remnant in postmenopausal female.

Ovarian remnant syndrome (ORS) is a rare condition, in which the ovarian tissue is inadvertently left behind after difficult oophorectomy. The most common preexisting conditions associated for this complication include endometriosis, pelvic inflammatory disease, and prior abdominal surgery as in these conditions, removal of ovarian tissue becomes difficult. This is likely due to the presence of the dense fibrotic adhesions between an ovary and the surrounding structures. This residual ovarian tissue can become functional and cystic. A 56-year-old multigravida postmenopausal female was diagnosed with intestinal obstruction. She had multiple abdominal surgeries in the past, including cholecystectomy, appendectomy, hysterectomy, and bilateral salpingo-oophorectomy. Patient underwent exploratory laparotomy. Intraoperatively, extensive adhesions and scarring of bowel wall were present and approximately 15 cm proximal to the terminal ileum, a small bowel mesenteric nodule was present. Histopathology of the mesenteric nodule was consistent with the diagnosis of overian remnant. ORS can be prevented with careful resection of the entire ovarian tissue during the difficulty oophorectomy so that no ovarian tissue is left behind.

Postpartum Vaginal Stenosis Due to Chemical Vaginitis.

Acquired vaginal stenosis is a rare obstructing anomaly, which can be caused by use of chemicals in the vagina. A 21-year-old gravida 1 para 1, presented with secondary amenorrhea and inability to have sexual intercourse, after normal spontaneous vaginal delivery complicated by post partum bleeding. The delivery was conducted by untrained traditional birth attendant at home. The wash cloth soaked with caustic soda was packed in the patient's vagina and was left in situ for 10 days, which ultimately led to the severe scarring and stenosis of the vagina. Patient underwent surgical management and the extensive vaginal adhesions were excised and a patent vagina was reconstructed. Patient then reported successful vaginal intercourse without dyspareunia. Post partum vaginal stenosis due to chemical vaginitis is rare. These cases can be prevented by adequate training of untrained health care workers.

Uterine Rupture: A Seven Year Review at a Tertiary Care Hospital in New Delhi, India.

OBJECTIVE: To identify the obstetric risk factors, incidence, and causes of uterine rupture, management modalities, and the associated maternal and perinatal morbidity and mortality in one of the largest tertiary level women care hospital in Delhi. MATERIALS AND METHODS: A 7-year retrospective analysis of 47 cases of uterine rupture was done. The charts of these patients were analyzed and the data regarding demographic characteristics, clinical presentation, risk factors, management, operative findings, maternal and fetal outcomes, and postoperative complications was studied. RESULTS: The incidence of rupture was one in 1,633 deliveries (0.061%). The vast majority of patients had prior low transverse cesarean section (84.8%). The clinical presentation of the patients with rupture of the unscarred uterus was more dramatic with extensive tears compared to rupture with scarred uterus. The estimated blood loss ranged from 1,200 to 1,500 cc. Hemoperitoneum was identified in 95.7% of the patient and 83% of the patient underwent repair of rent with or without simultaneous tubal ligation. Subtotal hysterectomy was performed in five cases. There were no maternal deaths in our series. However, there were 32 cases of intrauterine fetal demise and five cases of stillbirths. CONCLUSIONS: Uterine rupture is a major contributor to maternal morbidity and neonatal mortality. Four major easily identifiable risk factors including history of prior cesarean section, grand multiparity, obstructed labor, and fetal malpresentations constitute 90% of cases of uterine rupture. Identification of these high risk women, prompt diagnosis, immediate transfer, and optimal management needs to be overemphasized to avoid adverse fetomaternal complications.

Lippes Loop Inserted 45 Years Back: The Dilemma to Remove It or Leave It in situ. A Case Report with Review of Literature.

IUD's like Lippes Loop (LL), intended for long term use are retained for years and menopausal ladies often present with LL in situ either deliberately or forgotten. We report a case of Lippes Loop removal inserted 45 years back in a woman complaining of post menopausal bleeding. The inserted LL thread was incidentally discovered during clinical examination and Ultrasonography. We also reviewed literature to determine the evidence for and against removal of an inert IUD.

Management of Recurrent Stricture Formation after Transverse Vaginal Septum Excision.

Background. A transverse vaginal septum (TVS) is a rare obstructing anomaly, caused due to improper fusion of Müllerian ducts and urogenital sinus during embryogenesis. Case. A 15-year-old girl presented with primary amenorrhea. She had multiple congenital anomalies. Initial examination and imaging investigation revealed the presence of a unicornuate uterus and a TVS. The TVS was excised; however the patient was unable to perform vaginal dilation postoperatively leading to recurrent stricture formation. She underwent multiple surgeries for excision of the stricture. The patient was eventually evaluated every day in the clinic until she was able to demonstrate successful vaginal dilatation in the presence of a clinician. Summary and Conclusion. Properly guided regular and intensive vaginal dilation after TVS excision may decrease the need of reoperations due to recurrent stricture formation.

Finger prosthesis: a boon to handicapped.

This is a clinical case report of a 52-year-old male patient with four partially missing fingers of the left hand. The article describes the clinical and laboratory procedure of making prosthesis with modern silicone material. A wax pattern was fabricated using the right hand of the patient. A special type of wax was formulated to make the pattern so that it can be easily moulded and carved. Intrinsic and extrinsic staining was also performed to match the adjacent skin colour. The patient was given the finger prosthesis and was asked to use a half glove (sports) to mask the junction between the prosthesis and the normal tissue. It also provides additional retention to the artificial fingers. The patient felt his social acceptance improved after wearing the finger prosthesis.

Robot-assisted laparoscopic repair of rare post-cesarean section vesicocervical and vesicouterine fistula: a case series of a novel technique.

OBJECTIVE: To present experience with robotic repair of complex vesicouterine fistula (VUF) and vesicocervical fistula (VCF) in 3 patients and to describe technique of repair with 18-months follow-up. METHODS: Three patients were diagnosed with VUF or VCF. Two patients had prior history of lower segment cesarean section complicated by bladder injury and the third had difficult labor with vaginal birth after previous cesarean section. Preoperative diagnosis of VUF/VCF was based on classical history, cystoscopy, and imaging studies. All patients underwent pure robotic repair of fistula. The steps of the technique of repair include cystoscopy, bilateral temporary ureteral catheterization, placement of ports, adhesiolysis, separation of bladder and uterus or cervix, closure of bladder and uterus or cervix and omental interposition. RESULTS: Robotic repair was successful in all patients. There were no intraoperative and postoperative complications. All patients were ambulatory on day 1 and were discharged on day 2. Foley catheter was removed after 2 weeks and all patients were followed over 18 months. CONCLUSION: This technique demonstrates robotic repair of rare VCF and VUF performed safely and effectively. The robotic assistance helped in complex dissection and reconstructive steps. This approach is an excellent minimally invasive alternative at centers with robotic technology because these fistulae cannot be repaired vaginally. Experience of the team is important in managing such cases.

In in-vitro evaluation of effect of different finish lines on marginal adaptation in metal-ceramic restorations under thermo-mechanical loading.

The aim of this study was to evaluate the marginal gap in terms of cement film thickness associated with shoulder, shoulder with 45° bevel, shoulder with 30° bevel and chamfer, under thermo-mechanical loading. Forty human mandibular molars were prepared and restored with ceramo-metal crowns. Teeth were thermo-mechanically loaded and vertically sectioned to evaluate the cement film thickness. Shoulder with 45° bevel provided the least marginal gap as compared with all the tested finish lines.

Effect of various endodontic solutions on punch out strength of Resilon under cyclic loading.

BACKGROUND: Before obturation, various endodontic solutions are used as a final rinse. These solutions might affect the bond strength of Resilon-Epiphany system. The aim of this study was to evaluate the effect of NaOCl (5.25%), chlorhexidine CHX (2%), EDTA solution (17%), and BioPure MTAD on push out bond strength of Resilon-Epiphany system. MATERIALS AND METHODS: Seventy-five human premolar roots were prepared and divided on the basis of final endodontic solution rinse. The canals were obturated with Resilon-Epiphany system. All samples were restored using a fiber post system and indirect composite crown. The samples received 150 000 cycles of mechanical loading. Push out bond strength was performed in the apical third of root having Resilon obturation. RESULTS AND CONCLUSIONS: Different endodontic solutions tested, did not affected the push out bond strength of Resilon-Epiphany obturation system.

Successful treatment of severe sepsis with recombinant activated protein C during the third trimester of pregnancy.

BACKGROUND: Severe sepsis in pregnancy is associated with multiorgan failure and a high risk of death for the mother and fetus. CASE: We present the case of a pregnant patient at 26 weeks of gestation with severe sepsis secondary to pneumonia. She was admitted to the intensive care unit and started on combination antibiotics and bilevel positive airway pressure. Her condition continued to deteriorate, and she was treated with recombinant activated protein C (drotrecogin alfa). She improved and delivered at 28 weeks of gestation after preterm labor; neither the patient nor the neonate had evidence of drug-related complications. CONCLUSION: This report describes a case of severe sepsis at 26 weeks of gestation secondary to pneumonia, with successful maternal and fetal outcome after use of drotrecogin alfa (activated).