Recurrent vaginal vault dehiscence and evisceration following total laparoscopic hysterectomy, successfully repaired with polypropylene mesh and sacrocolpopexy.

Recurrent vault dehiscence is a rare and potentially serious complication following hysterectomy. We report a rare case of recurrent vault dehiscence and evisceration following a total laparoscopic hysterectomy (TLH) which was successfully repaired with polypropylene mesh and sacro-colpopexy. A 47-year-old multiparous woman underwent TLH for adenomyosis. During the surgery, vaginal wall was incised with monopolar diathermy and sutured with synthetic absorbable barbed suture in a single layer. She presented 12 weeks later with vault dehiscence and evisceration of omentum. Laparoscopically, eviscerated omental part was removed and the vaginal cuff was repaired vaginally with absorbable synthetic suture. She came with a recurrence in 3 months with vault dehiscence and a vault prolapse without any evisceration. She underwent laparoscopic mesh repair of the vault combined with laparoscopic Sacro-colpopexy with complete recovery. Incidence of vault dehiscence is found to be higher in TLH than abdominal or vaginal hysterectomy. Treatment options for recurrent vault dehiscence involve strengthening the vault with tissues, or with a prosthesis.

Nonpuerperal Uterine Inversion: What the Gynaecologists Need to Know?

INTRODUCTION: Nonpuerperal uterine inversion (NPUI) is a rare clinical problem with diagnostic and surgical challenges. The objective of our study was to review the literature on NPUI and describe causative pathologies, diagnosis, and different surgical options available for treatment. MATERIALS AND METHODS: A comprehensive literature review was carried out on MEDLINE and Google Scholar databases to look for NPUI using the term "non-puerperal uterine inversion," and further went through the cross-references of the published articles. Data are published case reports from 1911 to September 2018. Of the 153 published cases, 133 reports had adequate details of surgery for analysis. These reports were analyzed, concerning the clinical presentation, methods of diagnosis, and surgical treatment. RESULTS: Mean age of the women was 46.3 years (standard deviation: 18, N = 153). Leiomyoma remained the commonest (56.2%) aetiology. While malignancies contributed to 32.02% of cases, 9.2% were idiopathic. High degree of clinical suspicion and identification of unique features on ultrasonography and magnetic resonance imaging enable prompt diagnosis. In cases of uncertainty, laparoscopy or biopsy of the mass was used to confirm the diagnosis. Hysterectomy or repositioning and repair of the uterus are the only treatment options available. The surgical methods implemented were analyzed in three aspects: route of surgical access, method of repositioning, and final surgical procedure undertaken. The majority (48.8%) had only abdominal access, while 27.1% had both abdominal and vaginal access. Haultain procedure was the most useful procedure for reposition (18.0%) of the uterus. The majority (39.7%) required abdominal hysterectomy with or without debulking of the tumour abdominally, while 15.0% had uterine repair after repositioning. We reviewed the different surgical techniques and described and proposed a treatment algorithm. CONCLUSIONS: Fibroids were the commonest cause for NPUI. Malignancies accounted for one-third of cases. A combined abdominal and vaginal approach, followed by hysterectomy or repair after repositioning, seems to be better for nonmalignant cases.

Conservative Management of Placenta Percreta: Three Cases and a Review of the Literature regarding Conservative Management of Placenta Accreta Spectrum (PAS) Disorders.

BACKGROUND: The incidence of placenta accreta spectrum (PAS) disorders has risen over the last decades, and there has been a gradual shift towards expectant management. Conservative management of PAS is known to reduce major obstetric haemorrhage and salvage hysterectomy. There is a lack of consensus on the follow-up of patients undergoing conservative approaches. Here, we describe the follow-up of three patients with placenta percreta who were conservatively managed and review the literature for the conservative management of PAS. Case Presentation. We have successfully managed three cases of placenta percreta expectantly using combined methods involving symphysial-fundal height, serum beta-HCG, and ultrasonographic volume of placental mass. CONCLUSIONS: Use of a combined approach with symphysial-fundal height, serum beta-HCG, and ultrasonographic volume of placental mass with colour Doppler may guide the surveillance of these conservatively managed cases. However, at least one magnetic resonance imaging three months postoperatively may predict a further risk of delayed haemorrhage.

Blood flow changes in pelvic vessels associated with the application of an abdominal compression belt in healthy postpartum women

Introduction: Postpartum haemorrhage (PPH) accounts for a high proportion of maternal mortality and morbidity throughout the world. A uterine compression belt which has been developed recently represents a very low tech, low cost solution in managing postpartum haemorrhage. Objectives: To evaluate the blood flow changes in pelvic vessels following application of the postpartum haemorrhage compression belt (Laerdal Global Health, Stavanger, Norway). Methods: The sample included healthy postpartum women within 6 hours of vaginal delivery. The study was performed at Teaching Hospital, Ragama, Sri Lanka. PPH compression belt was applied on the lower abdomen in a supine position with a slight lateral tilt. Patient's pulse, blood pressure and Doppler indices (RI, PI and PFV) of the uterine, internal iliac and femoral arteries were measured using transabdominal Doppler ultrasonography. Lower limb oxygen saturation was also measured. Measurements were obtained by connecting the subjects to a multimonitor throughout the study period of 20 minutes. Median RI, PI and PFV was calculated and comparisons were made between the baseline and after belt application at 10 and 20 minutes. Results: A total of 20 healthy women were included and the mean time from delivery to study inclusion was 2.5 (range 0.5­5.0) hours. There were no adverse outcomes or altered vital signs noted among participants. Overall there were no significant changes in the internal iliac, uterine and femoral artery blood flow after application of the compression belt. Conclusions: There were no significant changes in the internal iliac, uterine and femoral artery blood flow after application of the compression belt. This preliminary study only shows that the application of the PPH compression belt has no apparent adverse changes in the iliac, uterine and femoral artery blood flow in postpartum mothers.

Hyperemesis gravidarum and fetal gender: a retrospective study.

This retrospective study of 9,980 women who delivered at the James Paget Hospital, Norfolk, UK, over 5 years, aimed to primarily determine whether the incidence of hyperemesis gravidarum (HG) is higher in the presence of a female fetus. The results showed that more women with HG had a female fetus compared with women without HG. Also found was that heavy ketonuria was more prevalent in women with a female fetus compared with women with a male fetus, and the mean number of admissions per woman was also higher in women with a female fetus compared with women with a male fetus. It can be concluded that women presenting with HG are more likely to have a female fetus and that women with HG and a female fetus tend to a higher level of ketonuria and an increased number of hospital admissions.

A qualitative study on patients' perceptions of expectant management of first trimester incomplete miscarriage.

INTRODUCTION: Efficacy and safety of expectant management of first trimester miscarriage are well known, though the patients' perceptions and attitudes are less clear. This study was designed to understand the women's perception of symptoms, acceptability, fertility wishes and care received. METHODS: A qualitative study among 25 women who were allocated to the expectant management arm of a randomised control trial, which compared expectant versus surgical management of incomplete miscarriage, was carried out. Interviews were recorded at the end of two weeks from the initial diagnosis based on five themes, which were transcribed and analysed. RESULTS: Out of the 25 interviewed, two had to undergo surgical evacuation due to failed expectant management. Excessive bleeding was the main concern especially for employed women. Ideas and beliefs of family members influenced the women's experience. Majority preferred expectant management in a possible future event. Many expected to conceive again but preferred to delay a pregnancy even in the absence of any contraindications. Inadequate knowledge of expectant management led to dissatisfaction regarding the care received. CONCLUSIONS: Better understanding on the natural course of events in spontaneous miscarriage will help not only the patient but also the relatives in accepting expectant management of first trimester miscarriage and influence their ideas, beliefs and feelings. Improved health education, counselling, and symptomatic relief are important aspects in improving the overall quality of care.

How can we reduce negative laparoscopies for pelvic pain?

Chronic pelvic pain is a common condition and the RCOG guideline provides an evidence-based framework for the initial assessment. This study investigated the adequacy and relevance of the initial assessment in patients who underwent elective laparoscopic procedure for pelvic pain. History-taking was found to be deficient and was unable to identify factors which may be related to the cause or perception of the pain. Only a small percentage benefitted from a therapeutic trial of hormonal and non-hormonal agents and referral to other specialities. Ultrasound and bimanual examination were both found to be of little value. Laparoscopy assisted in diagnosis in 45% of patients. A structured initial assessment and targeted selection of patients for laparoscopy would reduce the number of patients with normal findings and thus, it would reduce the number of women who suffer pain and isolation after a negative laparoscopy.

Laparoscopic management of genital prolapse.

INTRODUCTION: Genital prolapse is one of the most common indications for gynaecological surgery. Surgery is performed traditionally via abdominal, vaginal and laparoscopic approaches. METHODS: A MEDLINE computer search was performed to explore the recent evidence behind laparoscopic surgery for female pelvic organ prolapse. RESULTS: Advances in minimal access surgery have led to an increase in adoption of laparoscopic techniques. Current evidence supports the use of laparoscopy for sacrocolpopexy and colposuspension as an alternative to open surgery. However, the introduction of less invasive midurethral sling procedures for stress incontinence has reserved laparoscopic colposuspension for special indications. The scientific evidence regarding uterosacral suspension procedures and paravaginal and vaginal prolapse repairs are sparse. CONCLUSION: The current evidence supports the outcome of laparoscopic sacrocolpopexy as an alternative to open surgery. Further studies are required on the long-term efficiency in laparoscopic paravaginal repair and vaginal wall prolapse.