Vaginoplasty with Amnion Graft: Management of Mayer-Rokitansky-Kuster-Hauser Syndrome.

Mayer-Rokitansky-Kuster-Hauser syndrome also known as mullerian agenesis is a rare congenital condition in which there is absence of uterus along with upper vagina. Patient usually presents with primary amenorrhea with or without cyclical lower abdominal pain but have normal secondary sexual characters. Modified McIndoe Vaginoplasty with amnion graft is the commonest surgery performed worldwide. A 23 year old girl with normal secondary sexual characters presented with primary amenorrhea with cyclical lower abdominal pain; on examination blind vagina was present. Vaginoplasty with amnion graft was done and vaginal mould was placed. Vaginal dilatation with Hegar's dilator was done weekly until 6 weeks. She is under regular follow-up at present and advised for regular manual dilation at home. McIndoe Vaginoplasty with amnion graft is a simple yet rewarding procedure especially in low resource countries like ours, with good success rate and with minimal postoperative complications. Keywords: Amnion graft; Mayer-Rokitansky-Kuster-Hauser Syndrome; Modified McIndoe Vaginoplasty; Primary amenorrhea; Secondary sexual characters.

Clinical Outcome of Non-descent Vaginal Hysterectomy Versus Abdominal Hysterectomy.

BACKGROUND: Hysterectomy is one of the most common operations performed by the gynecologists second to caesarean section. Hysterectomies are done vaginally, laparoscopically or abdominally. This study has been conducted to compare the complications of abdominal hysterectomy with non-descent vaginal hysterectomy with an aim to establish a safer, superior and lesser complication for the patients. METHODS: This is a cross sectional study conducted at Kathmandu Model Hospital over the period of one year among 70 women. Women according to inclusion criteria were randomly allocated into two groups; 35 women in group 1 underwent non-descent vaginal hysterectomy and 35 in group 2 underwent total abdominal hysterectomy. Demographic data, intraoperative blood loss, intraoperative complications, operation time, postoperative complications, pain, and hospital stay was recorded and analyzed using statistical tool..  Results: The average age of the women was 45.77±6.33 years. Median blood loss (p=0.033) and hospital stay (p=0.005) was significantly low in group 1 as compare to group 2. Mean pain score at discharge (p=0.0005) and follow-up (p=0.0005) was also significantly less in group 1 as compared to group 2. Overall rate of complication was rare and not statistically significant between groups (p=0.643). Rate of wound infection was 5.7% that was observed in group 2, Vault infection 5.7% in group 1, UTI in 2 cases (5.7%) and paralytic ileus was found in 1 case in group 2. CONCLUSIONS: Non-descent vaginal hysterectomy is safe, effective and feasible procedure compared with abdominal hysterectomy. Less complications, faster operating time and easy recovery post operatively makes this a patient friendly mode of hysterectomy.

Successful pregnancy along with prevention of obstetric fistula in a subsequent pregnancy is possible if proper antenatal care and timely elective caesarean delivery are ensured. Keywords: Fistula recurrence; obstetric fistula.

Successful pregnancy along with prevention of obstetric fistula in a subsequent pregnancy is possible if proper antenatal care and timely elective caesarean delivery are ensured. Keywords: Fistula recurrence; obstetric fistula.

Comparison of Perinatal Outcomes between Borderline and Normal Amniotic Fluid Index in Term Singleton Pregnancies.

BACKGROUND: Amniotic fluid provides necessary fluid and growth factors for normal development of fetal lungs, cushions the umbilical cord from compression and protects the fetus. This study aims to compare the perinatal outcome between pregnancy with borderline and normal Amniotic Fluid Index that provide greatest chance for appropriate safe delivery with least maternal fetal and neonatal risk. METHODS: A total of 94 singleton full term pregnant women were included in the study-at Kathmandu Model Hospital from February to August 2020. Forty Seven women each with Amniotic Fluid Index 5-8 cm was taken as borderline oligohydramnios group and Amniotic Fluid Index 8.1-24 cm was taken as normal group. Ultrasonography was taken as the medium for measuring Amniotic Fluid Index. RESULTS: The rate of intra-partum fetal distress, meconium-stained amniotic fluid, low birth weight and neonatal intensive care unit admission were not statistically significant between the two groups while rate of cesarean section was noted to be 76.6% in exposed groups as compared to 44.7% among women with non-exposed normal group [RR=1.71; 95%CI: 1.2-2.44 p=0.006]. CONCLUSIONS: We concluded that in cases of borderline oligohydramnios there was higher risk of operative delivery.

Clinical Profile of Urogenital Fistula in Kathmandu Model Hospital.

BACKGROUND: To determine the causes of fistula and to share our experience in treating urogenital fistula and its surgical outcome. METHODS: This was a retrospective study done at Kathmandu Model Hospital from January 2014 to June 2019 including 261 patients operated for fistula. The patients were analyzed for age, type of fistula, cause, treatment and surgical outcome. RESULTS: Out of 261 patients operated, 59.38% cases had obstetric fistula, 38.69% had iatrogenic and 1.92% had traumatic fistula. Most of the patients with obstetric fistula were between 21 to 25 years of age whereas iatrogenic fistulae were between 46-50 years of age. The majority (54.84%) of obstetric fistulae were vesicovaginal fistula (54.84%) while the commonest type (77.36%) of iatrogenic fistula was vault fistula after abdominal hysterectomy. CONCLUSIONS: This study showed that obstructed and neglected labor was still the major cause of genitourinary fistula in Nepal nevertheless iatrogenic fistula following pelvic surgery is increasing. The surgical outcome of repair of fistula was good.

Uterine Rupture During Medical Induction for Second Trimester Abortion.

Medical induction is an alternative to dilatation and evacuation (D and E) in second trimester abortion, though it has higher risk of minor complications compared to D and E. Combination of mifepristone and misoprostol is commonly used for the medical abortion. A 32 years G3P2L2 with previous two cesarean delivery was referred to our center at sixteen weeks of gestation for termination of her pregnancy. After 63 doses of misoprostol, she had to undergo unintended major intra-abdominal surgery for partial uterine rupture. Keywords: Dilatation and evacuation; medical induction; second trimester abortion; uterine rupture.

Assessment of Caesarean Section Rates at Kathmandu Model Hospital Using the Robson's Ten Group Classification System.

BACKGROUND: Aims of this study was to assess the caesarean section rate and identify the indications contributing to the same using the Robson's Ten Group Classification System at Kathmandu Model Hospital. METHODS: This was a retrospective study conducted at Kathmandu Model Hospital among women who underwent caesarean section from 1 January to 31 December, 2018 and were grouped according to Ten Group Classification System. The overall caesarean section rate and the contribution of each group was calculated. RESULTS: The overall caesarean section rate was 66.1% (494 among 747 total deliveries) in 2018. Nullipara, singleton cephalic, >= 37 weeks, spontaneous labor (Group 1) was the major (24.2%) contributor to the overall caesarean section rate followed by previous caesarean section, singleton cephalic, >=37 weeks (Group 5, 22.6%) and nullipara, singleton cephalic, >=37 weeks, induced or caesarean section before labor (Group 2, 18.8%). Also, the caesarean section rate was 49.5% in nullipara, thus increasing the trend of caesarean section for previous caesarean section in future. CONCLUSIONS: Efforts must be focused more on Group 1, 2 and 5 to decrease the increasing trend of caesarean section Promoting vaginal delivery in nullipara and facilitating vaginal birth after caesarean are the most relevant areas of intervention.

Overview of Obstetric Fistula: From a Developing Country's Perspective.

Obstetric fistula is a hidden tragedy in the developing world, prevention is important and treatment is by surgical repair. However, failure, broken fistula, stress incontinence often demoralizes surgeons and patients. Keywords: Fistula repair; Obstetric fistula; Obstructed delivery.

Evaluation of Abnormal Cervix with Visual Inspection under Acetic Acid and Colposcopy.

BACKGROUND: Cervical cancer is a major public health problem especially in developing countries. It can be prevented through implementation of routine screening program. There are different screening methods but their efficacy are still questionable. So the purpose of this study is to evaluate the efficacy of visual inspection of cervix with acetic acid and colposcopy to detect precancerous lesion in women with clinically unhealthy or abnormal cervix. METHODS: Forty patients with abnormal cervix (35) and abnormal pap smear results (5) were enrolled for the study in outpatient department of Kathmandu Model Hospital. Patients were evaluated with visual inspection of cervix with acetic acid and colposcopy in the same sitting. Cervical punch biopsy were taken from suspected lesion or from four quadrant if colposcopy findings were normal and sent for histopathological examination. The finding of visual inspection of cervix with acetic acid and colposcopy were correlated with histopathological finding and compared with each other. RESULTS: The age of participants ranged from 24 to 68 years with mean age of 38.17 years and mean parity of 2.25. visual inspection of cervix with acetic acid and colposcopy were positive in eight (20%) and ten (25%) respectively. There were five (12.5%) cases of histopathologically proven lesion. The sensitivity of visual inspection of cervix with acetic acid and colposcopy were 80% and 100 % respectively and that of specificity were 88.5% and 85.5%. CONCLUSIONS: visual inspection of cervix with acetic acid is an effective screening tool with comparable sensitivity and specificity. It can be used as alternative screening methods especially in low income resource countries where the burden of disease is high.

Complete Labial Fusion in a Postmenopausal Woman Presenting with Retention of Urine.

Complete labial fusion with retention of urine is a rare clinical entity. It occurs when the labia are fused in midline, forming a raphe. It usually develops in postmenopausal women with hypoestrogenism. The usual treatment is with topical estrogen and surgical separation followed by some dilatation. Here we present a case of a 58 years' postmenopausal,unmarried, nullipara woman who came to our emergency ward with retention of urine.She had history of incomplete voiding and dribbling of urine since six months. General examination and investigations were normal. Her clitoris was normal in size, and the labia majora and anus were visualized well; however, the urethral meatus and vagina were not seen because of fused labia minora.Patient required surgical excision of fused labial folds to relieve the retention. Keywords: Labial fusion; postmenopausal; urinary retention.

Outcome of Sacrospinous Ligament Fixation of the Vault during Repair of Pelvic Organ Prolapse.

BACKGROUND: Pelvic organ prolapse includes descent of anterior/ posterior wall and apical (vault) prolapse with significant morbidity. In this study we evaluated the outcome of sacrospinous ligament fixation of vault through vaginal approach as part of the repair for massive uterovaginal (pelvic organ prolapse stage III and stage IV) and vault prolapse. METHODS: This study on sacrospinous ligament fixation along with repair for Pelvic organ prolapse at Kathmandu Model Hospital from November 2016 to April 2018 was done to assess the outcome in terms of early (during hospital stay) and delayed (six months) post-operative complications and need of removal of sacrospinous fixation suture and recurrence of vault prolapse. RESULTS: Out of 95 Pelvic organ prolapse patients, 80 (84%) were post-menopausal, 28 (29.4%) were in the age group of 70-79 years. There were 61 (64%) POPQ stage III. The post-operative complications during post-operative hospital stay were pain over right buttock in 42 (44%), urinary retention in 7 (7%) and UTI in7 (7%). Sacrospinous suture was released in two patients for severe pain over right buttock. At one-week follow-up, 35 (36%) had right buttock pain of moderate severity and 8 (8%) had vaginal cuff infection. Sacrospinous suture was removed in one patient for neuropraxia two weeks following surgery. At four weeks follow-up, 25 (26%) patients had mild right buttock pain relieved by oral NSAIDs on need. At six months follow-up, five had occasional buttock pain, six had some recurrences and two had some vault prolapse and one each had short vagina and stress incontinence. CONCLUSIONS: Sacrospinous ligament fixation is a good procedure for the management of Pelvic organ prolapse with better long-term outcome if performed with good surgical expertise.

Missing Intrauterine Device Copper-T: Case Series.

An intrauterine contraceptive device (IUD) is a long acting, highly effective, economic and reversible method of contraception used worldwide. The most used devices are copper IUD (Copper-T) or Progesterone IUD. Common complications include failed insertion, pain, vasovagal reactions, infection, menstrual abnormalities, expulsion and rarely uterine embedment and perforation. In this case series we will discuss three cases of missing Copper-T. In one case Copper T was inserted at our hospital and in the other cases it was inserted in the periphery and all the cases was managed surgically with different modality. Keywords: Copper-T; Intrauterine device; laparoscopy; laparotomy; perforation.

Managing Ureterovaginal Fistulas following Obstetric and Gynecological Surgeries.

BACKGROUND: Iatrogenic ureteric injuries leading to fistula are rare but devastating complications of obstetric and gynecological surgeries. The aim of the study was to review the demography of ureterovaginal fistula (UVF) and its surgical outcome in Kathmandu Model Hospital. METHODS: This is a review of 15 patients of ureterovaginal fistula who were referred to department of Obstetrics and Gynaecology of Kathmandu Model Hospital from Feb 2014 to Sept 2017. We reviewed the demography, causes and surgical outcome of ureterovaginal fistula (UVF). Ten patients who had complete blind end at the distal ureter, underwent Lich-Gregoir extravesical ureteroneocystostomy. In other five patients, guide wire was successfully negotiated beyond the fistula site, however retrograde double J stenting could be done in only four patients. RESULTS: All the patients had distal ureteric injury close to vesicoureteric junction leading to ureterovaginal fistula. Among them, majority were due to post-hysterectomy in 60% (n=9) followed by obstetrical procedures in 40% (n=6). Fourteen patients (93%) had successful closure of the fistula with complete preservation of renal function. Retrograde double J stenting was possible in patients who were referred earlier within two weeks of the onset of injury. CONCLUSIONS: Iatrogenic injury to the distal ureter during surgery was the leading cause for the ureterovaginal fistula. Endoscopic management with ureteric stents was still possible if the patients were referred earlier following primary surgery.

Caesarean Scar Endometriosis.

Endometriosis is a common benign gynecologic disorder defined as the presence of endometrial glands and stroma outside of the normal location. The overall prevalence is 8-15% in women of reproductive age group. Scar endometriosis is a rare disease, and is difficult to diagnose. It is commonly seen following obstetrical and gynecological surgeries. The symptoms are non-specific, typically involving abdominal wall pain at the incision site at the time of menstruation and palpable tender mass in the incision site. The diagnosis is frequently made only after excision of the diseased tissue and its histological analysis. We present here a case of abdominal wall scar endometriosis in a woman who had undergone a caesarean section four years ago. Surgical excision led to the diagnosis of scar endometriosis. The pathogenesis, diagnosis and treatment of this rare condition are discussed.