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.

Ovarian Carcinoma in a Young Pregnant Woman.

Ovarian cancer during pregnancy is a rare event. Little is known about the treatment of this condition due to the lack of randomized trials and cohort studies. A case of 28 years female, from Kathmandu, visited Out-Patients Department with complaint of amenorrhea for 8 weeks associated with nausea and occasional pain abdomen. Dating scan was done which showed a single live intrauterine pregnancy corresponding to 8 weeks 4 days of gestation with incidental finding of adnexal cysts in both adnexa, measuring 3.6 x 3.6 cm on right and on left 3.2 x 3.6 cm. The cysts did not show any septations. At 38 weeks, she underwent caesarean section and delivered a healthy baby girl. Intra-operatively, bilateral ovarian cysts were identified, both 2x2 cm simple-looking cysts. Enucleation of bilateral ovarian cysts was done. The specimen was sent for histopathology which showed serous carcinoma of low grade in bilateral ovaries. Staging surgery was then carried out after 6 weeks. Histopathology report showed serous carcinoma of low grade in both ovaries. We present here the case of ovarian cancer during pregnancy. Keywords: Ovarian cancer; pregnancy.

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.

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.

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.