Appearances Are Deceptive: Two Case Reports in Teenagers on the Conservative Laparoscopic Surgery for Adnexal Torsion with Apparent Infarction.

Introduction. Torsion of the ovary, tube, or both is estimated to be responsible for 2-7% of all gynaecological emergencies. Oophorectomy is commonly performed for adnexal torsion with a possible negative impact on fertility in women of reproductive age. Case Presentations. We report two cases of teenage girls presented with adnexal torsion describing their laparoscopy features. Detorsion without additional surgical intervention could save their ovaries. Discussion. Detorsion is a more conservative surgical approach that should be considered in all younger women with ovarian torsion.

Transvaginal two-dimensional ultrasound measurement of cervical volume to predict the outcome of the induction of labour: a prospective observational study.

BACKGROUND: Assessing the likelihood of success of induction of labour using ultrasonically measured cervical volume is an important research question. METHOD: A prospective observational study was carried out at North Colombo Teaching Hospital, Ragama, Sri Lanka. Pre-induction digital cervical assessment, transvaginal cervical length, and cervical volume measurements were performed. Inductions with singleton pregnancies at term were included. Basic demographic and clinical details, independent variables (Bishop score, cervical length and cervical volume), and dependent variables (frequency of delivery within 24 h and induction to delivery interval) were recorded. Vaginal delivery within 24 h was the primary outcome. RESULTS: We studied 100 pregnant women who had induction of labour. Median (IQR) Bishop score was 5 (3-6), mean (SD) cervical length was 3.6 (0.7) cm, and mean (SD) cervical volume was 27.5 (10.4) cm3. Cervical length was the best predictor for predicting the likelihood of vaginal delivery within 24 h [aOR - 12.12 (3.44, 42.71); < 0.001], and cervical volume also appeared to be a significant potential predictor [aOR-1.10 (1.01, 1.17); 0.01]. Cervical length was found to have the highest AUC (0.83) followed by the cervical volume (0.74). The best cut-off value for cervical volume in predicting the likelihood of vaginal delivery within 24 h was less than 28.5 cm3 with a sensitivity of 72% and specificity of 74%. CONCLUSIONS: Transvaginal sonographic measurement of cervical volume appears to be a potential novel predictor for the likelihood of vaginal delivery within 24 h of induction of labour. Cervical length is still more superior to cervical volume in predicting the likelihood of vaginal delivery. Bishop score was not a significant predictor in this context.

Mental Health Problems during Pregnancy and the Postpartum Period: A Multicenter Knowledge Assessment Survey among Healthcare Providers.

BACKGROUND: Mental illness related to pregnancy can have long-lasting consequences. Healthcare providers are often the most frequent medical contact with the potential for early detection of these. Objectives were to study the awareness regarding mental health problems during pregnancy and the postpartum period among healthcare providers. METHODS: A cross-sectional study was carried out with healthcare providers including the nursing staff, midwifery staff, and medical officers working at obstetric wards in three tertiary care hospitals in Sri Lanka. A self-administered questionnaire assessed staff experience with mothers having mental problems, knowledge on mental health problems related to pregnancy, and knowledge about risk factors, common symptoms, and possible consequences on a five-point Likert scale from "Strongly Agree" to "Strongly Disagree." RESULTS: A total of 300 staff were approached and invited to participate. Only 152 responded to the questionnaire (response rate of 50.1%). Mean (SD) age was 35.8 (9.7) years and mean (SD) years of experience was 10.1 (9.1) years. Age more than 35 years of healthcare providers is associated with statistically significant (p = 0.02) average knowledge scores on the consequences of maternal mental health problems. The symptom of "excessively worrying about baby's health" had the lowest score across all three categories with an average of 34.2%. Only 42.8% have ever heard of EPDS. Overall awareness and knowledge about risk factors, symptoms, and consequences regarding pregnancy-related maternal mental health problems are generally good among the healthcare providers studied. However, some of the few aspects are not satisfactory. Health education of pregnant women, promoting regular in-service training sessions, improvement of infrastructure, and involvement of family members from the antenatal period were discussed by the majority. CONCLUSION: Despite good overall awareness and knowledge, application into practice with the utilization of validated assessments is poor. This may probably explain why Sri Lanka has a high prevalence of postpartum depression suggesting urgent attention.

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.

Single center experience on implementation of the postpartum intrauterine device (PPIUD) in Sri Lanka: a retrospective study.

OBJECTIVES: to study the institutionalization of PPIUD services at Teaching Hospital, Mahamodara, Galle (THMG) and to study the feasibility, challenges and barriers for implementation. RESULTS: Total of 46,815 deliveries had occurred in the facility during the study period. Out of that 23,117 (49.4%) women had been counseled and 5775 (25.0%) of them were primigravida and 892 (3.9%) were teenage mothers. Total of 14,051 (60.8%) women were interviewed, but only 772 (5.5%) women consented for PPIUD. Consent withdrawal was seen in 29 (3.8%) cases. A total of 409 community health staff were trained for counseling and follow up. PPIUD uptake was 470 (3.4%) which is comparable to national figures. Follow up data at 1 year was available from 199 women and spontaneous expulsion had occurred in eight (6.7%) cases with no cases of perforation or failure in terms of pregnancy. This short report gives the impression that PPIUD can be successfully implemented in resource limited settings and this also provides a feedback for the policy makers to take the necessary actions to improve the uptake of this cost effective, safe PPFP method. A routine PPIUD service has been successfully established within a tertiary care maternity setting in Sri Lanka.

Granular Cell Tumor over the Mons Pubis: An Uncommon Tumor.

Granular cell tumors are uncommon, usually benign, soft tissue neoplasms of neural origin. They occur throughout the body; vulval involvement is uncommon and labium majus is the commonest site in vulva. Complete surgical excision is the preferred treatment of choice to prevent recurrence. Here, we present a benign granular cell tumor over the mons pubis of vulva in a 27-year-old woman.

Piloting of WHO Safe Childbirth Checklist using a modified version in Sri Lanka.

OBJECTIVES: Data was gathered to study the impact of a context-specific modified WHO Safe Childbirth Checklist (mSCC) at two tertiary care settings in Sri Lanka, as a part of an implementation program. DATA DESCRIPTION: We provide data sets of a prospective observational study which was conducted in the University Obstetrics Unit at De Soysa Hospital for Women (DSHW), Colombo and two Obstetric Units at Teaching Hospital, Mahamodara, Galle (THMG), Sri Lanka. These consist of demographic and checklist implementation details and data on the level of acceptance. The study was conducted over 8 weeks at DSHW and over 4 weeks at THMG. Checklists were kept attached to clinical records at admission and collected on discharge. Level of acceptance was assessed using a self-administered questionnaire. Outcome measures were adoption rate (percentage of deliveries where mSCC was used), adherence to practices (mean percentage of items checked in each checklist), response rate (percentage of staff members who responded to questionnaire) and level of acceptance (percentage of "strongly agree/agree" in Likert scale to five questions regarding acceptance of modified SCC).

Severe Preeclampsia, Antiphospholipid Syndrome, and Ulnar Artery Thrombosis in a Teenage Pregnancy: A Rare Association.

Antiphospholipid syndrome (APS) is associated with vascular thrombosis and pregnancy complications. It causes recurrent miscarriage and it is associated with other adverse pregnancy outcomes such as preterm delivery, intrauterine growth restriction, preeclampsia, and HELLP syndrome. Obstetric morbidity is one of the major manifestations of APS with a wide variety of clinical manifestations. This case describes a case of a severe preeclampsia in a 16-year-old primigravida at 29 weeks resulting in a caesarean delivery and subsequent finding of an ulnar artery thrombosis in postpartum period. APS was diagnosed on further investigations of her symptoms and signs.

Two potentially lethal conditions of probable immune origin occurring in a pregnant woman: a case report.

BACKGROUND: Thrombotic thrombocytopenic purpura and peripartum cardiomyopathy are potentially lethal complications of pregnancy. We describe a case in which both of these developed in the same patient. The etiologies of both conditions remain uncertain, but they share immune hyperreactivity as a possible cause. CASE PRESENTATION: A 33-year-old Lankan primigravida gave birth at 38 weeks of gestation by cesarean section when she presented with right-sided abdominal pain and a provisional diagnosis of appendicitis. Her pain persisted postoperatively, and on the second postoperative day, she physicaly collapsed suddenly with abdominal distention. Immediate laparotomy revealed generalized oozing from the peritoneum resulting in hemoperitoneum and intestinal hemorrhage. Her laboratory reports showed microangiopathic hemolytic anemia and thrombocytopenia. She also had elevated liver enzyme, lactate dehydrogenase, and creatinine concentrations. A diagnosis of thrombotic thrombocytopenic purpura was made. After a steady recovery, she was discharged from the hospital on the 16th postoperative day, but 12 hours later, she was readmitted with acute-onset progressively worsening shortness of breath. Echocardiography confirmed peripartum cardiomyopathy. She was treated with a bromocriptine and heart failure regimen. At 6 weeks postpartum, her laboratory test results and cardiac function had improved. CONCLUSIONS: A possible autoimmune association might have caused both conditions in our patient. This case report serves as a warning message that pregnant women with one possible condition with autoimmune association could go on to develop other similar conditions.

Foley catheter for cervical priming in induction of labour at University Obstetrics Unit, Colombo, Sri Lanka: a clinical audit with a patient satisfaction survey.

BACKGROUND: Intracervical insertion of a Foley catheter (FC) has shown to be a safe, effective and relatively feasible mechanical method of cervical priming in induction of labour (IOL). We evaluated indications, effectiveness, patient acceptability and outcomes of FC use in IOL adhering to the ward protocol in our unit. METHODS: A clinical audit with a patient satisfaction survey conducted between July and September 2013 in University Obstetric Unit, Colombo, Sri Lanka. Patients selected for IOL for obstetric reasons were primed with Foley as per ward protocol. All had singleton pregnancies with cephalic presentation, intact membranes and period of gestation of 37 weeks or above. Women with a history of more than one caesarean section or uterine surgery, low-lying placenta and fetal growth restriction were excluded. Subjects who had a Modified Bishop Score (MBS) of less than 3, a 16Fr FC was inserted into cervical canal. Catheter was left undisturbed until spontaneous expulsion or no longer than 48 h. In women with MBS of less than 6 at 48 h after FC insertion, 3 mg prostaglandin E2 vaginal tablet was used subsequently. Artificial membrane rupture with or without oxytocin was used if MBS of 6 or more and in women not in labour 24 h after prostaglandins. Patient satisfaction for Foley insertion was assessed with regards to the degree of comfort using a validated visual analogue scale (0-10). RESULTS: There were a total of 910 deliveries during the study period. Fifty-six women were primed with FC. Thirty-two (57%) were nulliparous. During induction of labour, 53(95%) reported mild or no discomfort. MBS of 6 or more was achieved in 36/56 (64%) Foley insertions. Twenty needed further intervention with prostaglandins. FC only group had 5 caesarean sections and 31 vaginal deliveries and Foley/prostaglandin group had 7 caesarean sections and 13 vaginal deliveries. Of the 24 women who were induced due to completion of 41 weeks of gestation with otherwise uncomplicated pregnancies, 17 had MBS >6 post priming with Foley and 20 (83%) delivered vaginally. Subjects who had Foley only had a lesser chance of having a caesarean delivery compared to subjects who had Foley followed by prostaglandin (relative risk = 0.40, 95% CI = 0.15-1.09, P = 0.09). DISCUSSION: FC is a good choice for pre-induction cervical priming with high patient comfort. FC becomes more important in IOL cost reduction in our setting. FC alone seems to be an effective for IOL in women who have completed 41 weeks of gestation with otherwise uncomplicated pregnancies.

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.