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.

Correlation of past tuberculosis with current screening for female genital tuberculosis in infertile women in a tertiary care hospital.

OBJECTIVES: To analyse correlation of past history of tuberculosis with present state of infertility with respect to HSG and diagnostic findings, with a view to assess the frequency of genital tuberculosis in infertile women, its clinical presentation and association with infertility. MATERIALS AND METHODS: The study is an ongoing study conducted in the Department of Obstetrics and Gynaecology, Kasturba Hospital, Delhi and included 174 infertile women enrolled as OPD patients in our hospital. A detailed history with special emphasis on past history of tuberculosis, thorough clinical examination, all routine investigations for Infertility & special investigations for genital tuberculosis was done. Diagnostic tests and laparoscopy was further performed as per the protocol. RESULTS: Female genital tuberculosis has been described as a disease of the younger population. The present study shows that 87.9% patients diagnosed for genital tuberculosis were between 20 and 35 yrs of age. It was observed that amongst 174 infertile patients who attended our OPD, 40 patients had a positive history of present or previous incidence of Koch's, pulmonary or extra pulmonary, namely 22.9% (Group I) and the remaining patient comprising 77.1%, who had no record of any previous tuberculosis (Group II). Active Tuberculosis was seen in 5 patients out of a total of 40 females. Out of the total of 174 infertile patients suffering from tubal disorder 52.5% of Group I patients had evidences of tubal disease as compared to only 27.6% in Group II thus suggesting a strong correlation of tubal destruction and subsequent infertility to a positive history of tuberculosis. Out of the 56 laparoscopies performed, it was seen that 75% of Group I patients with past history of TB had abnormal laparoscopic findings (18 out of 24 patients), as compared to Group II which had only 9 out of 32 patients (28%) showing positive pelvic pathology. This seems to be very significant. CONCLUSION: In conclusion the results of the present study validate arguments in favour of incorporating screening for genital tuberculosis as a part of the baseline investigation for all patients of infertility, in countries like ours and especially in such patients who have suffered from Tuberculosis sometimes earlier in their lives.

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.

Vaginohysteroscopy, a patient-friendly technique for outpatient hysteroscopy: experience of the first 100 cases.

OBJECTIVE: To evaluate the feasibility and tolerability of the vaginoscopic approach for office hysteroscopy. DESIGN: Prospective observational study. SETTING: Tertiary care hospital. SUBJECTS: Unselected, consecutive 100 patients scheduled for diagnostic hysteroscopy. INTERVENTION: Hysteroscopy with a vaginoscopic approach using a 5-mm rigid hysteroscope with single inflow channel, and normal saline for distension. OUTCOME MEASURES: Successful hysteroscopy by the vaginoscopic approach; operative time; and degree of pain experienced. RESULTS: The vaginoscopic technique was successful in 79% of the patients. The median operative time was 120 seconds in successful cases and 360 seconds in those in which the vaginoscopic approach was unsuccessful and had to be performed by the conventional technique with or without dilatation, the difference being statistically significant (P < 0.001). The procedure took < or = 2 minutes in 91.1% (72/79) of the successful cases. No pain or mild pain was experienced by 97.5% (77/79) of patients in whom vaginohysteroscopy was successful. CONCLUSION: Hysteroscopy with the vaginoscopic approach is the ideal method for outpatient hysteroscopy. It is feasible, quick, and very well tolerated, obviating the need for any analgesia or local anesthesia.

Volvulus, gangrene and perforation of transverse colon in an antepartum eclamptic pregnant patient post caesarean: a case report

Transverse colon volvulus leading to gangrene and perforation is an extremely uncommon acute surgical complication in pregnancy and puerperium, with a very high rate of mortality and morbidity. Surgical resection is the only treatment. Authors present a case of a 20 years. old women, with antepartum eclampsia, who underwent caesarean section for fetal distress. She complained of abdominal pain from second post-operative day. The pain increased in severity and on the third postoperative day, she developed sudden abdominal distention and appeared pale. Ultrasound revealed free intraperitoneal fluid suggestive of hemoperitoneum. An emergency laparotomy was performed. There was about a litre of blood in the peritoneal cavity with clots. The caesarean incision site, uterus adnexa and broad ligaments were all intact. On further exploration, volvulus of the transverse colon was seen along with gangrene and perforation of the middle part of transverse colon. Resection of the gangrenous part was done with closure of the distal loop. Proximal loop was brought out as colostomy. The patient had an uneventful postoperative course thereafter and was discharged on regular diet on 12th postoperative day. Volvulus of transverse colon leading to gangrene is rare in pregnancy and puerperium, but must form part of clinician’s differential diagnosis when encountering a patient with persistent abdominal pain and bowel distention. Early diagnosis and timely surgical intervention could significantly improve the outcome of this catastrophic condition.

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.