Factors related to maternal mortality rate in covid-19 patients - a cross-sectional study from an Indonesian covid-19 referral hospital.

BACKGROUND: The covid-19 pandemic may cause severe clinical manifestations in a vulnerable population, such as pregnant women. Based on Indonesian Obstetrics and Gynecology Association (POGI), the number of maternal deaths due to covid-19 from April 2020 to April 2021 reached 3% and increased to 9% since the delta variant of covid-19 emerged. This research was expected to identify factors that are related to the mortality rate of pregnant women with covid-19. MATERIALS AND METHODS: This was a cross-sectional study using secondary data collected from June 2020 to August 2021. The study was conducted in Universitas Indonesia Hospital, a national covid-19 referral hospital. Patient characteristics, pregnancy profile, comorbidities, laboratory results, chest X-ray examination, treatment options, and the severity of symptoms were evaluated. In addition, bivariate data analysis was carried out using the SPSS device. RESULTS: Out of 114 research subjects, seven patients (6.1%) died, and 107 patients (93.9%) survived. The risk of mortality was significantly (P < 0.05) related to patients' age, duration of hospitalization, gestational age, severity rate of covid-19, the level of hemoglobin, leukocyte count, platelet count, lymphocytes, the levels of D-dimer, C-reactive protein, transaminase enzymes, urea, creatinine, eGFR, sodium, potassium, and procalcitonin. In addition, significant differences (P < 0.05) related to maternal mortality rate were also shown in the presence of comorbidities (type 2 diabetes, congestive heart failure, coronary artery disease/acute coronary syndrome, and urinary tract infection), and the use of steroids and tocilizumab. CONCLUSION: Various factors significantly related to the mortality rate of pregnant women with covid-19. This study may become the basis for a further study with a larger number of subjects, adjustment of assessment and management of covid-19 infected pregnant women, thus hopefully reducing the risk of mortality in pregnant women with covid-19.

Rectovaginal fistula as a complication of rectal injury during vaginal reconstructive surgery: A case report.

INTRODUCTION AND IMPORTANCE: Rectovaginal fistula is a complication that may occur due to rectal injury during vaginal reconstructive surgery. To prevent these complications, the recognition of the injury is an important factor so that primary repair can be done. The primary repair can reduce the risk of complications such as fistula formation, and also reduce the physical and psychological impact on the patient. CASE PRESENTATION: A 33-year-old woman, came with a chief complaint of fecal leakage from the vagina and abdominal pain three months before admission with a history of vaginal reconstructive surgery due to vaginal agenesis. Eleven years after the reconstruction, the patient was diagnosed with recurrent obstruction caused by vaginal synechia. During the surgery of synechia release, rectum injury occurred. Even though primary closure repair was done at that time, several months later there was a complication of rectovaginal fistule formation in the form of fecal leakage from the vagina. The corrective surgery is performed in collaboration with a surgical gastroenterologist. CLINICAL DISCUSSION: Iatrogenic rectal injury may occur during gynecological surgery. A fistula that occurs after the reconstruction of vaginal agenesis is a high-type rectovaginal fistula, making the repairs more complex. Collaboration surgery between surgical gastroenterologist and gynecologist may be an option in such cases. CONCLUSION: Rectovaginal fistula is a rare but serious complication of vaginal reconstructive surgery. Early recognition, immediate management, and postoperative follow-up are essential in cases of rectal injury during vaginal reconstructive surgery.

Translation, Cross-Cultural Adaptation, and Validation of Indonesian Version of Australian Pelvic Floor Questionnaire: An Interviewer-Administered Female Pelvic Floor Questionnaire.

AIM: To adapt and determine the validity and reliability of the Indonesian version of the Australian Pelvic Floor Questionnaire (APFQ). METHODS: The original APFQ was translated and validated to obtain an Indonesian, physician-administered version on 41 urogynecology patients and 41 age-matched women without pelvic floor dysfunction. RESULTS: Missing answers never exceeded 2%. The questionnaire can significantly discriminate between pelvic floor dysfunction patients and those without dysfunctions. The results of each domain of the questionnaire correlated with clinical examinations and another questionnaire. Cronbach's alpha scores of all domains were 0.859 for bladder function, 0.829 for bowel function, 0.892 for prolapse symptoms, and 0.766 for sexual function. CONCLUSION: The Indonesian version of the Australian Pelvic Floor Questionnaire (APFQ) is a valid and reliable questionnaire for assessing pelvic floor symptoms among women in Indonesia.

Satisfactory Outcome of Various Novel Modified Laparoscopic Neovaginoplasty Using Autologous Peritoneal Graft.

Management of vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome patients is by creating functional neovagina through surgical or nonsurgical route. Surgical repair using minimally invasive technique is a favorable option in creating neovagina. In this study, the patients underwent neovaginoplasty. Clinical follow-ups were done at 3, 6, and 12 months postoperatively. The primary outcomes were anatomic and functional successes; anatomical success was defined as a ≥6 cm-long neovagina that allows for easy introduction of two fingers, and functional success was defined with Female Sexual Function Index FSFI-6 questionnaire score above 19. Modified neovaginoplasty using autologous peritoneal graft was performed on the patients (n = 6). Follow-up showed mean vaginal lengths of 8.16 cm, mean surgery time of 175 min, mean blood loss of 59.17 ml, and mean duration of hospital stay of 2 days, with an average FSFI-6 score of 25,2. Therefore, we concluded that laparoscopic approach using modified technique of autologous peritoneal graft provides satisfactory result.

Laparoscopic proximal neovaginoplasty using autologous peritoneal graft to correct short vagina.

INTRODUCTION AND IMPORTANCE: Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare condition characterized by congenital aplasia of the uterus and upper two-third vagina with normal secondary characteristics. Treatment of this condition consists of non-surgical and surgical management. After nonsurgical Frank method, neovaginal canal may be formed but sometimes the vaginal length may not be adequate to facilitate normal sexual intercourse. PRESENTATION OF CASE: A 27-year-old woman, sexually active, complained about the difficulty of sexual intercouse. The patient was diagnosed with vaginal agenesis and uterine dysgenesis with normal secondary sexual characteristics and chromosome (46, XX). The patient has had nonsurgical treatment by Frank method for 6 years and as a result we found a 5 cm-vaginal indentation but she still complaint of pain and discomfort during intercourse. Laparoscopy proximal neovaginoplasty using autologous peritoneal graft was performed to add the proximal vaginal length. DISCUSSION: In our case, the patient may have a short vagina as the result from inadequate Frank method dilatation. This may cause dyspareunia and discomfort to her sexual partner. Therefore, laparoscopic proximal neovaginaplasty and uterine band excision were carried out to correct the anatomical restriction and improve her sexual function. CONCLUSION: Laparoscopic proximal neovaginoplasty is a surgical method to increase proximal vaginal length by using autologous peritoneal graft which shows excellent result. This procedure should be considered in MRKH syndrome patients with unsatisactory nonsurgical treatment result.

Introducing Modified Technique of Combined Vaginal and Laparoscopic Approach for Creation of Neovagina.

INTRODUCTION AND IMPORTANCE: There are many methods described in the literature for creating a functional neovagina. However, the best method has yet to be determined. In our urogynecology training center, neovaginoplasty was usually performed by vaginal approach using modified McIndoe technique with amnion graft and >7 days hospitalization was required. However, we tried to combine both vaginal and laparoscopic modified technique of neovaginoplasty to improve the functional and surgical outcome as well as shortened hospital stay. CASE PRESENTATION: A 27-year-old woman came to our center with a chief complaint of primary amenorrhea and she was diagnosed with vaginal agenesis as part of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. She underwent neovaginaplasty using a combined vaginal and laparoscopic approach with autologous peritoneal graft. Patient was discharged the next day. The follow up result (6-24 months) was excellent with total vaginal length was 8 cm and FSFI score 34.5. CLINICAL DISCUSSION: The use of peritoneal graft using a laparoscopic approach for vaginal reconstruction was chosen in this case after proper counseling with the type of vaginal mucosal lining as the primary consideration. We combined our routine vaginal approach technique with laparoscopic approach to provide an autologous peritoneal graft and considered modifying the technique by extending the peritoneal dissection laterally to facilitate mobilization of the peritoneum to cover the whole surface of neovagina. CONCLUSION: Combined vaginal and laparoscopic modified technique of neovagina creation may present as treatment option for MRKH patients with excellent anatomical and functional result, minimal surgical complication and shorter hospital stay.

Management of recurrent adhesion after vaginal recanalization surgery by using interdigitating Y-flap technique: Case series.

INTRODUCTION: Adhesion is one of complication after vaginal recanalization surgery that occurs due to the free tissue attached during the wound healing process and should be treated carefully. Otherwise, it will become obstruction to the vagina and lead to hematocolpos. The chosen techniques should prevent recurrent adhesion, synechia or stenosis. In this case series, we performed interdigitating Y-flap technique for managing recurrent synechiae post recanalization vaginal surgeries to prevent future stenosis. PRESENTATION OF CASE: The first case was a 16 years old teenager, complained not menstruating and abdominal pain. Patient already had recanalization vagina surgery for correcting distal vaginal agenesis two years ago. After that, patient already had menstruation. There were hematometra, hematocolpos and vaginal adhesion from examination. The second case was a 12 years old teenager, complained having slight blood menstruation after septum excision surgery. From the examination, there was stenosis vagina at 3 cm proximal from hymenal ring. Both patients were treated by interdigitating Y-flap surgery for correcting the synechiae. After follow up treatment, there was no complaint from patients. DISCUSSION: Both patients were having synechia post vaginal recanalization surgery. To prevent recurrent synechiae, we decided to do interdigitating Y-Flap technique for correcting synechiae. With this technique, the scar tissue may not develop contractured scar and narrowing vagina. CONCLUSION: Interdigitating Y-Flap technique may become an option for managing complex recurrent adhesion, synechia or stenosis. This technique is simple, easier and reduces the risk of stenosis in the future with better scar formations.

Case series: Interdigitating "Y" flap for transverse vaginal septum management.

INTRODUCTION: Transverse vaginal septum found in 1/2100 dan 1/72.000 women. The classical management for transvers vaginal septum was septum excision, with risk for vaginal narrowing and vagina shortening after surgery. We reported four cases underwent interdigitating "Y" flap with no vaginal narrowing or shortening after procedure as alternative surgical technique for better result. PRESENTATION OF CASE: The transverse vaginal septums were right behind hymen to 5 cm proximal from hymen (low to mid location). The post-operative evaluation up to eleven months after surgery found no vaginal narrowing or vaginal shortening. A Case with haematosalphing was re-evaluated one month after surgery and found that the haematosalphing has been resolved and no recurrency on 10 months after surgery. Another case with bigger haematosalphing underwent laparotomy salphingostomy concomitantly with "Y" flap procedure and on 11 months evaluation found no recurrent haematosalphing. DISCUSSION: As the septum was relatively thick and composed of 2 embryonic origins, dividing them into distal flaps and proximal flaps was possible. Interdigitating "Y" flap technique offer better preservation in vaginal length and less constricture as the technique spread the tissue tension evenly. Cases with haematosalphings implies that adequate drainage through vagina help evacuate the haematosalphing and prevent recurrency. However longer-term evaluation shall be performed. CONCLUSION: Interdigitating "Y" Flap offers satisfying outcome besides short hospital stay (less intra operative bleeding, no need for postoperative vaginal dilatation, preserved vaginal length and vaginal caliber).

Vulvar-vaginal reconstruction surgery for sexual function in patient with disorders of sex development.

INTRODUCTION AND IMPORTANCE: Amenorrhea can be a transient, intermittent, or permanent condition reflecting the overall health condition of a woman. Primary amenorrhea and ambiguous genitalia appearance warrant more comprehensive diagnosis and treatment, especially in those planning to have a married life. CASE PRESENTATION: A case a 24 years old woman was referred to our hospital with a chief complaint of primary amenorrhea. Previously, she was diagnosed with vaginal agenesis. However, a thorough examination revealed ambiguous genitalia and karyotype result of 46, XY. Following several rounds of discussion with the patient, her family, and her partner, she chose to remain a female and even planned to be married following the treatments. A vaginoplasty followed by clitoral reduction was done with a satisfactory result. CLINICAL DISCUSSION: Disorders of sex development and differentiation is a rare but devastating condition. Various biological, psychological, and social issues are surrounding those affected by it. The burden was further aggravated for those who are late to discover their condition, especially those planning to be married. CONCLUSION: Comprehensive and multidisciplinary approaches are needed to ensure the best outcome for DSD patients.

A case report: Common channel anomaly with vaginal agenesis and rectal stone after posterior sagittal anorectoplasty (PSARP).

INTRODUCTION AND IMPORTANCE: We reported a case of common channel anomaly complicated with vaginal agenesis and rectal stone, which is a long-term complication of PSARP, a combination of very rare conditions with high morbidity and especially difficult treatment. PRESENTATION OF CASE: A 15-year-old female presented with a chief complaint of cyclic abdominal pain. The patient had no history of menstruation before. Physical examination showed a common channel. The diameter of the common channel was approximately 1 cm and 0.3 cm in length. A sound (±2 mm thickness) was inserted to the small opening between the urethra and anal mucosa with the length of the canal 6 cm. At the end of the opening, a stone-like structure was felt. The management of this case was abdominal hysterectomy with right salpingectomy and stone evacuation. DISCUSSION: Cloacal malformation is thought to be associated with vaginal agenesis since both malformations are considered to have a similar pathophysiologic background. Treatment can be performed using posterior sagittal combined with laparotomy approach. After surgery, patients will need a long-term follow-up since the conditions may be associated with many possible urologic and gynecologic comorbidities, including recurrent urinary tract infections, hematosalpinx, and vesicourethral reflux, including stone formation. CONCLUSION: Our case was considered one of the most complex common channel anomalies because it was complicated with a rare condition called vaginal agenesis and rectal stone after PSARP. A multidiscipline approach was necessary.