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Case Reports 95 r- CASE REPORTS 95 CASE REPORTS Past & family history were not contributory. General physical examination revealed no abnor­ mality. On abdominal examination- abdomen was overdistended, presenting part could not be made out, however there was suspicion of breech ABilA SINGH • NEERJA SETIII presentation. Fetal heart was not localised, mod­ erate uterine contractions were present. On per NEERA AGARWAL • K MISRA vaginum examination- cervix was fully effaced and 5 em dilated, soft irregular presenting part INTRODUCTION was felt high up at brim and liquor was blood 1 / Sacroccocygeal teratoma is a potentially stained. 2 2 hours later the patient delivered a 28 malignant congenital tumour. The incidence re­ weeks size still born female fetus weighing 850 ported in India is 1 in 30,000-40,000 live births. grns by breech. There was no PPH. Placenta These tumours present either as obstructed labour or dystocia. The case is reported because of its rare occurence. CASE REPORT Mrs. K. 22 year old unhooked, primigravida was admitted to G.T.B. Hospital with 7 months amenorrhoea and labour pains for 3 hours. Her antenatal period was uneventfull with no history of drug intake. Menstrual Cycles were regular. 'Dtpt. of 06Jt<t antf qynu, antf 'Patfw. ~cctp tttf for 'Pu6lication on 2216/ 91 fig. 1 96 JOURNAL OF OBSTETRICS AND GYNAECOLOGY weighed 120 gm. There was no gmss abnormal­ AIIMS as she was Rb -ve. She bad a diagnostic ity detected in the placenta. laparoscopy one year back at a private hospital Examination of the fetus showed a bilobed where a bicornuate uterus was diagnosed and massofl5x 17 cmarisingfromtbesacrococcygeal excision of complete longitudinal vaginal sep­ region with partial rupture of one lobe, cut tum was done. surface showed solid and cystic areas. Micro­ On investigation, ICT was negative. Ultra­ scopic examination of this mass revealed mature sound showed a single viable fetus with meningo­ and immature neural tissue, other elements like myelocele, neural tissue was seen in the sac. The cartilage, bone, skin, intestinal epithelium and ventricles were dilated. Both kidneys were nor­ respiratory epithelium were also evident in this mal and rest of the spine was normal. section (Fig. 1.) The pregnancy was terminated with PGF2 Histopathological examination proved the (I.M.) The placenta did not separate for half an diagnosis of Terdtoma. hour after the fetus was expelled, so an oxytocin drip was started and manual removal of the placenta was tried under G.A. Complete Pla­ centa accreta was diagnosed but there was no uterine abnormality. The placenta could not be removed so the umbilical cord was cut short and the placenta was left in situ. A 5% dextrose LV. drip containing 10 i.u. oxytocin was run, blood was arranged and the patient was observed care­ fully for postpartum haemorrhage. Consent for DEKA DIPIKA • BucKSIIEE KAMAL hysterectomy was taken. The patient was put on broad spectrum i.v. antibiotics gentamycin, • MrrrAL SUNITA cloxacillin and metronidazole. The patient was then given a course of Hysterectomy bas been and is the safest methotrexate 50 mg I.V. x 4 doses alternating recommended method of treatment for placenta with lnj. Leucoverin. accreta. Attempt.<> at uterine conservation in pa­ She did not have P.P.H. and the post deliv­ tients desiring fertility bas been fraught with ery period was uneventful. A check curettage serious risks of infection and haemorrhage, and was done after 10 days by which time the uterus the ultimate need for an emergency hysterectomy had involuted. Histoatbology report showed that as a life-saving proceudre. A case of placenta the material was scant and consisted mainly of accreta in a primigravida bas been successfully necrotic and inOanuned debris. A few small managed conservatively with methotrexate fragments of secretory endometrium were therapy. Methotrexate therapy for conservation present. of the uterus is recommended in cases of morbid The patient was discharged 14 days after adhesions of the placenta. delivery. On follow up- she bad very scanty, regular CASE REPORT periods and hysteroscopy was pia nned to rule out Mrs. P.S., 27 years a resident of Delhi G2 intra-uterine adhesions. But the patient con­ P +0+ 1 was referred on 1.8.88 at 24 weeks to 0 ceived and is now 6 weeks pregnant- proving her fertility. 'Dept. of 06stet Ani fjyntc, fif. ./ . J.'.lt(.J . ~UI 'Dclfli Jl.cceptel for Pu6f~tJtio n on 4110/ 91 CASE REPORTS 97 SYNOPSIS the saying that most grave injury is caused by Methotrexate therapy bas been used suc­ overentbusiasm & over confidence. cessfully for conservation oftbe uterus in a case Mrs. D.P. ~4 years para 1+1 was admitted of placenta accreta. on 28.8.89 with history of M.T.P. for 8 wks pregnancy on 18.7.89 bleeding per vagina per­ sisted and D & E was again performed on 18.8.89.' following second D & E she experi­ enced excruciating pain in abdomen and she attended gynaecological O.P.D. Her general condition indicated signs of internal hemorrhage so uterine perforation was suspected and diag­ RATNA SANYAL • KALYANSRI MUKHERJEE nostic laparoscopy was decided upon. Laparascopy was performed by P.G. but be KALYANI MUKHERJEE failed toentertbe peritoneal cavity meantime the patient collapsed, laparotomy was performed. Five perforations were detected in the uterus. CASE REPORT Two big cresentic boles with sharp margin were Uterine perforation is not infrequently met detected on posterior surface which were bleed­ with following uterine evacuation commonly D ing profusely; these injuries were caused by &E. Uterine perforation isalsocaused occasion­ trocar during laparoscopy. Three other small ally by vaginal manipulation during laparoscopy. boles were noted near lateral margins. These Injury to the uterus by trocar is however a rare showed lacerated margins and these were closed occurence. We found one such case of multiple with clotted blood, there were no fresh bleeding. uterine injury caused by trocarduringdiagnostic Considering the site, size and number of injuries Japarospic procedure in a case of 18 Wk size total abdominal bystererectomy was performed. uterus perforated by D&E. The procedure was The patient received two units of blood and she performed by a resident who was so confident bad uneventful recovery. that be made two rents by deliberate effort to overcome resistance which be thought was of­ fered hy the rel·tus sheath. This will remind us of NEERA SETifl • NEERJA GoEL NEERA AGARWAL :fiJ. sfwws S pcrjoratwns, 2 6!ff on post suifaa oozing from margin is cause/ 6y trocar J sma{( on latera( margins arc INTRODUCTION cause/ 6 y 'lJ&'£. Uterine rupture is rarely encountered in 'Dept. of 06stct ani qyncc, !4 .1./.!M.s . !f(Jw '!Jcf!U early pregnancy. Incidence of rupture in cases of !4cccptci for Pu6fication on 4/ 10191 98 JOURNAL OF OBSTEfRICS AND GYNAECOLOGY second trimester M.T.P. is reported to be 0.8/ fossa. PN - Os 2 ems. Uterine size 12 weeks 100.000 (Biale & Lewenthal). Sixteen such cases (reduced) firm and tender mass felt through left could be reviewed in literature since the fornix with the suspicion of rupture, laparotomy legalisation of M.T.P. The first case of rupture was done. uterus, following Emcredyl instillation is being Per operative : There was a haemotoma (8 x 8 reported. ems size) in the left broad ligament, fetus and placenta lying in it. A vertical tearof6cms along , CASE REPORT the lateral wall of uterus extending from the Mrs G, 30 years old, 6th gravida reported to attachment of ovarian ligament to isthmic region GTBH on 21-9-89 with 16 weeks pregnancy for was present. Hysterectomy with left adnexectomy MTP and Iiga tion. She had 4, ITND at home and was done, patient received 3 units of blood one spontaneous abortion 1 year ago during during surgery. Post operative period remained which she had instrumentation by a dai for uneventful and she was discharged on 9th post removing products of conception, Her menstrual operative day. cycles were normal. Past and family history not contributory. ON EXAMINATION -<i~neral physical & systemic examination re­ vealed no abnormality. Per/abdomen- Height of uterus 16 weeks, external ballotment + LEENA v. DESHMUKH PN Cervical os closed, uterus A V SHASHANK V. PARUUlKAR 16-18 weeks size, soft, forni- ces free. A~er taking consent and routine investigations CASE REPORT 150 cc of Emcredyl solution was instilled in the Mrs. A.P., a 31 years old woman, second extra-amniotic space through No. 14 Foley's gravida first para with 4 months of amenorrhoea catheter on 22-9-89 at 10 AM . There was no was referred to us for the management of cervical leaking or bleeding P/v during the procedure. incompetence. She had been diagnosed to have a Catheter was removed after6 hours and 10 units single uterus with a single cavity and a complete of syntocinon drip was started. Gradually the longitudinal septum with one cervix on either dose and rate of syntocinon was increased upto side of the septum. The refering gynaecologist 30 units. Patient started getting uterine contrac­ had put MacDonald' cerclage with No.2 black tions after8 hours ofsyntocinon drip and after24 braided silk on the right cervix for its painless hours repeat p/v examination revealed Os 2 ems dilatation to 2 em and effacement to 30%. One dilated products of conception tipped through week later he had noticed dilatation and efface­ os, fornices free. Patient continued to have mild ment of the cervix on the left side, for which he to moderate uterine contractions but did not referred her to us. abort. After 36 hours she was re-evaluated and Her general condition was fair and vital was found to be febrile (Temp.
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