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
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 - 'Dtpt. of 06st. t!f' qy11uc. q'T'JJ ~osplttd. SliaMarts, 'Dept. of 06Jt. t!f' qynuc. ?(.'E..!M. 1fospittd. '1Jom6ay 'Dtlli.l. Jtcuptel for Pu61kation on 2517/ !Jl Jtcupttl for 'Pu6lkatlo11 011 2016/ !Jl CASE REPORTS 99 1 / amination revealed no abnormality. The uterus routine checkup on 16.07.90 with 6 2 months was en Ia rged to the size of 16 weeks of gestation amenorrhoea. Sonograpby done on the same day and was relaxed. There was a longitudinal vagi showed the fetal bladder size to be 2.8 ems and nal septum from the introitus upto5 mm from the the fetus was of 27 weeks gestation. She was cervix. There was a single cervix, the right half followed up weekly and sonograpbic studies on of which bad been subjected to cerclage, the 30.07.90 revealed an increase in the size of suture passing through the top of the septum as bladder to 4.2 ems. There were early well. The membrances were bulging through the hydronephrotic changes in the kidneys with the lefthalfoftbecervix, which was 3 em dilated and presence of bilateral bydroureters. There was 40% effaced. After investigations for fitness for associated oligo-hydramnios. Hence a diagnosis anesthesia and ultrasonograpbicconfirmation of of posterior urethral valve obstruction was ar viability of the fetus and location of the placenta rived at and a decision to pedorm suprapublic in the upper segment, we performed MacDonald's fetal catheterization under sonograpbic control cerclage on the left half of the cervix, taking care was taken. The intention was to reduce the to pass beyond the limits of the initial cerclage. backpressure on the kidneys. The patient was given isoxsuprine hydrochlo ride, progesterone and cloxacillin postopera Procedure tively. Two days after the operation she started The point of entry of the needle was marked bleeding vaginally and it was found thattbe right out on the maternal abdomen after locating the side cerclage bad cut through the cervix. Both the site of fetal bladder by sonograpby. Under strict ·cerclages were cut off. The patient aborted com- aseptic conditions, the mother's abdominal wall pletely. The vaginal septum was excised after 6 was infiltrated with local anaesthetic at the point weeks. The patient made an uneventful recovery. marked out earlier. A long 12 G needle was We have advised her an elective cerclage of the guided into the fetal bladder under sonograpbic cervix in her next pregnancy. control. The fetal urine was aspirated which caused the bladder to collapse completely. Due to non-availability of Harrison's double pig tailed fetal bladder catheter, a no. 5 infant feeding tube about7 inches in length was fed into the bladder through the needle. About 3.5 inches of the tube was in the fetal bladder while the rest of the tube was left in the amniotic cavity simultaneously withdrawing the needle. The patient was put on antibiotics for a period of 5 days after the procedure and uterine relaxants. C.N. PURANDARE e S.J. NADKARNI The patient was followed up every week with ultrasound and there was no appreciable G. WARRIER increase in the size of the bladder noted. On 19.08.90 she presented at 4.00 am with PROM and had to be taken up for LSCS. The CASE REPORT baby when delivered, showed the catheter insitu Mrs. M. , 28 years, P1G2 presented for and draining well. The growth of the baby corresponded to 32 weeks of gestation (2.2 kg) and no other apparent congenital anomalies were 'Dept. of 06s. & t;yn., J.J. "ospital, '1Jom6ay J4cuptttf for 'Pu6fuation on 2617191 present. All biochemical parameters were within 100 JOURNAL OF OBSTETRICS AND GYNAECOLOGY normal limits. The baby underwent fulguration haemoglobin was 5.0 gm% at the time of admis of the posterior urethral valve, followed by sion. She was given 9 units of blood and ener suprapublic vesicostomy by the paediatric sur getic treatment. The gastric aspirate usually geon. Due to prematurity the baby needed incu ranged between 6 to 7 litres daily and fever bator care. continued. Abdominal tap revealed haemorrhagic Post-delivery 3 weeks follow up showed fluid which was sent for cytology and the report that the child was on breast feeds and under was inconclusive. After one week of conserva special paediatric care. tive treatment her distension was relieved and she started passing stool and flatus normally. A central mass arising out of the pelvis, finn in consistency with smooth surface was now pal pable in the suprapublic region. and the ultra sound examination revealed abdominal preg nancy. On 25.03.87 laparotomy was done, the gut was found adherent to a mass which consisted mostly of old blood clots and organised placenta and a dead foetus. The uterus was normal sized, M.K. BRAR e A.S. SAINI there were extensive adhesions on both tubes and ovaries which were carefully separated. Post operative period was uneventful. It was an un Clinical features of abdominal pregnancy usual case of secondary abdominal pregnancy may simulate an ovarian cyst, pelvic abscess, presenting as an acute intestinal obstruction. myoma or bladder tumour etc. The present case report is about a very odd presentation of such an entity not reported in the literature so far. CASE REPORT Mrs. S.K., admission No. 315,35 years,para 2 was admitted in Guru Ramdass Hospital, Amritsar on 16.03.1987 in an extremely emaci ated condition with enormous distension of ab domen associated with ascites. There was no RA1EsH PARIKH • SumiA GARG historyofamenorrhoea.Shecomplainedofspon R KEERTIIY SUNDER taneous, painless irregular bleeding for the last two months, accompa ined by repeated attacks of pain in abdomen, vomiting, diarrhoea and ir INTRODUCTION regular fever ranging between 100- 102°F. She An unusual case with very stypical presen was treated outside as a case of gastro-enteritis tation is described. Search of the literature con but her condition deteriorated and hence she was firms its rare occurance. In Indian Literature no referred to this hospital. On PN examination such case has been'described to our knowledge. there was fullness in the fornices. Her 'Dept. of 06st. & t;yuu. !ltltiiuu colkge, Jtmrit.uv 'Dept. of 06st. & t;ynacc. St/JU Zenana :Hospital, Jaipur Jtcuptttl for '1'u6ficatlo11 011 25171!11 Jtcuptcl for 'Pu6ficatio11 011 25171!11 100 JOURNAL OF OBSTETRICS AND GYNAECOLOGY nonnallimits. The baby underwent fulguration haemoglobin was 5.0 gm% at the time of admis of the posterior urethral valve, followed by sion. She was given 9 units of blood and ener suprapublic vesicostomy by the paediatric sur getic treatment. The gastric aspirate usually geon. Due to prematurity the baby needed incu ranged between 6 to 7 litres daily and fever bator care. continued. Abdominal tap revealed haemorrhagic Post-delivery 3 weeks follow up showed fluid which was sent for cytology and the report that the child was on breast feeds and under was inconclusive. After one week of conserva special paediatric care. tive treatment her distension was relieved and she started passing stool and flatus normally. A central mass arising out of the pelvis, finn in consistency with smooth surface was now pal pable in the suprapublic region. and the ultra sound examination revealed abdominal preg nancy. On 25.03.87 laparotomy was done, the gut was found adherent to a mass which consisted mostly of old blood clots and organised placenta M.K. BRAR e A.S. SAINI and a dead foetus. The uterus was normal sized, there were extensive adhesions on both tubes and ovaries which were carefully separated. Post operative period was uneventful. It was an un Clinical features of abdominal pregnancy usual case of secondary abdominal pregnancy may simulate an ovarian cyst, pelvic abscess, presenting as an acute intestinal obstruction. myoma or bladder tumour etc. The present case report is about a very odd presentation of such an entity not reported in the literature so far. CASE REPORT Mrs. S.K., admission No. 315,35 years,para 2 was admitted in Guru Ramdass Hospital, Amritsar on 16.03.1987 in an extremely emaci ated condition with enormous distension of ab domen associated with ascites. There was no RA1EsH PARIKH • SumiA GARG historyofamenorrhoea.Shecomplainedofspon R KEERTIIY SUNDER taneous, painless irregular bleeding for the last two months, accompa ined by repeated attacks of pain in abdomen, vomiting, diarrhoea and ir INTRODUCTION regular fever ranging between 100- 102°F. She An unusual case with very stypical presen was treated outside as a case of gastro-enteritis tation is described. Search of the literature con but her condition deteriorated and hence she was firms its rare occurance. In Indian Literature no referred to this hospital. On PN examination such case has been'described to our knowledge. there was fullness in the fornices. Her 'Dept . of 06st. & t;yuu. 9¥ltlir.al Cofkgt, l'.mritsar 'Dept. of 06st. & t;ynacc. SttzU Zenana :Hospital, Jaipur l'.cuptttl for 1'u6ficatlon 011 2517191 l'.cuptcl for 'Pu61ication on 2517191 CASE REPORTS 101 CASE REPORT uterine segment. Separation done with diffi Patient'S', 35 years old, a grand multipara culty. came to the emergency room of the State Zenana Supracervical Hysterectomy of the ruptured Hospital, SMS Medical College, Jaipur on 19th Right horn was carried out. Left horn was also September 1990 with the complaints of continu well developed. Tubal ligation by pomeroy's. 1 / ous bleeding PV- 1 2 months, Pain in abdomen method done on Left tube. Abdomen closed back off and on 1 month, loss of fetal movements- 5 after adequeate peritoneal toilet and a drain was days with an amenorrhea of 9 months duration. put in. It was removed on 3rd post-op. day. She She was referred from a district hospital after was transfused with 1 Unit blood and made a being treated for 5 days. No H/0 any fall or smooth post operative recovery. direct trauma to the abdomen obtained. Her obstetric history was of 7 FIND ( all home deliveries) 6 alive and healthy , 1 died due to medical illness, with last delivery 2 1/2 years ago. Examination revealed her to be morbid looking, pale and of moderate build with vital parameters well settled. On P/A examination there was generalized distension with slight muscle guarding. A firm mass arising from the pelvis and upto 3" above the umblicus was fiiRALAL KONAR .palpable. No fetal parts could be palpated. FHS P SARKAR not audible over the mass. Bowel sounds occa- sional. Pelvic examination showed that external INTRODUCTION os was patulous, Internal os closed, Cervix firm Angiomatous tumours of the placenta are in consistency,uneffected, uterus was not made mostly hamartoma in nature. Various sizes have out separately from the mass. Slight bleeding been diagnosed but a big size is rare to find. The with foul smelling discharge present. overall incidence has been reported about 1%. Investigations: Hb- 7 gm%, BT- 2 Mts. CT 2 While the small growths are asymptomatic, the Mts 50 Sec. large tumours maybe associated with hydramnios CR - 25 Mts. or antepartum haemerrhage. Fetal death or mal Ultrasound : Fetal parts visualised. formation are uncommon complica lions although No measurements could be taken there may be a positive correlation with birth FHP - Absent, Fetal movement - weight. Large lesions provide an arteriovenous Absent, Placenta post. grade - Ill. shunt in the fetal circulation that can lead to heart Provisional Diagnosis: Silent Rupture of Uterus. failure with all of its complication. Here is the Under full broad spectrum antibiotic cover, report of a case that had big size ( 7 em x 4 em) laparotomy was undertaken. On entering, the angiomatous lesion. peritoneal cavity, foul smelling pus was filling the abdomen. Right Horn of the Uterus Bicornis CASE REPORT Unicollis (TOTAL) was ruptured at the fundus. Mrs. K.S., a 21 year old woman was admit An old macerated dead Female Child was lying ted on 20.XI.90 with the problem of uncon half extruded out in the peritoneal cavity through trolled P.I.H. Her previous menstrual cycles the rent. Same removed. No active bleeding was 'Dept. of 06st. & (jyna.u. 9(.'1{,S . !Metficaf Cofkge present. Placenta removed from the post. wall of 9fospita.{. Calcutta. the uterus. Bladder was adherent to the lower 54cccptcl for Pu6lir.a.tion on 2517191 102 JOURNAL OF OBSTETRICS AND GYNAECOLOGY were regular. L.M.P. on 23.2.90 making her E.D.C. on 30.11.90. Her initial pre-natal check up reports were nonnal only lately she developed pedal oedema a_nd raised blood pressure (140/96 - 150/100 m.m. of Hg). Examination showed Term size pregnant uterus, Jonigtudinallie, ce phalic presentation (free), adequate liquor and NAYs. KANBUR • TARA BIRLA F.R.S. + Reg. Her investigation reports : Hb - 10.8 gm% T.L.C., D.L.C. within normal lim CASE REPORT its, Blood group '0' Rh + ve ; V.D.R.L. - Mrs. P., 20 year old Gl0A0 15 days away nonreactive, Urea,uric acid, creaitnine levels from her due date, was admitted to the hospital were within normal range, Urine : Routine, with severe pain in the lower abdomen, lasting microscopic and culture reports revealed no about four hours. Her antenatal checks were abnormality. She went into spontaneous labour regular and normal. On admission, her vital on 25th Nov. 90. But labour process was termi parameters were as follows : Pulse - 120/min., nated by caesarean section becauseofunsatisfac B.P. - 110.180 mm of Hg., Per Abdomen - tory progress and raised blood pressure. It was a Uterus was at full term with a single live preg live born female baby weighing 2.9 kg and it nancy with cephalic presentation and a good cried immediately after birth. foetal heart rate. Head was floating with good Examination of placenta : Diameter 14 pattern P.V. - os was 2cm. open. A clinical l:a!. At one pla~e there was a swelling consisting diagnosis of C.P.D. was made and the patient of soft reddish tissue (7 em x 4cm) that could be was submitted to an emergency Caesarean sec easily marked out from the rest of the placenta. tion. Under spinal anaesthesia the abdomen was Histopatholigical report confirmed opened via a vertical midline subumbilical inci chorioangioma of the placenta. sion. On opening the peritoneum, 200ccs. of pus Postoperative period was uneventful: She gushed outofthe incision. The pus was promptly was discharged with her baby well on 2.XII.90. mopped after isolation and a healthy 3.0lkg. Her follow up visit was satisfactory. female child was delivered. The abdomen was later explored for the source of pus. There was perforation of the appendix with a gangrenous tip, lying pelvic in position. The caecum was oedematous. A surgeon was called in and appen dectomy done. Generous peritoneal lavage with Beta dine (diluted Povidone Iodine) in Saline was given and a corrugated drain left in the pelvis. Post operatively, despite receiving high an tibiotics, patient had fever with chills, on the 9th P.O. day. Abdomen was soft and patient on a full diet. Ultrasound of the pelvis showed collection in the uterus. Under a general anaesthetic the cervix was dilated, releasing 100ccs. of pus. Patient settled clinically and was discharged on the 13th P.O. day after uneventful recovery. Jtccepttl for Pu6fication on 6/12191 CASE REPORTS 103 Post operatively periostonel dressing with zinc oxide and routine care of colostomy was done. Main (C.S.) wound was dressed once only on 4th post operative day. Stitches were removed on 9th day. C.S. wound had healed well. Surgical opinion on the matter advised a loopogram which confirmed the diagnosis and level of uncanalisation. Abdominoperineal pull through was planned in second stage and closure of loop colostomy at third stage- all of those at least six months after the C.S. PANKAJ DESAI • PARESII BRAIIMBIIATI Patient was duly discharged with a live healthy baby and is being regularly followed up. MAuNJ DESAI CASE REPORT Mrs. MMU, 20 years old female Glo pre sented to our labour room on 22.1.91 with pregnancy full term and labour pains- more than 12 hours. No history of leaking or bleeding per vaginum. Patient bad a Left pelvic colostomy on anterior abdominal wall. She had this function ing colostomy from one month of her age, which was done for high imperforate anus. Attempts of anal restoration bad reportedly failed. MURAllDHAR V. PAl • PRATAP KUMAR Her vital signs were normal. Per abdomen H P ANAND obstetric examination revealed a full term uterus, LOA-Head 4/5th palpable, FHS present, regular - 144/mt, uterine contractions one or two, lasting INTRODUCTION for20secs. recurring every seven to ten minutes. Congenital cervical atresia is a rare entity, Per vaginum examination revealed a 5 ems di less than fifty cases have been reported in the lated cervix, more than 75% effaced, presenting literature. Why the cervix alone would undergo part-vertex not well applied to cervix, station : atretic change remains unknown. Surgical recon high at brim. Though the bony pelvis seemed struction may restore fertility and the perception adequate, the thickly fibrosed firm anal canal of health but hysterectomy remains the definitive effectively reduced the pelvic diameters to pro therapeutic modality as reconstructive proce duce a nonprogression of labour. dures described in the literature have generally In view of this situation, patient was taken been disappointing (Jacob & Graffin 1989) up for caesarean section. C.S. was done by a subumbilical vertical midline incision. There CASE REPORT was no intra-operative difficulty. She delivered Twenty six year old Mrs. Rathna was re- a live male child of2500 gms weight. 'Dtpt. of 06Jt. & (jynacc. '.Mttfica{ Cofkgc, & S.S.(j. 'Dept. of 06Jt. & (jynau. 'l(D.Jtur6a '.Mdica{ Cofkgt, :HoJpita{, 'Barola '.Manipaf J4cccptcl for Pu6fication on 6/12191 J4cctptcl for Pu6lication on 28/8191 - 104 JOURNAL OF OBSTETRICS AND GYNAECOLOGY ferred to us for the investigation of primary infertility and amenorrhoea. But for cyclical abdominal pain of five to six years duration, she had no medical or surgical problem. Her two sisters attained menarche at the age of fifteen. She was poorly built and nourished. How ever there was no somatic abnonuality. Second ary sex charecters were well developed. Breast and thyroid were normal. No palpable pathology MANEsH H SHAH was detected per abdomen. She had normal S!WIANK v PARULEKAR external genitalia and a rugose vagina that ended in a blind pouch superiorly without defects or openings. On bimanual examination under gen INTRODUCTION eral anaesthesia, a small mass was felt which Clinical Data Presentation :Two cases treated represented the uterine corpus and rudimentary for this anomaly at the KEM Hospital Bombay cervix. There was a cyst ( 5 x 6 ems) in the left have been presented with the objective of illus • fornix. trating how attempts at conservative manage Ultrdsonography showed no shadow of cer ment proved futile. vix, kidneys were normal. Diagnostic lapa roscopy revealed a normal uterus, right ovary and tube. CASE REPORT 1 There was a chocolate l"yst (5 x 7 ems) on the left Miss S.P., a 16 year old presented with side and left tube was adherent to the ovary. primary amenorrhoea and acute exacerbation of Diagnosis of isolated congenital cervical chronic abdominal pain. Examination revealed a atresia with endometriosis, presenting quite late, transverse vaginal septum with a 14 weeks sized as a case of primary amenorrhoea and infertility mass above. Ultrasonography revealed was made and reported because of its rarity. hematometra and hematosalpinx. Laparoscopy showed a bicornuate uterus with a rudimentary left born and a distended right born and hematosalpinx. The septum was excised vagi nally. No cervix could be found hence a utero vaginal anastomasis was carried out after drain ing the baematometra. Patency was maintained with the help of special manual dilatations done repetetively daily, with strict aseptic precau tions. She was discharged. 2 weeks later she came back with high fever. On examination the tract had closed. It was opened surgically and a collection of pus drained. Laparoscopy done simultaneously revealed pus in the pelvic cavity. Laparotomy was carried out and a right side pyosalpinx was excised. A Malecot's catheter was placed vaginally into the uterine cavity to 'Dept. of 06st. & (jyntu:c. 'l(.'E. .!M. ?lospital, '1Jom6ay f4cceptttf for Pu6fication on 22/6/91 CASE REPORTS 105 facilitate drainage and maintain patency of the with nom1al ovaries. Laparoscopy confirmed the stoma . This was replaced after a week by a Foley above findings. The septum was dissected vagi catheter. A special mould was made for stomal nally: no cervix could be found. Per abdominally patency. However the patient continued to have an anterior hysterotomy was done and a sound high fever and a decision to perform hysterec passed through os. Tissue over the sound was tomy was taken. She underwent an abdominal excised and an utero-vaginal anastomasis was operation and had an uneventful convalescence. done. The uterine incision was then closed. A foley catheter was placed subsequently devel CASE REPORT 2 oped high grade pyrexia and a pelvic abscess was Miss A.R., a 16 year old presented with detected. A total abdominal hysterectomy with primary amenorrhoea. Examination revealed drainage of the collection was then carried out. nom1al external genitalia and secondary sexual characteristics. There was a transverse vaginal septum at a depth of 1.6cm from the introitus. Ultrasonography showed a small hematometra 106 JOURNAL OF OBSTETRICS AND GYNAECOLOGY local examination urethra was normal in position and the vaginal orifice.was replaced by a dimple at the introitus. Per rectally a mass correspond ing to 6 weeks pregnant uterus size was felt high up on left side. INVESTIGATIONS Patient was positive for sex cbromation on NEERA AGARWAL buccal smear. Her urine examination, haemoglobin and blood urea were within normal RENU M!SIIRA limits. A skeletal survey showed bone age of 16 years with hypoplastic C vertebra and congeni INTRODUCTION 1 Association of Skeletal deformities with tal fusion of c6 & c7 vertebrae. Mullerian agenesis is well known but occurence On ultrasonography a bypoecboic mass was of Klippel Feil deformity in these cases is rare. seen on feftside of the pelvis. Cervix and vagina In 1912 Klippel and Feil described a syndrome couldn't be made out. Both ovaries and kidneys characterised by rare congenital malformation of were normal. cervical vertbrae namely congenital fusion of Diagnostic laparoscopy revealed bipartite two or more cervical vertabrae or hemivertebrae uterus with wide separation of both the horns. manifested by shortening of neck and limitation Right born was rudimentary while on left side of movement. Occasionally this syndrome coex there was baematometra and baematosalpinx. ists with Sprengel's defom1ity of shoulder. Right ovary was normal, left ovary could not be The present case of partial Mullerian a gens is visualised. Abdomino-perineal exploration con is reported here because of its rare association firmed a bipartite uterus and absence of cervix. with Klippel Feil syndrome and Sprengel's de Right born of uterus was rudimentary while left formity. born was functional as revealed by baematometra and baematosapinx on that side. Both ovaries CASE REPORT were normal. Both the horns of uterus were A 16 year old girl reported to the gynae OPD excised followed by Mcindoe vaginoplasty. Pa with cyclical pain in the abdomen for the past one tient bad an adequate length of vagina on follow year. She had not yet attained menarche. up at 6 months. Adenarche and thelarche were at 12 & 13 years respectively. There was no family history of similar disorder. On examination she was of average intelli gence and thin built. Her height was 154 em., arm span 142 em and weight 32 kg. Patient bad a short neck with limited cervical movements and high right shoulder because of high placement of scapula. General and systemicexaminations were essentially normal. The growth of breast, axil P. GoGor lary hair and puibc hair conformed to Tanner's stage IV. No mass was felt in the abdomen. On INTRODUCTION Uterus didelpbys with unilateral imperfo 'D 'Dop:. of o6st. & (jynau. qaufi.ati !Mdicaf ColU:gt, 'Dept. of 06st. & qynaoc. !M.(j.l .!M.s., 'Hiartlfi.a Jtcctptttf for Pu6fication on 2517191 Jtcccptd for Pu6{ication on 217/91 108 JOURNAL OF OBSTETRICS AND GYNAECOLOGY Sevagram from P.H.C. as a case of post meno pausal bleeding. Patient gave history of self cutting of a mass protruding through the vagina with the help of a razor blade. She gave history of bleeding profusely following this for which she packed her vagina with mud. She was taken to nearby P .H.C. by her relatives after 3 bours.She was pale but with fair general condition. She gave history of inability to pass urine since the RA.lYASHRI SHARMA • VEENA MAHESIIWARI time ofinjury. Her respiratory and cordiovascular NAHEED R.Izvt • T ARUN GuosH systems and abdominal examination were within normal limits. Mud was seen at vulva and va CASE REPORT gina. It was removed. Loops of intestines and Mrs. R.B., aged 30 years was admitted in urine came out through the vagina. A catheter the Casualty of J.N. Medical College, Aligarh introduced through the urethra came out of cut on 31.8.1990 with the H/0 amenorrhoea and vagina. Cervix was not visualised. lump in abdomen 3 months, acute pain left leg Exploration was done through a midline followed by swelling and inability to walk for J vertical incision. Intraoperatively small size uterus one day. She bad 4 FIND with last delivery 5 with cervix was found intact. Bladder dome was years back. 8 months back she had undergone found cut. open 3 inches. Mud was present in the laparoligation. Thereafter her menstrual cycle peritoneal cavity between the loops of intestines. bad became scanty till it went into amenorrhoea Mesentry of these coils was traumatiscd at many and then she noticed a Jump in abdomen which places. About a foot of non viable part of the gradually attained the present size. On examina small gut was removed and anastomosis done. A tion she was average by built, pulse 94/min. parallel team at the same time carried out total Temp. N., B.P. 120/80 mm Hg. Per abdomen a abdominal hysterectomy. Bladder repair was hard smooth lump was felt arising from the pelvis done in 3 layers. Vesical/pelvic fascia was used upto the umblicus. It's boundaries were well to give support and decrease tension. Ureteric defined, and were mobile from above down openings were intact and away from injury site. wards, but side to side mobility was restricted A malecot's catheter was kept suprapubically due to pain. There was no free fluid. and urethral catheter was also inserted. Abdo On P/V examination, uterus was nom1al, men was closed in layers after thorough perito deviated to right fornix. The same Jump, hard in neal toilet. consistency was felt through anterior and left Post operative recovery was uneventful. fornices. Other systems did not reveal any abnor Patient was discharged on 45th post operative mality. The left calf muscle was hot and tender. day. She was put on conservative management with analgesics, anti-inflammatory and antibiotics Hb. DISCUSSION 8 gm %, TLC 7,800, Urine- NAD, Blood sugar The patient had self inflicted vaginal injugy Random 87 mg %, Blood group B Rh +ve, X with protrusion of intestines and torn bladder out ray chest normal. When her pain in leg subsided, of vagina. Surprisingly her general condition swelling decreased and she was able to walk, remained stable. There are reports of accidents laparotomy was done on 15.9.1990. A solid ovarian tumour ofleft side approximately 16 em like, injury to cystocele while doing waterskiing but such a case of self inflicted injury, we could , 'Dept. of 06st. & {j!ftltUc. J.!f(..'Mttfical Colkge, Jl.ligarf< not get in the available litrature. Jilcceptttf for Pu6lication on 24110191 CA\$E REPORTS 109 in diameter, having smooth outer surface and no adhesions, was removed. Uterus was normal. Right ovary was cystic, 5 em in diameter, a biopsy taken and sent for histopathological ex amination. Abdomen closed in layers. Morphological Changes The left ovarian tumour was solid firm, weighing 2 Kg. measuring 16 x 12 em, well BABOO H.A. e DIXIT S. encapsulated, smooth outer surface, CIS was MAHF..SHWARY G. homogenous white, fasciculated with no areas of cystic degeneration. The fallopian tube showed a CASE REPORT fall ope Ring (Fig. 1). M/E revealcd intersecting A 40 year female was registered in our bundlcs ofspindle cells producingcoll:~gcn which hospital with chief complaints of bleeding per vaginum in June 1979. She had delivered 10 healthy and full term children. On examination an ulceroproliferative growth was found, grow ing to whole of cervix and adjacent fomices. Growth was extending to both pelvic wall. Rou tine investigation, x-ray chest, and intravenous pylography were normal. Histopathology was squamous cell carcinoma grade I. She was staged as III b. She was given external radiotherapy to whole pelvis. Total dose was 45 GY in 20 fractions, followed by Intracavitory radiation of about 35 GY to point ' A' was also given. She was put on routine follow-up, to know the recurrence of Fig. 1. Cut surface of ovarian fibroma disease. She remained disease free upto June showing interlacing bands of dense fibrous tis 1987 (About 8 years), when she developed right sue. supraclavicular node. Biopsy from node was taken and histopathology turned out as lympho stained positive by Van Gieson's stain. cytic predominance Hodgkin's lymphoma. No A diagnosis of Fibroma left ovary was nodes were palpableatothersite. X-raychestand made. The right ovary showed a 3 nun follicular bone marrow was normal. She was treated with cyst and the rest was normal. mantle field radiotherapy, considering stage lA The patient had an uneventful recovery. She Hodgkin's disease. Patient remained without was discharged on 12th day with no difficulty in any disease upto July 1990. walking. Her edema and pain had subsided. Inference : Appearance of supraclavicular node in cases of carcinoma cervix is often consid ered as distant metastasis in patients. In such instances treated with palliative Intent. This is 'Dept. of 06st. & {jynaec. {jujarat Cancer & '1/._esearc/i. Institute, J41imt:ia6ai J4cceptti for Pu6/~ation on 23110191 110 JOURNAL OF OBSTETRICS AND GYNAECOLOZiY also commonly seen in other malignancy, where about 5" diameter was seen to be replacing the appearance of disease at known metastatic site, is left ovary and adherent to omentum and anterior not biopsied and managed as advanced case. surface of uterus and tube: Right tube and ovary Chances of patient having second primary ~ust looked normal. Therefore, after separating the be kept in mind, particularly cases having long adhesions, left salpingo-ovariotomy, wedge re NED duration. section of right ovary and partial omentectomy done. There were no metastases in the peritoneal cavity. Liver was free. C/s waxy yellowish haemorrhagic areas. Post op recovery was un eventful. Histopathology -Left ovary : Mixed germ cell tumour showing differentiation towards embryonal cell carcinoma, yolk sac tumour, mature teratoma with focus of dysgerminoma. Right ovary: Normal. Omental biopsy piece was RAJESH PARIKH • SUDIIA GARG lost in transit and histopath, report was not obtained. Therefore, a multi-drug postop Che R KEERTIIY SUNDER motherapy was planned, but the patient was CASE REPORT 1 taken away against medical advice. She reported Malignant germ cell tumors of ovary are again at Zenana Hospital on 28/12/90. With the rare - 1% ·of all ovarian tumors. Combination complaint of lump in abdomen - 7 days. 0/E germ cell tumors constitute 8% of all malignant General conditionfairwitha well healed scar and germ cell tumors. · two ill-defined masses of3" and 4" size on right A seven year old girl, presenting with pain and middle of abdomen harder than previous lower abdomen and lump abdomen- 2 Mths. was mass, fixed and non-tender. Sonography showed ..... admitted on 22/8/90 at State Zenana Hospital, multi pie dense echo genic masses in abdomen and Jaipur. The pain was intermittent and aching and ·pelvis. Nothing else could be visualized in the the swelling was gradually increasing in size. 0/ pelvis. E her general condition was fair, pall01 was CBC differential and platelet counts -Normal. present, no edema feet, no lymphadenopathy. Diagnosis of recurrence ofthe tumour was made. Systemic examination - NAD. Abdominal ex POMB - ACE chemotherapy Evincristine, amination revealed a solitary and almost a spheri MTX, Bleomycin, Folinic Acid, Cis-Platin, cal swelling with a smooth surface, firm consis Etoposide, Actinomycin - D & Cyclophos tency and free mobility arising from the pelvis phamide was planned and started with firstPOMB and reachingjust below the umbilicus. A'icites course on 1/1!91, followed by next POMB on absent. Rectal exam showed a firm mass arising 16/1/91 and ACE on 1/2/91 alternating POMB from the pelvis. Provisional diagnosis- Ovarian and ACE every 8-14 days. Side effects- nausea, Tumour.Uitrasound exam showed mixed vomiting a·nd alopecia were tolerable. echogenic area of more than 10 em. size. Preop Current status of the patient- General con investigations were within normal limits except dition is fair; CBC, differential and platelets Hb 7 gm% . On laparotomy a grayish white within normal limits P/A no tumour mass felt. yellowencapsulated, hard, multi-lobulated mass On ultrasound exam- no tumour areas seen with normal uterus and right ovary. Facilities for biochemical tumour markers 'Dept. of 06.st. & qynau. Zenana !Ho.spita£. Jaipur J4cccp ttl for Pu6f~ation on 2517191 were not available. CASE REPORTS 111 Further management - We shall continue The biopsy from the growth was sent for with this regimen till the patient has clinical and · histopathology. Hematoxylene eosine staining radiological remission for 12 weeks after which showed small cell carcinoma (Fig. 1). But the she will be restaged again with Cf Scan. exact origin could not be confirmed. Biopsy was Thus this case illustrates two things i) A further processed for immunoperoxidase reac conservative surgery coupled with multi-drug tion with monoclonal antibody to neurone spe postopchemotherapy; ii) the impressive result of cific enclose. This neuroendocrine cell marker POMB -ACE therapy. showed dense coarse cytoplasmic positivity. Hence final diagnosis of small cell carcinoma of the cervix of neuroendocrine type (stage III B) was made. SUVARNA s. KliADILKAR • DATIA PANANDIKAR S.K. G AW HALE • C.N. PuRANDARE K K D ESHMUKH C~()E REPORT Mrs. S.S. a 28 yea rs old housewife was admitted to Sir J.J. Hospital , Bombay on 21.10.89. She complained of foul smelling vagi nal discharge since 1 year, irregular bleeding per vaginumsince 1 year. She had normal menstrual pattern earlier and had 4 full term normal deliv 1 / !fig. 1 /mmunopcrol(iiasc staining of ccrt•&ea{ biopsy. eries. The last delivery was 1 2 years back and had lactational amenorrhoea for 6 months. The patient underwent teletherapy of 4500 R Patient was cachectic and on speculum ex in 20 fractions over28 days. Followup examina amination a large necrotic vascular polypoidal tum after 1 month showed only a small lesion mass was seen obliterating the vagina upto the similar to erosion on cervix. Patient was dis introitus. On per vaginal examination, mass was charged and advised regular follow up. found to be arising from anterior lip of the cervix. Vaginal walls were free from the mass. There were thickening in the fornices reaching lateral pelvic walls. On PR rectal mucosa was free. Differential diagnosis of carcinoma cervix, choriocarcinoma and a fibroid polyp was consid ered and patient was investigated. 'Dept. of 06st. & (jynacc. (jrant 'lt(ttfical Cofkgc & J.J. ?lospita{, 'BotiWay Jtcccptttf for Pu6lication on 4/ 10191 112 JOURNAL OF OBSTIITRICS AND GYNAECOLOGY RANJANA SHARMA CASE REPORT A twenty years old, mother of two, pre ANJAU KAMAT • SANDEEP l 'Dept. of 06st. & t;yntuc. qoa !Mdica( Cofkgc antf 'Dept. of 06st. & t;ynuc. qovintf 1fospitaf. Jotfftpur :Hospitals. Jteeeptctf for Pu6f~ati o n on 4/10191 Jt cceptctf for Pu6&ation on 4110/ 91 CASE REPORTS 113 parietal periotoneum densely. While separating plasmocytic infiltrate around the tumour mass is from the peritoneum the tumour ruptured and a observed. Rest of the areas show all elements of huge amount of yellow pulitaceous material teratoma like sweat glands, cartilage, intestinal drained out. After the size of the tumour was glands, areas of necrosis, calcifications, marked reduced it could be separated from the perito foreign body giant cell reaction around keratin neum on all sides and also from the bowels, material are also seen. Nests of tumour cells are bladder, pouch of Douglas. Inspection of the rest seen infiltrating into the fallopian tube, and the of the peritoneal cavity showed ascites around isthmus. 100cc Uterus normal, left tube, ovary normal, liver, diaphragm, paraaortic nodes normal. No obvious deposits in the omentum. Total hyster ectomy, right ovarian tumour; left adnexal re moval was done. Patient received two pints of blood during surgery. Post operative course was uneventful. She was disl'hargcd on the 14th post K.B. LooANI e S PAI A CHANDRA CASE REPORT Clinical features : A 16 years old female presented with progressively increasing painless swelling in the vulval area for the past 4 years. On examination, the patient was otherwise in good health except for the soft nodular Jump in the region of the left labia minora. There was no other swelling anywhere on the body. A clinical diagnosis oflipoma was made and the lesion was excised. operative day. She was advised chemotherapy. Pathology : Received a partially skin cov Pathological Findings ered nodule, 5 em x 3.5cm x 1 em. in dimen Gross : Macroscopically the right ovary sions. On palpation, multiple firm ill defined showed total replacement by partly cystic, partly deep seated cutaneous nodules were felt with no solid mass measuring 13x9x5 ems. cut section fixation to overlying skin. Cut section showed showed pultaceous material with tuft of hair, deep dermal multiple well circumscribed firm Part of the cyst showed greyish white solid areas greyish white nodules of 0.2cm to l.Scrns in with fair amount of cheese like material. Uterus, diameter, separated from each other by com left adnexa showed no gross pathology. pressed out soft connective tissue septa. Microscopic : Multiple sections studied Microsections showed well formed circum from the ovarian mass showed sheets and nests of scribed multiple expanded modules of whorled Malignant squamous cells arising from the as well as wavy bundles of spindle shaped elon- Teratomatous elements. The tumour cells show moderate pink cytoplasm, large hyperchromatic 'Dept. of .'Ptztlio. Ltztfy Hutfirt,!t 91letfktz( CoffeJe t!r nucleus. Fair number of mitotic figures and Sucliettz 9(rlpflull Hospit.U, ?(,fll 'DeUit epithelial pearls, mild to moderate lympho Jllcuptel for 'Pu6fktzfiort ort 2216/91 114 JOURNAL OF OBSTEfRICS AND GYNAECOLOGY gated nerve fibre cells surrounded by well de fined perineurium and compressed dermal tis sue. The nerve fibres have oval to needle thin elongated uniformly stained palvading nuclei, with intercellular wavy fibrillar collagen mate rial intersepted with bands of homogenous pink stained neurofibrillar tissue. A diagnosis of solitary cutaneous plexiform type, neurofibroma was made.