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NON DESCENT VAGINAL HYSTERECTOMY

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NON DESCENT VAGINAL HYSTERECTOMY    ----


A SAFER APPROACH IN HIGH RISK CASES:


Introduction:


Hysterectomy is one of the common gynecological surgery performed through abdominal/ vaginal /laparoscopic routes. Vaginal techniques have been practiced for centuries, but has been outdated  especially in recent years after the fancy  invention of Laparoscopic hysterectomies. This is due to lack of experience and enthusiasm among evolving gynecologist and due to misconception that abdomen route is safer and easier.




  • Vaginal route is the least invasive route of all, utilizing a naturally existing anatomical orifice .

  • The ease and convenience offered by a an abdominal incision have led to the preponderance of abdominal hysterectomies.

  • However proper selection of patient is a critical factor is determining the success of vaginal procedures.

  • Lack of expertise and curve  in learning the technique has major impact on choosing the route of hysterectomies.

  • In our center hysterectomy is performed by Laparoscopic, Abdominal and vaginal routes.

  • However we prefer the later route as we find it less time consuming and cost effective for patients.


CASE DISCUSSION - I:

 48years Mrs. S , Heavy menstrual bleeding -6 years,  Fibroid uterus - Intra manual fibroid with Adenomyosis.  

  • Patient was a K/C/O systemic Lupus erythematosus on immunosuppressants. 

  • With H/O lung involvement four years back for which she underwent tracheostomy.

  • She had several risk factors like hypertension, Renal impairment secondary to SLE/morbid obesity.

  • We opted for trial vaginal Hysterectomy as even Laparoscopic on abdominal route was risky often this patient.

  • Patient underwent vaginal Hysterectomy with multi disciplinary perioperative case and was discharged 4 th post operative day.   





CASE DISCUSSION - II:

44 years Mrs. X, A P2L2  / Sterilised.

  • K/C/ - Fibroid Uterus, submucosal with 3cm fibroid polyp protruding through the os.

  • With C/O - Heavy menstrual bleeding and pain 1yrs. 

  • P/V - Uterus 12week mobile, VTT positive. Underwent vaginal Hysterectomy for non descent Uterus.

  • Patient discharged on II POD. 











DISCUSSION - DOCTORS CORNER:


  • NDVH is an Passion of Gynec Surgeon.

  • Vaginal route is the safest and most cost effective route because of shorter hospital stay,

  • No visible scar .

  • No risk of General Anesthesia hence  can be used in cases with Cardio Pulmonary complications  where Laparoscopic route  is difficult.

  • More time Saving is experienced hands. Laparoscopic route is associated with increased operating times and risk injuries.

  • Quick recovery and early discharge.

  • Using single clamps is easier in difficulty cases with decreased space.

  • Using straight needle prevents lateral injury.

  • Aqua dissection might reduce blood loss.

GESTATIONAL DIABETES MELITUS AND PREGNANCY – CASE REPORTS

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Case Discussion - 1


DIAGNOSIS - GDM ON MEAL PLAN WITH FETAL CARDIAC DEFECTS


26 yrs – Primi/ Mrs. R 25/F, accountant by occupation , booked elsewhere ,  LMP-10/02/2020, EDD - 17/11 2020/ First visit to SNS Hospital on 07/10/2020 @ 35 weeks. Known case of GDM on Meal plan since three months of pregnancy  / she was under vigilant monitoring of blood glucose , maternal wt gain, Bp, monitoring throughout the pregnancy.

 




  • The plasma Glucose levels seems apparently well under control.



  • Her serial growth scans showed EFW - <50th percentile.



  • Underwent cesarean delivery on -18/11/2020 for Dystocia of Labour, and delivered Girl – 4.00 kg. Early neonatal and postnatal period uneventful. No episodes of hypoglycemia is the baby. Maternal Blood glucose within normal limits.                                                                         




 

 

 

 

 

 

 

 



 

 

 

 

 

 

 

 

 

CARDIAC screening of the baby was done - is fourth week of life. Showed -

> Acyanotic congenital heart disease.

VSD - 5mm - muscular non - 

restrictive.

ASD - 4mm - L-R shunt

PDA - 2.5mm - L-R shunt. Baby under follow up.



Points to ponder - Doctors` corner:


  • Even one marginally higher blood glucose - (151mg/dl - 13weeks) in the earlier trimester -though we name it as GDM - Should, arouse a suspicion of embryonic defects.



  • All the parameters were apparently under control throughout pregnancy, with meal plan - yet the Fetus has undergone the insult at the very earliest stage - should we redefine the terminology - GDM?



  • How far does the meal plan take care of the Intra uterine fetus - is Questionable.



  • Defining any single abnormal blood glucose values as diabetes melitus complicating pregnancy - like what has been done in this case helps us to keep a close watch.



  • Asian ethnicity being a high risk for Diabetes complicating pregnancy - we see a tremendous increase in the incidence of number of pregnancies complicated with Diabetes.



  • Strict monitoring and control of blood glucose helps us prevent late intra uterine complications (sudden fetal death) intrapartum and early neonatal complications, not reliable is preventing embryonic insults though. Which says the pathogenesis of congenital abnormalities seen in babies born to diabetic mothers might be because of cytopathic effect of maternal immune system.




TWO CASES OF TUBAL ECTOPIC PREGNANCY – CASE REPORTS – FEB 2021

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INTRODUCTION:

ECTOPIC PREGNANCY OCCURS WHEN A FERTILIZED EGG IMPLANTS OUTSIDE THE UTERINE CAVITY.   THE MOST COMMON SITE BEING FALLOPIAN TUBE. ECTOPIC PREGNANCY IS ONE OF THE LEADING CAUSE  OF MATERNAL MORBIDITY DURING FIRST TRIMESTER.

CASE STUDY 1:          

DIAGNOSIS – TUBAL ECTOPIC PREGNANCY  WITH TUBAL LEAKAGE AND PELVIC HEMATOCELE 

CASE HISTORY 

23 YRS  MRS A PRESENTED TO THE OPD ON 26/02/2021 @ 11 .00 AM  WITH PAIN – 4 DAYS  WITH C/O LOOSE STOOLS –TREATED ELSEWHERE WITH  ANTISPASMODICS. HER LMP – 18/2/2021. (PREVIOUS MENSTRATION 7/1/2021).

MANAGEMENT 

URINE GRAVINDEX  WAS DONE WITH SUSPICION FOR TEN DAYS OF AMENORRHEA PRECEDING THIS CYCLE – FOUND POSITIVE AND ULTRASOUND SCAN DONE SHOWED  ECHOGENIC   MASS 4 * 4 CM   LEFT ADNEXA, FREE FLUID +  BETA HCG – 5550 Iu/ml. PATIENT WAS PALE WITH HB – 6.8 gm/L. LAPAROTOMY DONE WITH ONE UNIT OF PACKED CELL DONE  AT 1.00PM AND SHOWED  HEMOPERITONEUM WITH 100 ML OF BLOOD STAINED FLUID ,PELVIC HEMATOCELE – 200gm OF CLOTS, LEFT AMPULLARY PREGNANCY – 4x4 cm. LEFT SALPINGECTOMY DONE AND CLOTS REMOVED, PREITONEAL WASH DONE.SPECIMEN SENT FOR HISTO PATHOLOGY . BLOOD TRANFUSIONS WAS DONE. POSTOPERATIVE PERIOD UNENENTFUL AND PATIENT WAS DISCHARGE ON D3. 

 

 

 



 

 

 

DISCUSSION 

  • TUBAL LEAKAGE IS THE MOST USUAL COURSE OF AN ECTOPIC PREGNANCY.

  • PROCESS TO PERITUBAL HEMATOCELE / PELVIC HEMATOCELE / ON TUBAL ABORTION.

  • BY TUBAL ABORTION IS MEANT EXTRUSION OF THE OVUM FROM FIMBRIAL END. (COMMON  DIAGNOSIS).

  • 10%  CASE GO FOR TUBAL RUPUTURE.

  • PELVIC HEMATOCELE – RECTAL DISCOMFORT.


      WHAT THIS CASE  TEACHES US -

THE SIGNIFICANE OF HIGH DEGREE OF SUSPICION.

  1. ITS IMPORTANT TO CONSIDER ANY BLEEDING FOLLOWED BY EVEN A SHORT PERIOD OF AMENORRHOEA, EVEN WHEN IT MIMICKS REGULAR MENSTRUATION .

  2. ECTOPIC CAN HAVE ANY SYMPTOM OTHER THAN THE CLASSICAL TRIAD ( AMENORRHOEA, PAIN AND BLEEDING )

  3. THE LOOSE STOOLS IN THIS CASE IS BECAUSE OF PELVIC HEMATOCOELE.

  4. HEMORRHAGE AND HEMODYNAMIC INSTABILITY  CAN HAPPEN EVEN WITHOUT RUPTURE .

  5. AN ORGANISED CLOT MAY PRESENT AS ECHOGENIC MASS LESION , A BLEDING INSIDE THE CAVITY NEED NOT ALWAYS BE FREE FLUID IN THE PELVIS .


 

 

CASE-  2:           

DIAGNOSIS -    RECURRENT TUBAL ECTOPIC PREGNANCY- UNRESPONSIVE TO METHOTREXATE MULTIDOSE . 

 

CASE HISTORY 

MRS. A 32 YRS,  WAS ADMITTED ON 05/02/2021. SHE WAS G3P1L1A1/ LAST CHILD – 7 YRS.  PAST H/O – LEFT TUBAL ECTOPIC – MEDICALLY MANAGED WITH SINGLE DOSE METHOTREXATE  IN 2019 .

NOW ADMITTED WITH H/O – 42 DAYS AMENORRHEA . NO H/O PAIN ,  BLEEDING P/V. UPT POSITIVE, ULTRASOUND PELVIS WAS DONE BECAUSE OF THE PREVIOUS HISTORY OF ECTOPIC PREGNANCY -  SHOWS RIGHT TUBAL ECTOPIC – 2 cm . BETA HCG – 803 Iµ/ml ( REPEAT )  SHE WAS GIVEN INJ. METHOTREXATE 50mg/m2 ON 05/02/2021AT 4.00 PM.

A REPEAT SERUM BETA HCG SHOWED A RISE TO 12040 Iµ/ml ON 08/02/2021.SECOND INJ. METHOTREXATE WAS GIVEN AS THE PATIENT WASHEMODYNAMICALLY STABLE AND USG SHOWED NO E/O RUPUTURE . KEEPING IN MIND THE INTIAL RISE OF SERUM BETA HCG AFTER METHOTREXATE BEFORE ITS FALL.

ON 11/02/2021 SERUM BETA HCG MEASURED, SHOWED NO FALL IN TITRE . THE PATIENT HAD PAIN  ABDOMEN USG SHOWED AN INCREASE IN THE SIZE OF THE RIGHT TUBAL ECTOPIC. HENCE THE PATIENT WAS TAKEN UP FOR SURGERY. RIGHT TUBAL SALPINGECTOMY DONE. LEFT TUBE AND BOTH OVARIES FOUND NORMAL. SPECIMEN SENT FOR HPE .

DICUSSION:

THE RISK FACTORS FOR RECURRENT ECTOPIC PREGNANCY ARE PREVIOUS ECTOPIC PREGNANCY ,  PREVIOUS TUBAL DAMAGE,         AGE > 30YRS/ PREVIOUS SPONTANEOUS MISCARRIAGE ,PELVIC INFECTIONS AND SURGERIES.

AFTER TREATMENT WITH METHOTREXATE 60% - 70% OF WOMEN HAD

SUBSEQUENT HEALTHY  PREGNANCIES AND AROUND 8% HAD RECURRENT ECTOPIC PREGNANCY

.

WHAT THIS CASE HAS TAUGHT -

1.RECURRENT ECTOPIC PREGNANCIES CAN  BE DIAGNOSED AT THE EARLIEST . ANY PREVIOUS H/O ECTOPIC SHOULD BE WATCHED WITH CAUTION . IN THIS CASE THE PATIENT NEITHER HAD BLEEDING PV NOR PAIN ABDOMEN

2. REP - THE SUCCES RATES OF METHOTREXATE  IN CASES OF RECURRENT ECTOPIC BASED ON SEVERAL CASE STUDIES IS ASSUMED TO BE POOR .

IN A STUDY OF 262 PATIENT WITH RECUURENT ECTOPIC PREGNANCY – IT WAS CONCLUDED THAT. OTHER OPTIONS  THAN SINGLE DOSE OF METHOTREXATE SHOULD BE CONSIDERED FOR THE MANAGEMENT OF REP.

COMMONLY ASKED QUESTIONS:

  1. WHAT IS ECTOPIC PREGNANCY ?



  • PREGNANCY OCCURS OUTSIDE THE UTREUS.

  • MOST COMMONLY ECTOPIC PREGNANACY OCCURS IN TUBES.

  • VERY RARELY IT OCCURS IN OVARIES, CERVIX OR ABDOMEN.

  • IF ECTOPIC PREGNANCY IS NOT DETECTED OR TREATED EARLIEST  RUPUTURE CAN CAUSES SERIOUS PROBLEMS OR  EVEN CAUSES DEALTH.

  • கரு கருப்பை விட்டு இடம் மாறி தங்குவது, பெரும்பாலும் கருகுழாயில் தங்கும்.



  1. CAN ECTOPIC PREGNANCY BE MANAGED WITH DRUGS OR MEDICATIONS.


FEW ECTOPIC PREGNANCYIES WHICH FULFILL CERTAIN CRITERIAS CAN BE MANAGED MEDICALLY, IF PATIENT’S GENERAL CONDITION IS STABLE. BUT IT REQUIRES VIGILANT MONITORING OF SERUM BETA – HCG LEVELS IN BLOOD AND ULTRASOUND SCAN EXAMINATION.

3.WHAT ARE THE SURGERIES FOR ECTOPIC PREGNANCY?

ECTOPIC PREGNANCY WHICH CANNOT BE MANAGED  MEDICALLY OR WHICH HAVE RUPUTURED OR WHICH IS BLEEDING INSIDE REQUIRES SURGERY. EITHER OPEN SURGERY OR LAPAROSCOPY CAN BE DONE.

  1. WHAT ARE THE PRECATIONS TO BE TAKEN TO DIAGNOSE ECTOPIC PREGNANCY AT EARLIEST?



  • ONLY 40% TO 50% OF PATIENTS IN ECTOPIC PREGNANCY WILL HAVE BLEEDING.

  • 75% OF PATIENTS WILL HAVE PAIN IN ABDOMEN.

  • 20% OF PATIENTS WILL HAVE BLEEDING INSIDE AND HEMODYNAMICALLY COMPROMISED WITH LOW BP AND LOW HB REQUIRING BLOOD TRANSFUSIONS.


FORTUNATELY BECAUSE OF MODERN DIAGNOSTIC TECHNOLOGY LIKE ULTRASOUND SCAN, SERUM BETA – HCG. ECTOPIC PREGNANCIES ARE DIAGNOSED EARLIER  BEFORE RUPUTURE.

  1. WILL THERE BE ANY CHANCES OF HEALTHY PREGNANCY AFTER   ECTOPIC  PREGNANCY?


THE CHANCES OF HAVING SUCCESSFUL PREGNANCY ARE VERY GOOD. 65% OF WOMEN WILL HAVE HEALTHIER PREGNANCY.