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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 Vaginal techniques have been practiced for centuries, but has been outdated  especially in recent years after the fancy  invention of Laparoscopic hysterectomies.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.

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.




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