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Endoscopy Case Report

Creating Happiness

RARE CASE OF GIANT UTERINE MYOMA AT ADOLESCENT AGE OF 17 YEARS

Introduction :
Myomas are the commonest benign tumours in reproductive age group, rarely affecting women below 30 years of age, for which the incidence is below 4%. Secondary changes occur in 65% of myomas in descending order of hyaline degeneration (63%), myxoid degeneration (19%), calcification (8%) and cystic changes (4%).

Case Report :
A 17 years old unmarried girl, presented to gynaecology opd on 8th September 2012 with
1.Distension of abdomen since 1 year
2.Pain in abdomen on and off since 1 year
3.Frequent constipation since 1 year

Her menstrual history was unremarkable. She denied prior sexual activity and use of hormones. Her past medical and surgical history was not significant. Family history suggestive of hypertensive father and hypothyroid sister.

On abdominal examination, there was intraabdominal lump corresponding to about 24 weeks of pregnancy,size-about 15X20 cms occupying the hypogastrium and umbilical region extending to the left iliac and lumbar area.It was non tender and soft in consistency with restricted mobility above downwards.

Imaging :

Ultrasonography revealed a large sessile subserous fibroid emerging out of cranial and left lateral surface of uterine fundus of approx 13x7.8x12.3cms.45mm wide area of the fibroid seen to be attached to uterine fundus. Fibroid found to be solid with multiple cystic areas of degeneration and dilated vessels on its surface. Magnetic resonance imaging suggestive of large exophytic masss of 9x12x17cms arising from the fundus of uterus with multiple cystic degenerative areas.
Patient was planned for Laparoscopic Myomectomy.

Pre-operative Concerns:

1.Port entry due to extremely thin patient
2.Preservation of fertility
3.Avoiding uterine manipulation to preserve virginity
Intraoperative highlights :
On laparoscopy, a 20cms myoma seen occupying the entire lower abdomen, arising from the fundus of uterus. Horizontal incision taken on the myoma after instilling Inj Vasopressin 1 in 200 dilution in myometrium. Myoma screw inserted for traction purpose.
Myoma enucleated by traction and counter traction method. Enseal vessel sealing device was used for minimizing blood loss intraopera
Uterus was sutured with continuous interlocking V-loc sutures. Myoma then was morcellated using Gynecare morcellator and pieces removed through laparoscopic ports. Bilateral fallopian tubes and ovaries found to be healthy.

End result: Clean pelvic cavity.
Weight of resected specimen-approx 2 kgs
Dimensions-20x15x10 cms
Post operative period was uneventful with patient being discharged in the same evening
 
Histopathology showed leiomyoma of uterus with cystic degeneration changes.
 
Discussion:

Myomas are extremely uncommon in paediatric and adolescent age group. Estrogens and progesterones play an important role in development of these neoplasms. Exogenous estrogen, obesity and pregnancy influence their growth, all of which were excluded in our case.

Genetic inheritance plays an important role. For example cytogenetic abnormalities in chromosome 6,7,12,14 are linked to development of these tumors.When seen in young population, adenomyosis, adnexal masses and neoplasms must be excluded specially when such a huge mass is detected.

MRI is considered superior to USG in diagnosing and localising uterine myomas most accurately. While myomas are most often straightforward in their presentation and management, they can undergo various kinds of asymptomatic degeneration like cystic one in our case which alters their appearance.
Images:

Fig 1 : Anterior aspect of large fundal myoma

Fig. 2: Posterior aspect of large fundal myoma.

Fig. 3: Line of incision marked.

Fig. 4: Enucleation in progress with Enseal

vessel sealing device.

Fig. 5: Sututring with V loc Sutures.

Fig. 6: Morcellation of the myoma.

Fig. 7: End Result: Clean pelvic cavity.

Fig. 8: Placing Surgicel hemostatic material over sutures.

Infertility Case Report

Creating Happiness

Case Report 5

Introduction:

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. The re- ported incidence of Caesarean scar pregnancies is 1:1800 to 1:22161, 2 pregnancies although the overall prevalence seems to be increasing.
The true incidence of ectopic pregnancy in previous Caesarean scar has not been determined because very few cases have been reported in medical literature till now, the first of which was reported in 19783.
The increase in the incidence of Caesarean scar pregnancies may reflect an increased incidence in Caesarean sections being carried out and easy availability of transvaginal sonography for diagnosis.
Pregnancy in a Caesarean Section scar has increased risk of serious complications such as placenta accrete, invasion of bladder, rupture of scar which may require hysterectomy and can cause significant maternal morbidity and mortality.

The exact mechanism of implantation into the scar is not very well understood. However it has been hypothesized that the blastocyst enters through micro tubular tracts between the scar tissue and the uterine cavity4,5.

A number of risk factors6 have been associated for development of Caesarean scar pregnancy including previous uterine procedures such as dilatation and curettage, in-vitro fertilization, prior placental pathologies and prior ectopic pregnancies.

Although some have suggested that the number of previous cesarean deliveries may increase the risk1 of subsequent cesarean scar pregnancy due to increased scar surface area, a larger review showed that approximately half of patients had only one prior cesarean delivery6,7.

Case Report:

37 years old 6th Gravida, IVF-ET conceived, presented with pv spotting and positive beta hCG.

She has one living issue delivered by Caesarean section. Her previous pregnancies include three ectopic gestations (right tubal, left tubal and cornual) for which bilateral laparoscopic salpingectomy has been performed. She also had one missed abortion (IVF conception) for which dilatation and curettage was performed.

Her current pregnancy was an IVF conception with single blastocyst transfer. Her beta hCG done two weeks post transfer was positive with a value of 3161 (gestational age 4weeks 4 days).

She had light pv spotting from for 5 days after beta hCG was positive. She did not have any other presenting complaints.

Transvaginal Sonography performed at gestational age 6weeks 2 days showed a single live embryo corresponding to 6 weeks 2 days situated in the myometrial gap at the site of previous Caesarean scar. The surrounding chorionic reaction reached upto the uterine surface, without any intracavitary component.

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Two approaches for termination were considered. One was Transvaginal USG guided aspiration of products and the other was laparoscopic excision of ectopic.

 Transvaginal approach was considered in this case, as it would give the patient a chance for future conception as opposed to laparoscopic excision which would considerably decrease the uterine wall thickness, leading to an early rupture.

Her beta hCG repeated the next day (6weeks 3days) had a value of 45,472. Transvaginal  USG guided aspiration of the embryo and amniotic fluid was done and 0.4cc of Injection Methotrexate was instilled into the gestational sac and surrounding decidual tissue.

The absence of fetal pole was confirmed on USG and the procedure was uneventful.

The beta hCG levels were repeated 4 days later was found to be 19,623.

Repeat Transvaginal sonography confirmed the absence of fetal pole and embryo and presence of lytic decidual reaction.

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The implantation of a blastocyst in the previous Caesarean scar is a rare but life-threatening form of ectopic pregnancy. This is due to the high risk of uterine rupture and its related maternal morbidity and mortality.

There are two types of Caesarean scar pregnancies described8: one with a progression towards the normal uterine cavity, the other is a deeper implantation, likely to invade bladder and other structures. The latter type is at greater risk for rupture.

The presenting complaints may be similar to those of other types of ectopic pregnancy including light spotting per vaginum, abdominal pain in addition to amenorrhea. In some cases the woman may be asymptomatic9.

Any sign of hemodynamic instability would indicate a rupture or impending rupture. In a patient with impending rupture, one would be able to demonstrate uterine tenderness at previous scar site.

The first line of diagnosis for a Caesarean scar ectopic is transvaginal ultrasound4, 5. The transvaginal USG findings should include: an empty uterine cavity and cervical canal without any contact of gestational sac, presence of a gestational sac with fetal pole in anterior part of uterine isthmus and absence of or defective myometrial tissue between bladder and sac.

Some recommend a combined approach: transvaginal for detailed study of gestational sac along with its relation to scar and an abdominal scan to see the relationship with the bladder.

A Doppler study may be performed to demonstrate peritrophoblastic flow around the sac. A 3 D ultrasound enhances accuracy by helping to identify finer details2,4,8.

Magnetic Resonance Imaging (MRI), is a useful tool, however it takes time for the acquisition of report and is also costly.

Laparoscopy can be used for diagnostic and therapeutic purposes.

With the imminent threat of rupture of scar, the treatment of Caesarean scar pregnancy is termination. The patient can be treated conservatively with systemic methotrexate in a regimen similar to that for tubal ectopic pregnancy. Medical line of management is acceptable for unruptured pregnancies with less than 8 weeks duration with considerable thickness between the myometrium and urinary bladder. Consent for surgical intervention however, must be taken.

Sac aspiration under ultrasound guidance can be performed, along with local injection of embryocidal agent such as methotrexate, potassium chloride, hyperosmolar glucose etc. Double lumen 16 gauge needle used for oocyte retrieval have been used, which allows aspiration of products through one lumen and instillation of embryocidal agent through other lumen.

Serial beta hCG titres are carried out to confirm successful aspiration of the products.

Conclusion:

Caesarean Scar pregnancies are still a rare entity despite an increased Caesarean section rate worldwide.

Early diagnosis and management can help in avoiding life-threatening complications, which could affect future fertility and contribute to maternal mortality.

As this a very rare entity, there is no conclusion as yet as to the best treatment modality. From all the treatment options available, none appears to be entirely advantageous over the other with respect to retaining integrity of the uterus.

Further studies are required to conclude whether there is any association between Caesarean section technique and increased risk of scar ectopic, time between Caesarean and scar ectopic and regarding treatment options.

Case Report 4

Introduction:

Adenomyosis refers to a disorder in which endometrial glands and stroma are present within the uterine musculature (uterine adenomyomatosis). The ectopic endometrial tissue appears to induce hypertrophy and hyperplasia of the surrounding myometrium, which results in a diffusely enlarged uterus (often termed “globular” enlargement). However, some women have only small areas of diffuse disease that are only apparent by microscopy, whereas others develop nodules (termed adenomyomas), which clinically resemble leiomyomas.

Until recently, adenomyosis was only diagnosed at the time of hysterectomy. Most studies suggest that women undergoing hysterectomy for adenomyosis are in the later part of their reproductive years. However, this results in a lack of information about early stages of disease. Studies that use pelvic imaging, rather than hysterectomy, for diagnosis suggest that adenomyosis can be found in adolescents.

Case summary:

18 year old unmarried girl with severe dysmenorrhea for 2 years, not responding to medical line of management was diagnosed to have a 4×5 cm adenomyoma in the posterior wall of uterus.
She was posted for laparoscopic removal of adenomyoma under general anesthesia. Maximum adenomyotic tissue was removed to prevent recurrence of the mass, with minimal damage to normal uterine tissue.
She received GnRH injection (Leuprolide) post-operatively to further suppress any residual adenomyotic tissue.

Pre-operative concerns:-
•    Port entry done after creating pneumoperitoneum with Veress needle, as patient very lean.
•    Preservation of normal uterine tissue, as adenomyoma does not have a capsule and thus not well defined as a myoma.
•    Avoiding uterine manipulation to preserve virginity

case report 5
Extensive bowel adhesions to posterior uterine wall released

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Excision of adenomyoma in progress

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Morcellation of specimen
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Adhesion barrier placed to prevent future bowel adhesions.
End result: clean cavity.

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Horizontal incision taken over adenomyoma; chocolate fluid drained.

suturing
Suturing done vertically
through
Thorough irrigation and lavage given

Case Report 3

Rare case of torsion of right hysdrosalpinx in adolescent girl aged 16.

Isolated fallopian tube torsion is a rare event, occurring most commonly in the reproductive years and rarely in adolescents. Hydrosalpinx is one of the predisposing factors of adnexal torsion. The incidence of hydrosalpinx in adolescent virgin patients is very rare, thus it may cause diagnostic dilemma, leading sometimes to suboptimal treatment. The exact cause is not known but majority of the cases occur secondary to certain intrinsic and extrinsic tubal factors, which include abnormal length or spiral course of tube, hydrosalpinx, paraovarian cysts, pelvic adhesions, pelvic congestion, and pregnancy.

Case:
A 16 year old sexually inactive girl presented with left abdominal pain for two days associated with nausea. The physical examination revealed left lower quadrant tenderness. Abdominal ultrasound showed right tubal enlargement and Doppler study reveal compromised adnexal blood supply indicating adnexal torsion.

She was managed laparoscopically. Torsion of the right fallopian tube on its longitudinal axis was observed in a clockwise direction. The tubal swelling was probably a hydrosalpinx, which became a hematosalpinx as the patient did not seek treatment for 2 days since the onset of symptoms. The tube was untwisted in anti-cloakwise direction and a salpingectomy was performed.

The right ovary was very minimally handled and no compromise of ovarian blood supply was done during the process of salpingectomy.
The right ovary and left adnexa was free of any pathology.

The earlier tubal torsion is diagnosed, the greater the likelihood of salvaging the fallopian tube.
Laparoscopic management of twisted hydrosalpinx in a 17 year old girl

 

Laparoscopic management of twisted hydrosalpinx in a 17 year old girl

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Twisted hydrosalpinx in young girl. As she presented 48 hours after the onset, hydrosalpinx became a hematosalpinx

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Twisted hydrosalpinx in young girl. As she presented 48 hours after the onset, hydrosalpinx became a hematosalpinx

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Case Report 1

Dr. Sunita Tandulwadkar

Chief, IVF and Endoscopy Centre, Ruby Hall Clinic


Dr. Vineeta Kharb

Fellow in Reproductive Medicine, Ruby Hall Clinic


Dr. Nirzari Mangeshikar

DNB OBGY (1st Year), Ruby Hall Clinic



Can we freeze time?

We all know the answer to this question is



‘NO’.


Time does not wait for anyone.


But ‘YES’, we can freeze time before birth.

In IVF, with advances in science and technology, it is possible to freeze life!

Mrs. Jain*(name changed) underwent IVF treatment with us in 2010, when we prepared her embryos and froze them as her husband was going abroad for 2 years.

Technology allows us to not only cater to patients medical needs, but also their emotional needs as she wanted her husband by her side during the entire process.

Her husband came back in 2012 and then two embryos were transferred in her, and to her luck they both implanted. She had a successful twin pregnancy and delivered twins on 13th February 2013.

The 2 day old babies with us today would have been 2 years old, had the Jains chosen not to freeze their embryos !

We can perform freezing of gametes (eggs and sperm) or embryos. It is the process of cryopreservation in which the embryos are stored in liquid nitrogen at -196°C.

Embryos and sperms do not deteriorate much even when stored for long in Liquid Nitrogen.

Sperm preservation is done in patients for various reasons, patients with cancer planned for chemotherapy and radiotherapy, those who find it difficult to produce sample repeatedly, patients who come from out of town whose sample may be difficult to obtain later. Similarly, patients who work away from home for extended period may wish to freeze their sperm for their wives to use in their absence.

Embryo freezing is also one of the active programmes run in our centre. Spare excellent quality embryos are always frozen. If couple conceives in very first attempt, they can come after 2-3 years, to transfer frozen embryos for yet another baby.

There is increasing trend of oocyte freezing among unmarried girls in their thirties who wish to pursue their career and delay the marriage.

So yes, advances in science and technology do sometimes help us to freeze time before birth.

Happy Couple With the Twins

Case Report 2


Introduction :

Adnexal torsion comprises 2.7% of all gynecological emergencies1 presenting with acute abdominal pain in patients of reproductive age. Ultrasonography with Doppler imaging may prove useful in the diagnosis2,4.

We report a case of adnexal torsion two hours after embryo transfer in a 28 years old female with primary infertility who conceived even after extensive laparoscopic surgery.

Case Descripion

28-year-old female, with primary infertility was taken for IVF on antagonist protocol with 150 IU Gonal ‘F’. 16 eggs were retrieved on 17th June 2012.

She underwent day 3 Embryo transfer on 20th June 2012. Two grade A embryos of 8 cells were transferred.

Patient had severe abdominal pain 1 hour after embryo transfer. She also had vomiting, syncope and giddiness.

Pain was not relieved with analgesics. Emergency Color Doppler-USG was done which revealed haemoperitoneum with enlarged hemorrhagic right adnexa with torsion.

Patient was taken for emergency operative laparoscopy.

Care taken:
  • Anesthesia time to be kept to minimum.
  • No intrauterine manipulation done.
  • Avoiding Trendelenburg position.
  • Minimal handling of uterus.
Intra-operative findings :

On laparoscopy, there was gross haemoperitoneum. Left ovary was enlarged due to stimulation but normal. Right ovary was enlarged about 12-15 cm, fragile, hemorrhagic and had undergone torsion (Fig 1) and was bleeding from multiple sites.

Untwisting of torsion was attempted, but ovary was very fragile and also hemostasis could not be achieved with techniques like cautery or local coagulants hence decision for right oophorectomy was taken. The mass was retrieved out by morcellation in endobag. (Fig. 2)

Throughout the procedure, the uterine handling was avoided even while cleaning the pouch of Douglas. Careful and thorough irrigation and lavage of the entire pelvic and abdominal cavity was done. Hemostasis confirmed (Fig 3).

Postoperatively, patient was put on antibiotics, analgesics and luteal phase support with estrogen and progesterones.

She was stable on discharge.

On 16th postoperative day the Beta-HCG values were 832. She continued to take luteal phase supports.

On 30th post-operative day Ultrasonography was done which revealed fetal pole with cardiac activity.

Discussion :

Adnexal torsion can occur after ovarian stimulation for IVF 5,6.

Ultrasonography remains an important primary modality in evaluation apart from clinical picture.

If diagnosed early, before necrosis sets in, detorsion and conservation of adnexa is possible. In this case, though diagnosed immediately, could not save adnexa, as was enlarged due to stimulation, fragile and was bleeding from multiple sites due to rupture of multiple follicles.

Dialogue of good embryo and healthy endometrium: This case clearly shows that if the embryo is good quality and the endometrium well prepared in spite of an intervention immediately post transfer implantation can be achieved.

Laparoscopy gives upper hand in reducing uterine handling and reducing the operative time: This case exemplifies how endoscopy goes hand in hand with infertility as without laparoscopic surgery neither the operative time could have been reduced nor could we have managed to avoid uterine handling which was so important in the end to get the desired implantation.

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