A case is described of profuse uterine bleeding with a dislodged Multiload Cu 250 intrauterine device (IUD). Multiple blood transfusions were necessary, and ultimately, an emergency hysterectomy was performed.
A case of spontaneous rupture of uterine artery in the second trimester of pregnancy is described. Haemorrhage from rupture of uterine artery during pregnancy was discovered at laparotomy. This was an unusual but serious complication of pregnancy. This condition is extremely rare and one must consider it in cases of incomprehensible abdominal pain with or without haemodynamic collapse. A review of the literature revealed only four similar cases so far. This pregnancy continued till 37 weeks pregnancy and had a spontaneous vaginal delivery. Immediate institution of effective resuscitative measures and early surgical intervention were essential to both foetal and maternal survival.
Transvaginal sonography was performed in 70 patients diagnosed to have placenta praevia by transabdominal sonography. The diagnosis was confirmed either by digital examination in theatre at term or operative finding at delivery. Forty-nine cases (70%) were correctly diagnosed to have placenta praevia by both modes of sonography. Transvaginal sonography ruled out placenta praevia in 12 cases (17%) thought to be placenta praevia by transabdominal ultrasound. Both transabdominal and transvaginal sonography demonstrated 'placental migration' in 4 cases (6%) which were no longer praevia at delivery. Five patients (7%) were erroneously believed to have placenta praevia by both sonographic techniques. Overall, the diagnostic accuracy of transvaginal sonography was 92.8% compared with 75.7% for transabdominal sonography. None of the subjects experienced any exacerbation of bleeding or other complications. The results suggest that transvaginal sonographic localization of the placenta is safe and superior to the transabdominal route.
Over a 17-year period, 15 patients with acute puerperal inversion of the uterus were managed at the University Hospital, Kuala Lumpur, an incidence of 1 in 4,836 deliveries. Injudicious traction on the umbilical cord before the uterus was well contracted, was probably the most important causative factor. Haemorrhage was more severe when removal of the placenta was done prior to correction of the inversion. Either the hydrostatic method or manual replacement were used but more often a combination of both techniques was found necessary. With careful management of the third stage of labour, this complication can be avoided.
This is a rare case of antepartum haemorrhage arising from the nonpregnant uterus in a woman with uterine didelphys. The bleeding and subsequent passage of a decidual cast did not have any adverse effect on the ongoing pregnancy.
Fistula formation following pelvic surgery and radiotherapy, including ureteric-arterial fistulas (UAF), is well documented, however, ureteric-arterial-enteric fistula is extremely rare. Conventional autopsy is usually required for the definitive diagnosis of pelvic vascular fistulas although an accurate diagnosis can still be complicated and challenging. The role of post-mortem computed tomography (PMCT) as an adjunct to conventional autopsy is well documented in the literature. One of the limitations of PMCT is the diagnosis of vascular conditions. Post-mortem computed tomography angiography (PMCTA) is a recently introduced technique that can assist in detecting such pathology. We present a case of post-radiotherapy ureteric-arterial-enteric fistula presenting as massive rectal and vaginal bleeding diagnosed prior to autopsy on PMCTA. The role of PMCTA in the diagnosis of such a UAF has not previously been reported in the literature.
A 28-year-old G3P1+1 at 6 weeks period of amenorrhea with a previous Caesarean section presented with per vaginal bleeding. A cervical ectopic pregnancy was confirmed by a transvaginal scan. An intramuscular methotrexate was given followed by intracervical route due to poor decline of the serum βHCG. However, due to persistent increment of serum βHCG, an additional four doses of intramuscular methotrexate with folinic acid rescue were administered and she responded well to the regime. Unfortunately, following the last dose, she developed an episode of excessive per vaginal bleeding which required suction and curettage of the cervical canal. A Foley‘s catheter balloon was placed intracervically as a tamponade and the bleeding was successfully arrested.
A 3 year retrospective review (1995 to 1997) of 127 patients with cervical dysplasia who underwent Laser Vaporisation of the cervix and LEEP at the Gynaecological Cancer Centre, KK Women's & Children's Hospital, Singapore, was undertaken. Amongst the patients in the Laser Vaporisation group, the mean age was 37.7 years (SD 8.8), the mean operating time was 14.8 minutes (SD 8.5), 63.6% were given prophylactic antibiotics and the mean follow up period was 15.3 months (SD 12.0), whilst in the LEEP group, mean age was 40.3 years (SD 8.4), mean operating time, 11.8 minutes (SD 4.9), prophylactic antibiotic rate, 53.8% and mean follow up period was 19.1 months (SD 9.3). Mild and moderate haemorrhage post procedure were the only complications encountered, 10.2% (5/49) in the Laser group and 3.8% (3/78) in the LEEP group. 98% (48/49) and 97.4% (76/78) of the Laser and LEEP groups, respectively, were free of disease on follow up. None of the 3 patients with persistent or recurrent disease were diagnosed as having invasive cancer. Overall, there were no significant differences in the patient characteristics, histopathology, operating times, follow up period, the use of prophylactic antibiotics, and complications in the 2 groups. The low complication rate, high disease-free rate and the relatively short operating time of Laser Vaporisation and LEEP in our study suggests that, indeed, both the procedures can be done safely and efficiently in the outpatient setting. However the discrepancy between the histology of colposcopically directed biopsy and that of LEEP specimens suggests that colposcopically directed biopsy may not be as accurate as one might believe, and further studies analysing the concordance between colposcopically directed biopsy and LEEP biopsy histologies are needed.
Near-miss cases in life-threatening obstetric patients occurring over a one year period are analysed retrospectively with regards to morbidity measured in terms of hospital stay, utilisation of high dependency ward and intensive care beds and adequacy of clinical management. One-hundred and twenty two cases occurred among 9932 deliveries. Massive obstetric haemorrhage (54.2%) and hypertensive disorders of pregnancy (36.9%) were the two main diagnostic groups. Seventy one (58.2%) cases were referred from peripheral centres for obstetric management and 77 (63.1%) were not booked at this hospital for antenatal care. A majority were not ill-looking (92 cases) at the time of admission but turned for the worse in the course of labour. Interventional measures taken in clinical management were considered appropriate in all cases. Delay in instituting treatment was present in 6 cases. Remediable measures were recognised in 15 (12.3%). This study, apart from supplementing mortality audits, demonstrates that high risk obstetric patients can be triaged at the time of admission to labour wards by trained midwives and junior doctors in busy obstetric units without compromising standards of care.
Study site: Obstetric and Gynaecologic Unit in Ipoh Hospital.
This study reviews experiences in the management of three cases of lacerations of the vagina following coitus. A brief review of the recent literature is made. Although the extent of injuries can be very variable, the principles of management consist of prompt
resuscitation and arrest of haemorrhage, appropriate surgical repair under general anaesthesia, and systemic or local antibiotic therapy to combat infection. Avoidance of vigorous or abnormal coital practices, especially in single women, in the immediate postpartum period, and in postmenopausal women, can help to reduce the frequency and severity of such injuries.
Intramyometrial ectopic pregnancy (IMEP) is a rare form of ectopic pregnancy. It is defined as a conceptus implanted within the myometrium and is completely surrounded by myometrium with clear separation from both the uterine cavity and tubes. IMEP possesses not only diagnostic but also therapeutic challenge. The majority of reported cases were managed by hysterectomy. Early management of unruptured IMEP using methotrexate may help to preserve fertility. We, for the first time, report a case of ruptured IMEP managed successfully using suction and curettage followed by Bakri balloon tamponade and avoiding hysterectomy. Post-procedure, the patient received two doses of intramuscular methotrexate 50 mg/m2 due to plateauing serial beta human chorionic gonadotropin (β-hCG) levels and subsequently achieved undetectable level 10 weeks post-methotrexate. She also had complete resolution of the ectopic intramyometrial mass.
Ovarian germ cell tumours are very rare and affect mainly young girls and women. Due to this, the conservation of reproductive potential is of great concern. One of the most remarkable advances in oncology is in the treatment of malignant ovarian germ cell tumours. Two histological groups are distinguished: dygerminomas, equivalent to testicular seminomas, and non-dysgerminomatous tumours. We report a case of a 30-year-old nulliparous woman who presented with persistent per vaginal bleeding and was found to have a malignant mixed germ cell tumour comprising of both embryonal carcinoma and choriocarcinoma.
Morbidly adherent placenta with spontaneous rupture of membrane at extreme prematurity poses poor pregnancy outcome. Various issues on different management modalities still remain perplexed and individual consideration is vital. Two cases of morbidly adherent placenta with symptomatic per vaginal bleeding and spontaneous rupture of membrane at severe prematurity were reviewed and discussed. We found that, active intervention by termination of pregnancy and methotrexate therapy at early gestation can prevent the need of hysterectomy following major obstetrics haemorrhage.
Sixty cases with uterine leiomyomata in pregnancy are presented. The incidence was 1 in 1033 deliveries. The median age of the patients was 33.4 years. The majority were primigravidae (60%). A significant number of patients gave a history of infertility (43%) and spontaneous abortions (25%). The commonest antenatal complication was malpresentation and in all these patients the myomata were larger than 6 cm. Typical features of red degeneration occurred in 10% of cases. The cesarean section rate was 73%, the commonest indication being obstructed labor. Severe hemorrhage was encountered at cesarean section in 10 patients, 3 of whom needed hysterectomy. There were no perinatal deaths.
Bilateral ligation of the internal iliac artery with or without ligation of the ovarian arteries was carried out in 17 patients who had life-threatening pelvic haemorrhage; 14 were due to obstetric haemorrhage, 2 followed abdominal hysterectomy and 1 intractable haemorrhage associated with carcinoma of the cervix. The procedure was successful in arresting the haemorrhage in 13 patients but 4 needed hysterectomy in spite of the ligation; 1 patient died from disseminated intravascular coagulation following surgery and 1 had cardiac arrest due to extensive blood loss during surgery and died 12 hours later. A review of the literature, a brief description of the procedure and its indications are discussed.
The mother of a 9-month-old female infant complained that her child was unable to pass urine at the same time noticing a mass protruding from the vaginal orifice.The infant had a single episode of vaginal bleeding.The primary concern of the mother was the inability of the daughter to micturate. Malignant germ cell tumour arising from an infant vagina is rare and accounts for about 3% of all paedriatic malignancies. These are also referred to as endodermal sinus tumours or yolk sac tumours, and are mostly the commonest form of infant vaginal malignancies encountered. A diagnosis of endodermal sinus tumour was established based on the histology and raised α-fetoprotein levels.These tumours had Schiller-Duval bodies which are primarily blood vessels surrounded by primordial germ cells and were periodic acid shift (PAS) positive diastase resistant hyaline globules which also stain positive with α- fetoprotein which is an important diagnostic feature. Tumours with high α-fetoprotein levels have a poorer prognosis. However, they respond satisfactorily to chemotherapy.