English

Abstract

Vaginal evisceration following lower segment caesarian section is a rare occurrence. There is no documented case report available although omental prolapse following third stage of labour have been reported due to old uterine perforation following multiple curettage and uterine rupture in multi gravid patients respectively. This is a life threatening complication diagnosed only after a high index of suspicion and a thorough clinical examination. We report a case of post caesarian vaginal omental prolapse in a primi gravida. CASE REPORT: A 26 year old primi gravida was admitted with us from 34 weeks onwards as a case of hypothyroidism with mild pre-eclampsia for observation and further in-patient management. On admission, her blood pressure was 150/100 mm Hg, urine albumin was +2 by dipstick method with no premonitory signs or symptoms. On general examination: bilateral pedal edema with facial puffiness was present and deep tendon reflexes were normal. On per abdominal examination: uterus was 30-32 weeks gestation with mild abdominal ascites. She had been diagnosed as hypothyroid in her first trimester and was on thyroxine for the same. She was started on antihypertensives. Laboratory investigations for pre-eclampsia were within normal limits. Obstetric ultrasonography showed evidence of fetal growth retardation with oligohydramnios with AFI of 4-5. Doppler ultrasound showed bilateral uterine artery notching with no evidence of utero-placental insufficiency. Patient was managed conservatively with steroids being given for fetal lung maturity, weekly investigations being monitored and blood pressure stabilized at 140/90 mm Hg. She went into spontaneous labour at 36 weeks of gestation and liquor being thick meconium stained, a decision for emergency LSCS in view of severe fetal distress was taken. Lower segment caesarian section was done with midline infraumbilical incision taken in view of severe fetal distress being done in late first stage of labour and a preterm, FGR male child was delivered by vertex. Mild to moderate ascites was present. As the LSCS was done in late first stage of labour, there was an extension of the uterine incision on the right side to the lower segment. Consequently, the right sided uterine artery ligation was done and hemostasis satisfactorily achieved. The uterus was sutured in two layers with the visceral and parietal peritoneum being closed separately followed by abdominal closure in layers. The neonate required urgent resuscitation and was admitted to the NICU for further management. In early post operative period patient had pyrexia for which high grade antibiotics were started. Despite antibiotic coverage, patient developed a full length wound gape on day 10. The wound gape was managed conservatively with daily wound dressing with full