Normal-sized Uterus Research Articles

Complete transverse transection of the normal-sized non-pregnant uterus associated with wearing a safety belt in abdominal blunt trauma: Narrative review and case study.

This review and case study illustrates a patient with a complete transverse transection of a non-pregnant uterus caused by blunt trauma associated with wearing a safety belt. The 31-year-old patient, who had a previous cesarean section, presented with impending hypovolemic shock caused by intra-abdominal hemorrhage secondary to blunt trauma while wearing a safety belt. On physical examination, a transverse straight line of ecchymosis along the line of a fastened safety belt was noted without any other external injury. The operative findings revealed a complete transverse transection which had cut through the lower part of the non-pathological, normal-sized uterus with active bleeding and mild injury to the small bowel without active bleeding. Total hysterectomy and simple closure of the small bowel were performed with successful outcomes. We hypothesize that transection was caused by the enormous pressure produced by blunt trauma transmitted through the abdomen by the fastened safety belt and the weakness of the uterine wall caused by the previous low transverse cesarean section which facilitated the separation and extension to the entire wall. In conclusion, this case study provides the following learning points: (1) Enormous forces produced by a fixed fastened safety belt during a car accident can cause complete transverse transection of a normal-sized, non-pathological uterus, leading to life-threatening intra-abdominal hemorrhage. (2) A previous cesarean section may potentiate the transection, especially when the uterus is repositioned above the pelvic brim. (3) The gynecologic condition should also be included in the differential diagnoses in cases of intra-abdominal hemorrhage. If highly suspected, gynecologists should be notified for early recognition and avoidance of delayed actions.

Abdominal Ectopic Gestation In The Second Trimester At A District Hospital: A Rare Case

Introduction: Abdominal ectopic pregnancies are uncommon forms of ectopic pregnancies. They might be unnoticed until late in pregnancy and are associated with an increased risk of maternal complications and mortality. This is a case report of an abdominal ectopic gestation diagnosed at the first visit to a district hospital in Ghana and how it was managed in a low-resource setting.
 Case Presentation: A 28-year-old gravida 4 parity 3, presented with 4 months history of amenorrhoea associated with recurrent bleeding per vaginum. Ultrasound showed a slightly bulky uterus with very scanty echogenic material within the endometrial cavity. There was however a right adnexal gestational sac with a live foetus at 19 weeks + 4 days and no free fluid was seen in the pouch of Douglas. The patient was counselled and prepared for an emergency exploratory laparotomy and intraoperative findings showed normal size uterus of about 8 weeks in size with an unruptured right adnexae gestation. The gestational sac was in the region of the right ovary which could not be visualised and attached to the uterus via the ovarian ligament with a normal-looking right tube. Post-operative recovery was uneventful and she was discharged three days later. 
 Conclusion: Abdominal ectopic gestation can pose a diagnostic challenge, particularly in low-resource settings. There is a need for clinicians to have a high index of suspicion and provide timely surgical intervention necessary to reduce complications and mortality associated with the condition.

Leiomiomul vaginal: prezentare de caz şi review narativ

Leiomyoma is one of the most common tumors of mesenchymal origin, being detected in 70% of women of reproductive age. Vaginal leiomyoma (VL) refers to quite rare tumors. To date, about 300 cases of VL have been published in the English language specialized literature. We present the case of a 25-year-old patient, complaining of vaginal discomfort and periodic pains of varying intensity. Ultrasonography examination revealed a 21.9x17.6 mm hypoechoic mass on the anterior vaginal wall, normal-sized uterus, and normal bilateral adnexa. MRI examination determined a 25x18x22 mm isointense solid tumor in the fornix (the left side of the cranial part of the vagina), clearly dissociated from the surrounding tissues. Surgical enucleation was performed. Histopathology testing of the specimen revealed that it was a leiomyoma of the vagina. A clinical examination at a follow-up consultation, after 14 months, showed that her vagina was normal. We also present a brief review of the English language literature on the features of diagnosis and treatment methods for vaginal leiomyoma.

PS-R06-7: CAUDAL REGRESSION SYNDROME AS A CAUSE OF SECONDARY HYPERTENSION

Hypertension (HT) is a disease with a mainly multifactorial etiology. Although monogenic, embryological, epigenetic causes are rare and the interdisciplinary approach is essential to arrive at the diagnosis. We present the case of a 22-year-old patient with a history of congenital myelomeningocele and daughter of non-consanguineous parents, hospitalized for a hypertensive crisis (220/112 mmHg). It is referred to rule out genetic causes of hypertension. The genealogy shows a history of hypertension and ischaemic heart disease in both parental lines, in two previous generations. Physical examination revealed bilateral pes cavus in the lower limbs, edema, and overlapping of the second toe over the first toe on the left foot. She presented calf atrophy and incontinence, with the use of a bladder catheter and a continent stoma, as post-surgical sequelae. As a relevant finding, elevated aldosterone and plasma renin activity. Normal blood and urine catecholamines, VMA and normetanephrines. MRI of the abdomen and pelvis revealed a double left renal artery corroborated by CT angiography, a right extrarenal pelvis and a bicornuate uterus of normal size. Doppler of renal arteries showed no signs of significant stenosis. Right renal artery 43 cm/s and left renal artery 103 cm/s. The patient presents diagnostic criteria compatible with a caudal regression syndrome, a spectrum of clinical phenotypes with malformations in the lower hemibody that involve the 3 embryonic layers. It is postulated that, in this case, the hypertension is secondary to the embryological defect. The patient continues to be medicated with perindopril/indapamide 10/2.5 mg with adequate blood pressure control. JOURNAL/jhype/04.03/00004872-202301001-01322/figure1/v/2023-10-24T163949Z/r/image-jpeg

Nonvirilized external genitalia in a Nigerian female neonate with salt-wasting congenital adrenal hyperplasia

Abstract A 3-week-old female neonate presented with complaints of weakness and inability to feed. She had been delivered at a general hospital with a birth weight of 3.3 kg. She had jaundice, which was treated with phototherapy and resolved after 3 days. Pregnancy and delivery were uneventful. Parents identified her as female. Examination revealed hanging skin folds, dehydration, tachycardia, hyperpigmentation and swelling of the labial folds, no clitoromegaly, and no palpable gonads. She had lost 30% of her birth weight and was hypoglycemic. Serum investigations showed hyponatremia, metabolic acidosis, hyperkalemia, and hypocortisolemia with elevated testosterone and 17-hydroxyprogesterone. Pelvic ultra sound scan showed normal-sized uterus and no testes suggesting a diagnosis of salt-wasting congenital adrenal hyperplasia (CAH). She is being managed with hydrocortisone, fludrocortisone, and added salt to feeds. Labial swelling and hyperpigmentation have resolved and external genitalia is typically female in appearance. She is gaining weight and thriving. Salt-wasting CAH can present with adrenal crisis without obvious virilization of the external genitalia in the female neonate and can be diagnosed by scrutiny of electrolytes in the sick neonate.

A rare case of the new entity of müllerian anomalies mimicking the noncommunicating rudimentary cavity with hemi-uterus: accessory cavitated uterine mass

To demonstrate the laparoscopic excision of an accessory cavitated uterine mass (ACUM) and show that atypical anomalies can lead to the misdiagnosis of a noncommunicating rudimentary horn. Description and step-by-step demonstration of the surgical procedure using a video recording (Canadian Task Force Classification 3). University hospital. A 17-year-old virgin girl with chronic pelvic pain and severe progressive dysmenorrhea despite using nonsteroidal anti-inflammatory drugs and oral contraceptives since her menarche. We could not perform transvaginal examination and ultrasonography because of the virginity of the girl. Transabdominal ultrasound revealed a 24 × 24-mm heterogeneous cystic mass on the left adnexal region suggesting a noncommunicating functional rudimentary horn. This mass was within the left lateral uterine myometrial wall, and otherwise, the uterus and endometrial cavity seemed normal on ultrasonographic examination. Magnetic resonance imaging showed a cavitated nodule of 25 mm with hemorrhagic components inside the mass on the left side of the uterus and the normal endometrial cavity with a normal size uterus. After detailed evaluation and counseling, a decision was taken to perform laparoscopy. Laparoscopic resection of the ACUM. On laparoscopic exploration, we first observed a globular enlargement on the left wall of the uterus under the round ligament. Both the ovaries and the uterus were normal, and there were two normally developed fallopian tubes with no abnormality communicating with the normal uterus. The mass had irregular muscle fibers and ambiguous limits for detaching from the normal myometrial tissue. Afterward, the mass was resected completely without entering the endometrial cavity. It was thought that these irregular borders may be a factor of confusion as a degenerated myoma on the diagnosis. The blunt and sharp dissection methods were used bidirectionally, and finally, the lesion was enucleated. The mass was incised, and chocolate-like brownish fluid spilled out from the cavity of the mass. The endometrium-like epithelium and surrounding muscular layer were seen on the mass. The myometrial defect was approximated and closed with a polyglactin absorbable suture. Histopathological examination revealed the endometrial lining cavitated mass surrounded by myometrium, and thus, it was consistent with the diagnosis of ACUM. The postoperative period of the patient was uneventful. She was discharged without any complaint. Her severe pelvic pain and symptoms of dysmenorrhea were resolved 1 month after the surgery. We did not prescribe any medication for menstrual suppression and pain management before or after surgery. During the follow-up period, she had a regular menstrual cycle and no pelvic pain and dysmenorrhea for 2 years. Accessory cavitated uterine mass is a new entity having a normal endometrial cavity and is different from other müllerian duct anomalies. Severe dysmenorrhea and chronic pelvic pain are early-onset, and they are persistent despite using medications, but suspecting this problem is the main determinant for confirming the diagnosis. The final diagnosis of ACUM can be made after resecting the mass and confirming with histopathological examination. Accessory cavitated uterine mass may be confused with a similar lesion of juvenile cystic adenomyosis (JCA). They present very similar clinical and pathological findings, but JCA is a rare form of focal adenomyosis that contains cystic contents inside the lesion, and it has more intense adenomyosis surrounding the endometrial lining of a cavitated mass. In our case, histopathological examination revealed muscle fibers around the endometrial epithelium, with no adenomyotic foci. It was so difficult to distinguish these two similar lesions during the surgery. Thus, we could distinguish ACUM from JCA with this pathological confirmation. Accessory cavitated uterine mass may also be misdiagnosed as U4a of ESHRE/ESGE classification and 2b of ASRM classification, but it should be distinguished from these anomalies. Moreover, it is important to define ACUM clearly in the U4 or U6 class of the ESHRE/ESGE and 2b of ASRM classification systems.

Correlation of laparoscopic finding with ultrasonography and hysterosalpingography findings in females with infertility

Infertility is best defined as the inability to conceive after one year of unprotected regular intercourse or many couples, infertility and its treatment cause a serious strain on their interpersonal relationship, and cause disturbed relationships with other people.Diagnostic laparoscopy is generally not a part of initialinfertility evaluation, however, number of reports haveshown that it is effective procedure for evaluation of long- term infertility. A total of 207 patients were studied from at GMCH, Gondia, Maharashtra. Total 207 patients had primary/secondary infertility and 5 patients had primary amenorrhea were selected for study. Uterus, ovaries, tubes and cul de sac were inspected and findings noted. Next chromopertubation test was done with 10-15 ml of 1% aqueous methylene blue via the leech-Wilkinson cannula was inserted and findings noted and statistical Analysis was done.India showed the mean age of infertility was 28.4years. 81.16% subjects had primary whereas 16.43% had secondary infertility.In the present study maximum 165 (79.7%) had normal size uterus. Out of which 8 (3.86%) had bicornuate uterus.6.28% subjects had large size uterus. Out of which 5.80% had fibroid and 0.48% had adenomyosis.Diagnostic Laparoscopy and hysteroscopy is a better modality for diagnosing uterine, tubal and ovarian causes of infertility compared to hysterosalpingography and ultrasonography. Most of the patients had normal ultrasonographic, hysterosalpingographic and laparoscopic findings. Out of the rest, Structural adhesions were the most common cause of infertility among women in reproductive group.

Infrahepatic Implantation of an Ectopic Pregnancy

Background: Ectopic pregnancies occur predominantly in the fallopian tubes or ovaries. Very rarely, the distal part of the greater omentum may have close contact to the fallopian tubes and implantation of the embryo may occur in this part of the greater omentum. In the absence of signs of pregnancy in the uterus or the fallopian tubes, the greater omentum has to be closely examined for ectopic pregnancy. Case Presentation: A 22-year-old woman in her 4th week of pregnancy presents with spotting and severe pain in the right lower abdomen with a history of 2 cesarean sections. The sonographic examination showed a normal uterus with a thin endometrial line. The uterine cavity did not present with any signs of a gestational sac. A great amount of free fluid in the Douglas cavity suspicious of a hemoperitoneum. ßhCG-values in serum was highly elevated up to 16749 mU/ml and confirmed the suspicion of an ectopic pregnancy. A diagnostic laparoscopy was performed, during which a blood clot reaching from the right lower abdomen to the greater omentum was detected. After removing the blood clot, a normal-sized uterus with regular ovaries and no signs of a pregnancy in the fallopian tubes were seen. However, an abdominal adhesion in the right upper part of the omentum close to the liver with bleeding was seen. While examining the abdominal cavity for the cause of bleeding, a small cystic lesion adherent to the greater omentum – close the offspring from the colon – representing an ectopic pregnancy became apparent. A partial omentectomy of 9,5 cm x 5,5 cm x 2,5 cm was performed with the finding of trophoblast and embryoblast implantated in the infrahepatic part of the greater omentum. Conclusion: In cases of ectopic pregnancy with hemoperitoneum, special care has to be taken examining not only the fallopian tubes or ovaries but also the greater omentum, which may harbour an implanted trophoblast and embryoblast – even in the upper part directly beneath the liver – as presented in this case. In cases of ruptured ectopic pregnancy of the greater omentum, the cases may be dealt with laparoscopic partial omentectomy if the case is early detected.

Laparoscopic blockage of uterine artery in the management of large cornual pregnancy

To present a technique of temporary uterine artery clamping before laparoscopic surgery for prevention of blood loss in cornual ectopic pregnancy. Step-by-step explanation of the entire surgical procedure using video and still images (Canadian Task Force classification III). Tertiary university-based hospital. A 37-year-old woman who presented with amenorrhea of 55 days and extremely high β-hCG level of 281,400 mIU/mL. Transvaginal ultrasound examination revealed a 7 cm mass with ample blood supply invading the muscularis layer around the right uterine cornua. Institutional Review Board and Ethics Committee approval was obtained. After pelvic adhesiolysis, retroperitoneum was dissected and the bilateral uterine arteries were exposed. To reduce the possibility of massive hemorrhage, titanium clips were used to temporarily block the bilateral uterine arteries. Laparoscopic inspection showed the mass as dark and blue, consistent with the diagnosis of cornual pregnancy. After removal of the cornual lesion, 2-0 Vicryl was used to reconstruct the uterine cornua. At the end of the surgery, the titanium clips were removed to reverse the uterine blood supply. The surgery lasted for about 2 hours, with estimated blood loss of only 50 mL. The patient recovered completely and was discharged 2 days postoperatively, without any further bleeding or postoperative complications. The pathological examination confirmed the diagnosis of cornual pregnancy. One month later, the β-hCG levels decreased to within normal range. At 6-month postoperative follow-up, ultrasound examination showed a normal size uterus. Temporary blockage of the uterine artery during surgery could prevent heavy blood loss, especially in difficult surgeries such as myomectomy for complex uterus fibromas or adenomyomectomy. Moreover, this technique would be feasible for emergent cases, including conservative surgery for cesarean scar pregnancy, and could also replace traditional uterine artery embolization for treating cornual pregnancy.

Does Uterine Manipulator Type Affect Surgical Outcomes of Laparoscopic Hysterectomy?

Objectives:Many surgeons use uterine manipulator (UM) during laparoscopic hysterectomy (LH). In this study, we aimed to compare the outcomes of LH operations performed by using partially reusable UM with the articulated system (artUM) and disposable (dUM) UM without articulation.Materials and Methods:A total of 99 patients underwent the LH operation. This study was carried out with 35 of those 99 Caucasian patients who met the inclusion criteria. Group 1 consisted for 7 LH operations using the articulated RUMI® II/KOH-Efficient™ (Cooper Surgical, Trumbull, CT, USA) system (artUM), while Group II consisted of 28 patients using old-type V Care®(ConMed Endosurgery, Utica, New York, USA) dUM as UM.Results:Mean operation time was found to be 157.1 ± 42.0 min. The operation time was found statistically longer in Group 1, consisted of artUM used patients (P = 0.006 and P < 0.05). No statistically significant difference was found between two groups in terms of surgical results such as, delta hemoglobin value (P = 0.483 and P < 0.05), length of hospital stay (P = 0.138 and P < 0.05), and postoperative maximum body temperature (P = 0.724 and P < 0.05).Conclusion:The UM type did not alter the surgical outcomes except the operating time in our study. According to our results, the surgical technique is a more significant variable than instruments used in LH for normal size uterus. Further prospective, large-scale studies comparing various UM systems are mandatory.

Adnexal Mass with an Unknown Histology

Background: Ovarian malignancy is a common malignancy in women. Most malignancies are adenocarcinoma. However, adnexal metastases from squamous cell carcinoma (SCC) of the cervix are uncommon. Case: We present a 53-year-old nulliparous postmenopausal woman who presented with pain in abdomen, adnexal mass, and high CA125 levels. On local examination, vagina and cervix were apparently healthy with retroverted uterus of normal size, and bilateral (B/L) forniceal thickening was present. Pouch of Douglas and rectal mucosa were free. Clinicoradiologic diagnosis was an ovarian malignancy. Results: Intraoperatively, ∼150 mL mucinous ascites and omental caking with subcentimeter deposits on right subhepatic peritoneum were noted. Uterus was apparently normal and B/L adnexal masses with stretched and dilated B/L tubes were seen, ovaries could not be visualized separately (right = 6 × 5 cm, left = 7 × 4 cm). B/L pelvic lymph nodes were grossly enlarged with pelvic peritoneal deposits. A total abdominal hysterectomy with B/L pelvic lymph node dissection with total omentectomy with excision of pelvic and subhepatic peritoneal deposits with appendicectomy was done and a Sugarbaker's completeness cytoreduction score 0 (CC-0) was achieved. Final histopathologic examination postsurgery revealed disseminated SCC of the cervix. Conclusions: Before confirming a diagnosis of primary SCC of the ovary, a consideration of possible origin from a cervical tumor should be made, unless overt features of primary neoplasia are immediately obvious.

Laparoscopic Salpingo-oophorectomy for Left-sided Primary Ovarian Hydatid Cyst

A 39-year-old woman presented with dull aching, continuous, left lower abdominal pain for the past 6 months. Her menstrual history was normal, and she had 2 cesarean sections in the past. Her medical history was unremarkable. A gynecologic examination revealed an acutely anteverted normal-sized uterus and fullness in the left posterior fornix. An ultrasound of the abdomen revealed a large multiseptated left ovarian cyst with normal findings in the upper abdomen. A computed tomography showed a well-defined multiloculated left complex ovarian cyst in the pelvis, situated in the midline toward the left side (12 × 11 × 10-cm) along with left hydrosalpinx (Fig.

Severe direct and indirect complications of morcellation after hysterectomy or myomectomy

Introduction Despite the significant advantages of morcellation, it may be associated with severe complications. We aimed to determine both direct and indirect complication rates of morcellation at gynecological laparoscopy. Material and methods This multicenter retrospective study included patients traced from 2008 to 2017. We identified women who underwent an operation with the use of electromechanical power morcellation (EMM) or vaginal manual morcellation during laparoscopy. Clinical records, intraoperative-postoperative outcomes were reviewed. Results We analyzed 1795 patients who underwent laparoscopic supracervical hysterectomy (LASH), total hysterectomy (TLH), or myomectomy (45.5%, 14.2%, and 40.3%, respectively). No severe intraoperative complications associated with morcellation or parasitic leiomyoma were observed. Patients with unexpected sarcoma were detected in five cases (0.28%). Four of them were detected after LASH and one after vaginal manual morcellation following TLH, who had an intraabdominal recurrence and died after 18 months. The patients after LASH underwent secondary laparotomy for staging; no histological dissemination of sarcoma was observed, however two had a recurrence. The five-year survival rate was 80%. Conclusions There is a small risk of intraoperative complications or unexpected malignancy following morcellation, provided the surgeon adheres to regular surgical standards. In patients with a normal size uterus, TLH could be preferred over LASH to avoid morcellation.

Aromatase deficiency: A case series of 46, XX Chinese children and a systematic review of the literature.

Aromatase deficiency (AD) caused by cytochrome P450 family 19 subfamily A polypeptide 1 (CYP19A1) variants is characterized by a deficiency in androgen-to-oestrogen conversion. To investigate the clinical characteristics and accurate management of aromatase-deficient children. We described three 46, XX aromatase-deficient children, searched PubMed with "(aromatase deficiency) AND (46, XX OR ovaries)" and manually searched citations in identified studies for the literature review. Two girls and one boy (3.4-9.2years) with the 46, XX karyotype presented ambiguous genitalia and maternal antenatal virilization, normal-low height, delayed bone age, normal glucose and lipid profiles, markedly elevated follicle-stimulating hormone (FSH) levels and poor oestradiol responses to human menopausal gonadotropin stimulation. Ultrasound revealed normal-sized uterus and ovaries with undetectable follicles. Histopathology revealed primordial follicles and few primary follicles in ovaries. One patient presented granulosa and follicular membrane cell proliferation and interstitial sclerosis. We identified four CYP19A1 variants; c.146_158del and c.344G >A were unreported. We reviewed available data from thirty 46, XX patients (0.2-32years). Some patients were not diagnosed until puberty/adulthood; three were initially misdiagnosed with congenital adrenocortical hyperplasia. The main characteristics were maternal antenatal virilization (21/29), ambiguous genitalia (mainly Prader IV or III, 19/23), delayed bone age (16/17), low bone mass (5/8), markedly elevated FSH levels and ovarian cysts (13/30). 46, XX AD is easily neglected or misdiagnosed. Ambiguous genitalia, maternal antenatal virilization and markedly elevated FSH levels are important diagnostic indicators. We described two novel variants, new histopathological features of ovaries and an early management strategy.

A Novel Transvaginal Natural Orifice Transluminal Endoscopic Approach for Ectopic Pregnancy Surgery with Intra-abdominal Adhesion

A 29-year-old woman, gravida 2 para 1001, presented with irregular vaginal bleeding since 7 weeks 2 days and a serum β-human chorionic gonadotropin level of 3000 mIU/mL. The patient had undergone 2 open abdominal surgeries for necrotizing pancreatitis 4 years ago. Abdominal and bimanual examinations revealed an inverted, U-shaped surgical scar from a previous surgery (Fig. 1) and a normal size uterus without any tenderness or pain.

Laparoscopy-assisted Neocervicovaginal Reconstruction in a Rare Case of Müllerian Anomaly: Cervicovaginal Aplasia with Unicornuate Uterus

To demonstrate a technique of laparoscopy-assisted neocervicovaginal reconstruction in a case of cervicovaginal aplasia. Step-by-step demonstration of the surgery in an instructional video. Cervicovaginal aplasia is a rare congenital anomaly that occurs in 1 in 80 000 to 100 000 live births [1]. Occasionally, there can be other associated anomalies. Epigenetic modifications of homeobox and Wnt genes (wingless-type mouse mammary tumor virus integration site family) are hypothesized to cause defects in the development of the müllerian reproductive tract by interfering with cell migration during organogenesis [2]. Our patient was a 15-year-old girl who had a unicornuate uterus along with cervicovaginal aplasia (American Society for Reproductive Medicine class Ia, Ib, and IIc and European Society of Human Reproduction and Embryology class U4a, C4, and V4). The most common approach to treat this particular anomaly is hysterectomy, but there are many reports of neocervicovaginal reconstruction with good results [3]. Laparoscopic assessment showed a right unicornuate uterus with hematometra, right hematosalpinx, and a left noncavitary rudimentary horn with endometriosis. A vertical incision was made over the most prominent bulging part of the uterine fundus, and the hematometra was drained. Laparoscopic inspection of the uterine cavity showed an irregular cavity with thickened endometrium. The cervical canal could not be identified. The inspection of the external genitalia revealed complete vaginal aplasia. An inverted T incision was made over the vestibule and neovagina created by blunt digital dissection. The bladder was laparoscopically mobilized down. A Maryland dissector was inserted into the uterine cavity through the incision in the fundus and directed toward the neovagina. The myometrium was then punctured while simultaneously visualizing the neovagina to create a neocervix. A 16-F Foley's catheter was then pulled into the uterine cavity with the Maryland dissector from the vaginal end. The neocervix was enlarged around the catheter and then sutured to the vestibular epithelium with 6 interrupted 1-0 polyglactin sutures. The Foley's catheter was anchored to the myometrium laparoscopically, and the uterine incision was closed with interrupted 1-0 polyglactin sutures. The right hematosalpinx was then excised. The intravaginal plastic mold was removed after 4 days. The patient was advised to use the bulb of a plastic pipette to help maintain vaginal patency. She resumed her menses 3 weeks after the surgery. Follow-up at 8 months revealed a normal-sized uterus on transabdominal ultrasound and a vaginal length of 5.5 cm on speculum examination. She currently reports regular cyclic menstruation with mild dysmenorrhea and has not yet begun sexual activity. Cervicovaginal aplasia can be successfully treated by laparoscopy-assisted neocervicovaginal reconstruction as demonstrated in the video.

Feasibility and Outcomes of Opportunistic Bilateral Salpingectomy in Patients with Traditional Relative Contraindications to Vaginal Hysterectomy

To compare the feasibility of opportunistic bilateral salpingectomy (OBS) at the time of vaginal hysterectomy (VH) for benign disease in patients with and without relative contraindications (RCs) to the vaginal approach and to evaluate the factors that contribute to the inability to perform OBS. Retrospective chart review. Tertiary medical center. Women undergoing hysterectomy for benign indications between November 2014 and October 2017 who were consented for either VH with or without removal of tube(s) and/or bilateral salpingectomy. RCs to the vaginal approach are defined as lack of prolapse (cervix high, cervix not visualized, cervix tucked underneath pubis, or minimal descent), enlarged uterus (≥250 g or a size of a ≥12-week uterus), nulliparity, obesity (body mass index ≥30 kg/m2), previous cesarean section (CS), known adhesions, and known adnexal pathologic condition. A total of 258 patients underwent VH and attempted to undergo OBS within the study period; of these, 112 patients (43.4%) had no RC, and 146 patients (56.6%) had ≥1 RCs. Overall, successful salpingectomy was performed in 86.8% of patients. There was no significant difference in the rate of success in patients without or with ≥1 RCs (84.9% vs 89%, p = .15). Salpingectomy was unsuccessful in 13.2% of patients (n = 34). In a multivariable logistic regression analysis, the odds of unsuccessful OBS were 3.83 times higher in patients without prolapse (confidence interval [CI], 0.99-14.76; p = .051), 2.71 times higher in patients with obesity (CI, 1.23-5.94; p = .013), and 3.07 times higher in patients with previous CS (CI, 1.17-8.08; p = .023) as compared to patients without any relative contraindications. An enlarged uterus was associated with successful salpingectomy (odds ratio, 0.28; 95% CI, 0.08-0.94; p = .039) compared with a normal-sized uterus. When excluding enlarged uterus, patients with 2 to 3 RCs had 11.24 and 6.8 higher odds of an unsuccessful OBS than patients with no (CI, 3.73-33.87; p <.001) and 1 RC (CI, 2.36-19.63; p <.001), respectively. There were no differences in postoperative stay or rates of readmission among patients with or without successful salpingectomy at the time of VH. OBS is associated with a high overall rate of success in patients with and without traditional RCs to VH. Lack of prolapse, obesity, and previous CS were associated with failed attempt at salpingectomy. Patients with ≥2 RCs to VH should be counseled about the high likelihood of failed salpingectomy.

Retained Intra Uterine Contraceptive Device in a thirty year old woman leading to secondary infertility

The use of Intra-Uterine contraceptive device (IUCD) had been found to be associated with several complications such as bleeding, perforation or migration into surrounding tissues or the omentum and retention. This is a case of a 30-year-old woman who had insertion of IUCD six years before presentation in the clinic which was believed to have been removed. However, uterine ultrasound showed that the IUCD was retained. She then presented with inability to achieve pregnancy of three years duration despite adequate unprotected sexual intercourse. She had Intra-Uterine contraceptive device inserted six years before presentation which she said a Doctor at a private hospital had removed two years after insertion. Her last confinement was about six years before presentation. However, uterine ultrasound showed a normal-sized uterus containing an Intra-Uterine contraceptive device. The retained IUCD was subsequently removed by dilatation and curettage and the patient became pregnant two months later. With appropriate investigation, in this case, accurate ultrasound, it was possible to locate the IUCD and subsequently removed it to solve the patient’s problem.

2022 Laparoscopic Isthmocele Repair with Hysteroscopic Assistance

Video Objective To demonstrate the surgical technique of the laparoscopic isthmocele repair. Setting A 35-year-old woman with a previous caesarean refers secondary infertility of 1 year of evolution and abnormal uterine bleeding. Saline-infused sonohysterography shows a normal size uterus and an Isthmocele in the Left side with a residual myometrium of 0 mm. Interventions We describe the surgical technique for isthmocele correction by laparoscopy with the help of hysteroscopy to identify the area to be resected. Then, the abnormal tissue is resected with scissors and with a monopolar electrode. Finally the uterine wall is sutured. Conclusion The laparoscopic isthmocele repair is an easily reproducible technique for the treatment of this disease. In most cases the improvement of symptoms such as abnormal uterine bleeding and infertility is achieved.

A lady with repeated vomiting - unexpected diagnosis

Background: Vomiting is a symptom commonly encountered in emergency settings, with many differential diagnoses. In the following case, the diagnosis was nearly missed and the outcome could have been critical. Methods: A case study was performed, supported by literature review. A 32 year-old lady presented to the Emergency Department with repeated vomiting for one day. She has had epigastric discomfort for several days. Her blood pressure was 119/74 mmHg, heart rate 118/minute, and she was afebrile. She had been under the in-vitro fertilisation program and received human chorionic gonadotrophin, oocyte retrieval and embryo transfer 8, 6, and 3 days respectively prior to presentation. On examination, her abdomen was soft, non-tender. Urinary pregnancy test was negative. Her sodium level was 131 mmol/l, Hb 17.0 g/dL, white cell count 20.5 × 10*9/L, and platelet 485 × 10*9/L. The rest of the renal and liver functions and amylase, were normal. She was admitted to the Emergency Ward with a working diagnosis of gastritis. On reassessment, her abdomen was noted to be slightly distended although no tenderness or guarding was elicited. Ovarian hyperstimulation syndrome was suspected, and gynaecology was consulted for further evaluation. Results: Transvaginal ultrasound scan showed a normal-sized uterus with thickened endometrium and no intrauterine sac. Both ovaries were enlarged, left ovary 6.1 × 4.3 cm and right ovary 5.0 × 5.3 cm. Significant pelvic free fluid was present. The diagnosis was confirmed to be early ovarian hyperstimulation syndrome. Ovarian hyperstimulation syndrome is an iatrogenic complication from assisted reproduction technology. Following gonadotropin therapy, this condition usually develops several days after oocyte retrieval or assisted ovulation, with ovarian enlargement due to multiple ovarian cysts. Complications include ascites, haemoconcentration, hypovolaemia, and electrolyte imbalances. Conclusion: Emergency physicians should consider ovarian hyperstimulation syndrome in patients who had received assisted reproduction presenting with repeated vomiting.