| Abdominal
pain after delivery should not be taken lightly. It may mimic intestinal
obstruction. Ultrasound was done to find out the cause. After exploratory
laparotomy we could come to a diagnosis of torsion of ovarian cyst. |
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Fig. 1 : A huge 14 x 12 x 10 cm cyst in the region of R ovary with
omentum adherent anteriorly which had undergone torsion and was
the cause of acute abdominal pain. |
Fig. 2 : Cut
section of L adnexal dermoid
4 x 5 x 5cm with hair and sebaceous material |
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CASE
REPORT
Mrs. ABC, Gravida3 Para3 was admitted in active labour to LTMG Hospital.
She was antenatally registered at the same institute but with only 1 visit
at 6 months of pregnancy. She had no prior ultrasound examination. She
delivered a full term 2.7 kg male baby vaginally four hours after admission.
Sixteen hours after delivery she complained of sudden and severe abdominal
pain and distension. On examination her vital parameters were stable.
On general examination the abdominal girth was increased and the uterine
size corresponded to 24 weeks postpartum state. There was generalized
abdominal tenderness more in the right iliac fossa and right lumbar region.
The bowel sounds were sluggish. On the basis of these findings a provisional
clinical diagnosis of subacute intestinal obstruction was made.
The baseline reports were :
Hb - 9.5 gm%, TC - 6800, S Na+ - 140 mEq/L, S K+ - 3.2 mEq/L, X-ray findings
were normal, USG abdomen and pelvis
showed a postpartum uterus with dilated gut loops. Nasogastric
intubation was done, parenteral fiuids started and broad spectrum antibiotics
administered intravenously. The patient improved with this conservative
management. The abdominal girth decreased by 2", but tenderness persisted
for 24 hours. After this a well defined mass with regular borders, smooth
surface and solid consistency about 10 x 10 cm became palpable in the
right lumbar region and right iliac fossa. A repeat ultrasound done surprisingly
revealed a 14 x 10.6 x 7.3 cm sized right ovarian mass with internal echoes.
There was another 3.3 x 2.1 cm sized anechoic area in the pelvis. In view
of the above findings a decision to perform an exploratory laparotomy
was made. The patient was administered general anaesthesia. A
midline vertical infraumbilical incision was made. On laparotomy findings
in situ were: - Uterus 20 weeks postpartum involuting status. A huge twisted
cyst in the right ovary about 14 x 12 x 10 cm, well encapsulated, smooth
surfaced, omentum adherent anteriorly and appendix and ileocaecal junction
adherent posteriorly (Fig. 1). Examination of the left adnexal region
reveal a 4 x 5 x 5 cm dermoid cyst. (Fig. 2) The cyst was isolated and
separated carefully by blunt and sharp adhesiolysis. The pedicle of the
cyst was ligated and divided. Right ovariectomy was done and on the left
side ovarian cystectomy was performed for removal of the dermoid. The
small bowels were examined and revealed no gross abnormalities. There
was no evidence of tuberculosis. The appendix appeared infiamed hence
an appendicectomy was performed by a general surgeon. The wound was closed
in layers. Fig. 2 : Cut section of L adnexal dermoid 4 x 5 x 5cm with
hair and sebaceous material On histopathology of the cyst the findings
were consistent with those of an ovarian dermoid. The post operative period
was uneventful; the patient recovered well and was discharged on the 10th
postoperative day after suture removal. |
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DISCUSSION
Large sized ovarian cysts can undergo torsion during pregnancy and labour
due to an exacerbation of haemodynamic impulses.1 Though dermoids are
the most common ovarian tumours associated with pregnancy, it is important
to document the histopathology to exclude other conditions like “Sex
cord tumours”.2
CONCLUSION
This case is presented to highlight the importance of at least a single
antenatal ultrasound which would have probably detected this condition
earlier. The clinical diagnosis was obscured due to a bulky postpartum
uterus with abdominal distension.
REFERENCES
1. Williams Obstetrics. 21st edition. Neoplastic Diseases Ch 55-1452.
2. Shitecar P, Turner S, Higby K. Adnexal masses in pregnancy: A review
of 130 cases undergoing surgical management. Am J Obst Gynecol 1999; 181
: 19. |
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THYROID
EYE DISEASE
Grittiness or redness of the eyes alone or with periorbital oedema
is the commonest manifestation of thyroid eye disease (TED), and
is frequently mistaken for conjunctivitis. TED is often asymmetrical
and not infrequently unilateral. Up to 30 per cent of patients
present with TED months or years before developing thyrotoxicosis,
and up to ten per cent never develop thyrotoxicosis. Up to two
per cent of affected individuals actually present with hypothyroidism.
CT or MRI imaging can be used to diagnose TED, even in euthyroid
patients. The presence of multiple enlarged extraocular muscles
is diagnostic. This is of importance in planning treatment, as
active eye disease with oedema responds well to immunosuppression,
whereas burnt-out eye disease with fibrosis does not.
The Practitioner, 2003; 247 : 570. |
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