| 1. Importance of Repeat Angiogram in Non-Traumatic
Subarachnoid Haemorrhage |
| |
| Gunjan Aeron, Anand Alurkar, DB Modi,
Anil Karapurkar |
Most cases of non-traumatic subarachnoid haemorrhage
are caused by rupture of an arterial aneurysm or an arteriovenous
malformation. The first angiogram, performed within a week
of clinical presentation, may be negative in 10-30% cases of
spontaneous SAH documented on CT scan, MRI and/or lumbar puncture.
A repeat angiogram done about 2 weeks to 3 months after the
bleeding may reveal the origin of the haemorrhage in 5-10%
cases. Reasons for false negative angiogram include technical
and interpretation factors, vasospasm etc.
A 45 year old female was admitted in Bombay Hospital with complaints of severe
headache and neck pain. She had no neurological deficit. Two days prior to admission
she had subarachnoid haemorrhage. Clinically she was in Grade I of SAH (Hunt-Hess
classification). CT scan showed SAH and blood in the fourth ventricle. Four vessel
DSA was done on the 17th of July 2003. Bilateral vertebral artery angiography
revealed tortuous hypoplastic right vertebral artery. The left vertebral artery
was also tortuous. Basilar artery was hypoplastic. Both the posterior cerebral
arteries filled from the internal carotid artery and not from the basilar artery.
No aneurysm was seen. Repeat DSA was recommended and the patient was discharged.
She continued to have severe headache which was relieved after 2 lumbar punctures.
No readmission, repeat DSA was done on the 13 th of August 2003 which revealed
a small round 2 mm diameter aneurysm on left vertebral artery at its junction
with the posterior inferior cerebellar artery. The fundus of the aneurysm was
directed upwards. Endovascular treatment was advised as surgical treatment for
posterior circulation is associated with high morbidity and mortality. The risks
of endovascular treatment were explained. These occur in less than 2% of the
cases and include 1) perforation 2) thromboembolism 3) parent artery occlusion.
Satisfactory endovascular treatment was done using 2 mm x 2 cm GDC coil. |
| |
| 2. Traumatic Dissection of Carotid Artery |
| |
| Chetan Panchal, Anand Alurkar, Anil Karapurkar,
DB Modi |
The incidence of traumatic dissection of the
carotid artery is 0.5% of total post traumatic injuries. Following
increasing incidence of road traffic accidents and use of seat
belts this incidence is increasing. Delay in the diagnosis
is common because of lack of awareness. Late detection increases
the risk of morbidity and mortality. Increasing awareness and
proper management reduces the morbidity and mortality.
A 25 year old lady was admitted following road traffic accident. She was unconscious
on admission but rapidly recovered. CT scan showed left frontal depressed fracture.
She was operated and depressed fracture was elevated. Several hours later she
developed mild weakness of right upper limb and dysphasia. She later worsened
further. Repeat CT scan showed hypodense area in the left MCA territory suggestive
of ischaemia or infarction. This increased further on follow up CT scan. Clinically
there were bruises on the left side of the neck. Angiography showed subtotal
occlusion with a thin sreak extending upwards upto the cavernous ICA suggesting
ICA dissection. The neurological deficit was probably due to multiple episodes
of repeated embolism. After documenting adequate collateral flow through anterior
and posterior communicating artery, therapeutic occlusion was done to prevent
further embolism. Following this the patient improved clinically and CT scan
72 hours later showed marked reduction in the hypodense area. |
| |
| 3. Role of Radiation Therapy in Soft-tissue Sarcoma |
| |
| Avtar Raina, AJ Chaudhary |
Soft-tissue Sarcomas are highly heterogenous
group of tumours, arising from non-epithelial extra-skeletal
tissue of the body like-voluntary muscles, fat, fibrous tissues
and also peripheral nervous tissues, and constitute about 1%
of entire cancer burden.
Soft-tissue sarcomas are highly aggressive tumours, having the potential of spreading
locally, as well as to distant sites, lungs being the most common site of metastasis
(about 50%). Lymph node metastasis is seen in less than 5%. About 60% of soft-tissue
sarcomas arise in the extremities, 30% in trunk and about 10% in head and neck
region.
Conservative surgical excision and adjuvant radiotherapy achieves a high degree
of local control with improved cosmetic and functional results.
Radiotherapy can be delivered either by external beam alone or combining external
RT with brachytherapy.
External radiotherapy treatment encompasses the tumour site with 5-8 cm margins
on either side, sparing a generous long strip of normal tissue, upto dose of
60-65 Gy. Lymph node regions normally not treated.
Intraoperative brachytherapy with Ir-192 plays a major role in the management
of STS. Plastic tubes placed over the tumour-bed following the surgical excision,
are used to deliver the required dose to the bed. Total dose generally ranges
between 20-40 Gy.
Our study using brachytherapy with or without external radiotherapy has been
extermely satisfactory in terms of local control and complications and are comparable
to the data in literature. |
| |
| 4. Successful Endovascular Embolisation of Spontaneous
Retroperitoneal Haematoma Complicating Low Molecular Weight
Heparin Therapy |
| |
| Gunjan Aeron, Sundeep Punamiya |
Low molecular weight heparins are widely used
anticoagulants. However their liberal use is not without incident.
Major bleeding may occur as a complication in 5.2% cases. We
report three cases of spontaneous retroperitoneal haematoma
complicating low molecular weight heparin managed successfully
by endovascular embolisation.
Three patients in the age group between 55 and 75 years underwent angiographic
evaluation for retroperitoneal haematoma complicated by haemodynamic collapse
while undergoing LMW heparin therapy. Anticoagulation was indicated post angiographic
stenting in two patients and for management of ischaemic cerebrovascular disease
in one patient. Clinically all the three patients presented with haemodynamic
collapse, flank pain and abdominal mass within two to ten days of initiation
of anticoagulant therapy. The diagnosis of retroperitoneal haematoma was confirmed
on computed tomography/sonography. Digital angiography was done for further evaluation
and management. The origin of the bleed - the lumbar arteries, deep circumflex
iliac artery and the ilio-lumbar artery in respective cases - was identified
and selective endovascular embolisation done. Microcoil embolization using gelfoam/PVA
successfully controlled extravasation in all patients, with stabilization of
haemodynamic parameters.
Very few published reports are available on spontaneous retroperitoneal haemorrhage
complicating LMW therapy and its management. We conclude that although rare,
the possibility of LMW heparin therapy related bleeding must be considered in
patients on anti-coagulation presenting with haemodynamic collapse particularly
so in elderly patients.
Early diagnosis and management by selective transcatheter embolization may be
a viable life-saving option in spontaneous retroperitoneal haemorrhage complicating
low molecular weight heparin therapy. |
| |
| 5. Pictorial Essay of Mri in Orbital Pathologies |
| |
| Dinesh S Baviskar, Inder Talwar,
Sunila Jaggi |
Orbital pathologies have non-specific clinical
presentation and symptomatology, which mandates imaging, nonionising
nature, excellent soft tissue resolution and non-invasive nature
plays a vital role in imaging of the orbit.
Advent of higher field strength magnets (1.5 T) and surface coil have heralded
a new era in orbital imaging. MRI helps in determining the extent of the lesions
and differentiating lesions of the globe, optic nerve, intraconal and extraconal
pathologies, lacrimal gland and eyelid. MRI not only acts as a diagnostic modality
but also helps us to determine the response to treatment as in cases of thyroid
ophthalmopathy and orbital pseudotumour which shows change in signal characteristics
in response to steroid treatment.
Noninvasive vascular studies; i.e.; MR Angiography is useful in cases of carotid
cavernous fistula where a dilated superior ophthalmic vein can be demonstrated.
Contrast enhanced MRI demonstrates various orbital pathologies with excellent
details.
Optic nerve pathologies such as optic nerve glioma, meningioma of sheath of optic
nerve, optic neuritis and optic atrophy have characteristic MR features. Orbital
and periorbital vascular pathologies like capillary and cavernous haemangioma,
venous varix and eyelid haemangioma are demonstrated by MR Angiography and contrast
enhanced MRI. MRI also helps to differentiate Graves ophthalmopathy from pseudotumour
and lymphoma, which cause proptosis. Orbital neoplasm’s like melanoma,
retinoblastoma and metastases can also be evaluated using MRI.
MR imaging features of the various orbital pathologies were described and a comparative
study of MRI V/S CT imaging was done in 15 patients which revealed that MRI is
better as compared to CT in 14:1 cases. |
| |
| Abstracts of Papers Presented at The
112th Research Meeting of The Medical Research Centre of
Bombay Hospital, Convenor Dr. HL Dhar |
| |
| 1. De Novo Tuberculosis in Renal Allograft Recipients
- Our Experience |
| |
| HK Shah, SD Bichu, P Namboodiri,
V Dodke, UG Oza, AL Kirpalani |
To study the prevalence, clinical profile
and outcome of de novo post transplant tuberculosis (TxTB).
56/610 renal allograft recipients with TxTB between 1985 and 2003 were retrospectively
analysed. These patients (pts) received either Pred+Aza or Pred+Aza+CycA or Pred+MMF+CycA.
13 pts received antirejection therapy (Methylpred - 13; OKT3-2) for acute rejection.
The mean age was 34.3 ± 7.4 years. 18 pts. were diabetic and 12 pts. had
either Hepatitis B or C. 41 pts (73%) got TxTB in their first year after treatment.
Common sites of involvement were Pulmonary - 27, Lymphadenopathy - 14, Pleural
effusion - 6, Disseminated TB - 6, Pericardial - 3, Meningeal - 2, GI tract -
2, Spine-1, Palate-1; TB granuloma of renal allograft-1 and PUO which responded
to empirical AKT-5.11 pts (20%) had involvement of more than 1 site at the time
of presentation. The diagnosis was made by following methods: Radiological -
44, Bacteriological - 15, Serous fluid Biochemistry - 12; Histopathology - 10.
All pts. received INH, ETB and PZA. 25 pts. got Streptomycin, 19 Fluoroquinolones
and 10 Rifampicin in addition. 40/56 pts (71%) responded to ATT which was given
for 6,12 or 18 months. 10/56 pts (18%) expired during the course of treatment
due to other causes. One patient had relapse. 3 pts received second line ATT
for suspected drug resistant TB. ATT induced hepatitis occurred in 11 pts (19%)
of whom 6 had preexisting chronic liver disease.
The prevalence of TxTB was 9.2% in our centre. In contrast to other studies extrapulmonary
TB was more common than pulmonary and majority of cases occurred within the first
year of transplant. Predisposing factors for TxTB were : PTDM (25%), Hepatitis
B/C (23%) and antirejection therapy (23%). TxTB can be successfully treated without
Rifampicin.
|
| |
| 2. Hyperhomocysteinaemia in Chronic Kidney Disease |
| |
| Vidya Dodke, N Pravin, Hardik Shah,
B Shrirang, AL Kirpalani |
1. To study the incidence of hyperhomocysteinaemia
in Chronic Kidney Disease (CKD) patients (pts) on MHD and on
conservative treatment (Early CKD).
2. To study the effect of high dose Folate and haemodialysis in reducing and
normalising S. Homocysteine (Hcy) levels.
25 pts with CKD on MHD and 10 pts wit CKD on conservative treatment (ECKD) who
were on 5 mg of folate daily were included. Pts with Vit. B-12 deficiency and
those on folate antagonists were excluded from the study. All pts with hyperhomocysteinaemia
(S. Hcy > 15 mmol/l) were given folate in high doses i.e. 60 mg/d for 4 wks
and repeat Hcy levels done pre and postdialysis to see the effect of high dose
folate on S. Hcy levels.
The conventional 5 mg folate was able to keep only 8%, pts normohomocysteinaemic.
High dose folate increased the percentage of normohomocysteinaemic pts from 8
to 28% predialyis and 32 to 68% postdialysis. 50% of the pts receiving high folate
reduced Hcy levels by at least 5 mmols. High dose folate reduced Hcy levels by
22.6% in MHD group and by 33.47% in ECKD group.
Since each 5 mmol rise in Hcy levels has been shown by earlier studies to cause
50% increased risk of coronary artery disease (CAD), even the reduction of Hcy
in the absence of normalisation could help in reducing morbidity and mortality
due to CAD. On the basis of this finding we believe that the high dose of folate
was beneficial to 50% of the pts receiving it. Hyperhomocysteinaemia of CKD seems
to be refractory to even high doses of folate, suggesting that folate deficiency
is not the only cause of high Hcy levels in this population.
|
| |
| 3. Mycophenolate - An Initial Experience |
| |
| P Namboodiri, SD Bichu, HK Shah,
V Dodke, UG Oza, AL Kirpalani |
This is a retrospective analysis of the clinical
profile of 33 renal transplant recipients on MMF given either
as primary immunosuppression (group A, n=25) or switch over
therapy from azathioprine (group B, n=8). Patients with grafts < 3
months old were excluded. All patients also received Cyclosporine
and Prednisolone and 11 patients received Basiliximab as induction.
In group A, the major complications were : acute rejection - 3(12%), graft losses
- 4 (16%) [deaths - 3, graft thrombosis -1], post operative UTI-13 (52%), GI
complaints - 12 (48%), Opportunistic infections - 11 (44%) [HZV infection-3;
CMV disease-4, Pneumonia-2; Mucormycosis of paranasal sinuses-1; Pulmonary TB-1],
Seizures of unknown cause-3 (12%), Leucopenia-2 (8%). MMF was discontinued in
none. 3 patients (12%) needed readjustment of dose. In group B, (rescue therapy-5,
other causes-3), the major complications were : GI complaints - 3 (37%), Opportunistic
infections - 3 (37%) [CMV disease - 1, Pneumonia-2], Bronchiolitis obliterans-2
(25%), Leucopenia-1 (12.5%), while graft loss in 1 pt. (chronic rejection). There
was no patient loss. MMF was withdrawn in 4 patients (50%) [bronchiolitis obliterans-2,
leucopenia-1, GI complications-1].
When used as primary immunosuppression, the incidence of rejection was very low
(12%) and no graft was lost due to acute rejection. In these patients, MMF was
well tolerated with minor or no side effects in 72%. No patient needed withdrawal
of the drug, 12% needed reduction of the dose. When used as rescue or switch
over therapy from azathioprine patients did not experience acute rejections but
50% needed withdrawal of the drug due to side effects while one patient continued
to have inexorable chronic rejection. |
| |
| 4. Post Transplant Renovascular Complications |
| |
| H Shah, S Punamiya, S Bichu, P Namboodiri,
V Dodke, UG Oza, AL Kirpalani |
To study the incidence, clinical presentation
and management of renovascular complications in renal allograft
recipients.
This is a retrospective analysis of 523 consecutive renal allograft recipients
(519 live and 4 cadaver) between May 1988 and May 2003. The incidence of different
types of vascular complications, the clinical profile of these patients; the
diagnostic and therapeutic approach adopted and their outcome were analysed.
490 patients received azathioprine and 33 received mycophenolate while 17 patients
were given IL-2 Receptor antibodies as induction immunosuppression. All patients
also received cyclosporine and prednisolone.
20/523 patients (3.8%) developed stenotic or thrombotic complications of which
14 patients (2.6%) had angiography proven transplant renal artery stenosis (TRAS)
while 6 patients (1.2%) had thrombotic complications (3-venous; 3-arterial) with
graft loss in all 6. The mean age of these patients were 35 ± 17 years.
4/14 patients (29%) with TRAS, presented with asymptomatic rise in S. Creatinine
while 10/14 (71%) had concomitant resistant hypertension (requiring > 3 drugs).
10/14 patients (71%) presented within 6 months of the transplant; 2 patients
between 6 months and 2 years after transplant while 2 patients got TRAS in the
third year of their transplant. The severity of stenosis in our study was defined
as follows: mild : < 50%; moderate : 50-70% and severe : > 70%. The commonest
sites of stenosis were : (1) Renal artery branch stenosis - 1 patient (0.66%),
which was severe (30 Pseudo TRAS i.e. just proximal to anastomosis - 4 patients
(26.6%) of which 3 were severe and 1 mild and at external iliac artery - 2 patients
which were moderate stenosis. Revascularisation (i.e. Percutaneous Transluminal
Renal Angioplasty or Surgery) was done in 11 (85%) patients (PTRA - 10; Surgery
- 1) while intervention was deferred in 3 (15%) because of patients refusal.
Radiological success (i.e. < 40% residual stenosis post procedure with good
intrarenal blood flow) was seen in 8 (80%) patients. One patient had partial
success (i.e. > 40% residual stenosis) while 1 PTRA failed. A mean decrease
in S. Creatinine by 40% at the end of 7 days was noted in six patients (54%)
while 3 were lost to follow up. Restenosis of the revascularised segment was
seen in 2 (18%) patients at the end of 6 months.
The commonest vascular complication after renal transplant was TRAS. Thrombotic
complication invariably led to graft loss. The commonest site of stenosis was
at the anstomosis (with an angiographic success rate of 75%) although stenosis
could occur at other parts as well. The incidence of anastomotic stenosis (which
could be attributable to surgical technique) was acceptably low (1.5%) and comparable
to other large international series. |
| |
| 5. Phaeochromocytoma : Our 10-year Experience
of Laparoscopic Management |
| |
| R Varma, DD Gaur, RK Garg, UP Acharya,
KS Shivakumar, SJ Rizvi, A Arora, BK Jain |
Adrenal or extra-adrenal phaeochromocytoma is
usually managed laparoscopically at most centers throughout
the world. We hereby present our ten year experience of management
of phaeochromocytoma at our institute.
Since 1993 nine patients with phaeochromocytoma, including 2 extra-adrenal tumours
underwent laparoscopic surgery for their excision. Three of the adrenal tumours
were on the left and 5 on the right side. One patient had bilateral tumours.
Retroperitoneal approach was used in 7 and transperitoneal approach in 3. The
age range was 13 to 60 years and male to female ratio was 3 to 7.
The first three patients had a planned open conversion during the early part
of our experience. There was no open conversion during our last 7 procedures.
Adrenal tumours more than 5 cms and the extra-peritoneal ones were removed by
the transperitoneal approach. Harmonic scalpel was required only in one patient
with an 8.5 cm tumour. The mean operative time was 210 min and the mean blood
loss 125 ml. The patients were discharged from the hospital between 2 and 10
days and there were no complications. Blood transfusion was required only in
one patient. Significant blood pressure fluctuations were noted in only one patient,
who did not receive preoperative phaenoxybenzamine.
Conclusions : With proper preoperative preparation of the patient, laparoscopic
excision of phaeochromocytoma is a safe and feasible minimally invasive procedure.
The retroperitoneal approach should be limited to tumours smaller than 5 cm. |
| |
| 6. Retroperitoneal Laparoscopic Live Donor Nephrectomy
: Does A Phased Procedure Make It Safe? |
| |
| SJ Rizvi, RK Garg, UP Acharya, KS
Shivakumar, R Varma, A Arora, BK Jain, DD Gaur |
Laparoscopic live donor nephrectomy is regularly
being performed at many centres throughout the world. However,
the fear of losing the kidney is a big deterrent for most laparoscopic
surgeons. We, hereby, present our experience of a phased out
procedure for laparoscopic live donor nephrectomy.
After having performed more than 50 simple laparoscopic nephrectomies, 20 live
donors with single renal arteries were considered for retroperitoneoscopic nephrectomy.
In the first 7 donors, the laparoscopic procedure was performed in a stepladder
fashion starting from dissection of the ureter and posterior surface of the kidney
to a complete dissection. In the next 13 donors a total retroperitoneoscopic
procedure was planned. Balloon dissection was done in all and 3 to 4 ports were
used.
There were no donor or graft complications during phase one. During phase two
there were 2 open conversions for slow progress in 1 and renal vein tear in the
other. The remaining 11 donors had an uneventful retroperitoneoscopic procedure.
There were no complications except for lumbar vein bleeding in 2 donors. The
mean operative time was 150 min, the mean blood loss 106 ml and the mean hospital
stay 4.7 days.
In spite of a reasonably good laparoscopic nephrectomy experience, it is better
to be cautious by performing live donor nephrectomies in a phased out procedure. |
| |
| 7. Our Experience with The New Gaur Retroperitoneal
Balloon Dissector |
| |
| RK Garg, UP Acharya, KS Shivakumar,
SJ Rizvi, R Varma, A Arora, BK Jain, DD Gaur |
Since Gaur recently published his experience
with a new cost saving reusable balloon dissector for expanding
the retroperitoneal space, it has been successfully used in
more than 50 patients. The fixation of the fingerstalls by
the nut can sometimes be tricky and therefore, it has now been
simplified.
In the old design, the fingerstalls get attached to the instrument by the screwing
action of the retaining nut. This sometimes can be tricky and it can even cause
twisting of the balloon over the shaft. The problem has been solved by a recent
modification in this retaining nut.
The modified retaining nut now more easily slips over the fingerstalls and this
prevents twisting of the balloon over the shaft. The retaining nut gets easily
fixed over the fingerstalls by a simple pushing action. The new balloon dissector
was successfully used in 5 patients undergoing retroperitoneoscopic procedures.
Gaur retroperitoneal balloon dissector is a safe, simple, reliable and cost saving
instrument for expanding the retroperitoneal space. The newer version is more
user friendly. |
| |
| Abstracts of Papers Presented at The
113th Research Meeting of The Medical Research Centre of
Bombay Hospital, Convenor Dr. HL Dhar |
| |
| 1. Synopsis of A Case of Congenital Diaphragmatic
Hernia |
| |
| A Tagare, S Khambayate, D Pawar,
R Ramdwar, R Verma, Prem Sheth |
| An antenatally diagnosed case of congenital diaphragmatic
hernia was admitted in NICU. Baby was delivered by an elective
LSCS. Baby was full term/AGA. Baby was admitted in NICU and
intubated. Early rescue surfactant therapy administered and
baby was ventilated. Antenatal sonography and postnatal X-ray
studies were suggestive of bilateral pulmonary hypoplasia due
to abdominal viscera occupying thoracic cavity. Baby was operated
on day 3 of life. All abdominal viscera was repositioned in
abdominal cavity and diaphragmatic defect repaired. Left sided
intercostals drain was kept. Baby was ventilated post operatively.
Postoperatively both clinical and radiological findings suggested
expansion of right lung, shift of mediastinum to left and some
expansion of left lung. Baby was improving clinically and was
put first on nasogastric feeds and then gradually oral feeds
started. Baby was then put to breast and was sucking well.
Baby was discharged from NICU and then from wards as baby had
no respiratory problem, was sucking well and gaining weight
gradually and consistently. |
| |
| 2. Case of Swelling in The Neck in A Newborn |
| |
| R Dias, M Shinde, R Ramdwar, R Verma,
Prem Sheth |
10 day old male child presented in the OPD with
a swelling in the left side of neck noted since the 8th day
of life. Swelling was small in size and showed gradual increase
in the size. It was round smooth surfaced and soft. It did
not cause any feeding or breathing difficulty and the cry of
the baby was normal. There was history of oil massage to neck
over the next few days, there was an increase noted in the
size and the cry hoarse.
OPD examination - a healthy term male neonate, vitals stable with a swelling
in the middle of the left side of neck measuring 5*4* cms, soft cystic along
the lateral border of the sternocleidomastoid freely mobile, fluctuant and transillumination
+ overlying skin normal. No other swellings in neck or other parts of body systemic
examination was normal. D/D : 1. Cystic hygroma 2. Scm tumour 3. Bronchial cyst.
CT scan neck cystic mass in the left side of neck which extended to the deeper
structures-? cystic hygroma. Child took breast feeds well and was breathing comfortably
despite the stridor. Baby was evaluated by Dr. Ravi Ramadwar and posted for surgical
excision of the cyst which was done under GA the surgery lasted for 2 hrs and
the cyst was removed in total. Post operatively baby was kept in the IPCU on
pressure control ventilation and IV fluids for a day. 2nd day baby was extubated
and started on tube feeds of ebm. By 3rd day, baby was able to take full tube
feeds was active and alert. The surgical drains were removed thereafter and baby
was slowly restored to breast feeds. |
| |
| 3. Unusual Case of Endometriosis in Umbilical
Region - Misdiagnosed As Umbilical Hernia |
| |
| Daksha Bhangui, PB Paidhungat |
| Endometriosis occurring in various unusual sites
is well known. This is an unusual case of Umbilical Endometriosis.
This patient Narasimah Prassana 47/F was admitted. In Bombay
Hospital on 28th April 2003, with Chief Complaints of, 1. Swelling
and blackening of umbilicus and periumbilical pain for 1 year
2. Discharge through the swelling (4 Days before, during and
3-4 days after menses). MH 3-4 /30, mod. flow, no dysmenorrhea
LMP - 18/4/2003, OH P2L2A1. She had 2 previous FTLSCS and 1MTP.
MED/SURG/H not significant O/E No Pallor. P-88/-BP-110/80 RS-NAD
CVS - NAD PA uterus enlarged to 22 wks size. Mobile Umbilical
blackening + Severe Periumbilical Tenderness + PS Cx Healthy.
PAP SMEAR Taken PV Confirmed Abdominal Findings. USG Abd and
pelvis done showed E/O Large fundal fibroid 9.5 X 7.5 X 8 cm.
With mild (R) Hydronephrosis and hydroureter due to pressure
effect. Rest abdominal findings normal. Rest all Preop investigations
were WNL. Patient underwent DJ stenting of (R) ureter followed
by total abdominal hysterectomy followed by umbilical excision
on 29/4/2003. Post operative period was uneventful. Patient
was discharged on POD8. HPR (1) Leomyomata (2) Proliferative
Endometrium (3) Umbilical Endometriosis, No Granuloma, No atypia
or malignancy. |
| |
| 4. Vaginal Removal of Fibroids more than 850
Gms Along with Vaginal Hysterectomy |
| |
| Pradnya P Gujar, PB Pai-dhungat |
| Fibroid is one of the commonest indication for
hysterectomy in patients with small symptomatic myomata, vaginal
hysterectomy is treatment of choice. However, large fibroids
are considered as contraindication for vaginal hysterectomy.
We present two cases of large fibroids which were successfully
removed vaginally with no operative complications with less
morbidity and no mortality. Thus we conclude that large fibroid
is not a contraindication to vaginal hysterectomy if performed
at tertiary centre with good assistants and good anesthesia
with few exceptions like uterus adherent to anterior abdominal
wall due to previous surgery, highly pulled up cervix and cervical
and ovarian malignancy. |
| |
| 5. NST in Relation to Cord Around The Neck, Indicating
Decision for Caesarean Section - Case Presentation |
| |
| Sulbha Arora, PB Pai-dhungat |
NST is the simplest test which assesses the foetus
at risk for uteroplacental insufficiency during pregnancy and
helps in deciding the time as well as the route of delivery.
Here we present two cases in which ominous NST pattern along
with ultrasound finding of cord around the neck detected the
decision for performing caesarean section was taken.
In both these cases presence of ominous changes in the NST were a deciding factor
for caesarean section. Reactive NST suggests that the foetus is safe in utero
for at least a week and expectant management might safely be pursued, while non-reactive
pattern alerts the obstetrician well before the onset of labour regarding foetal
risk in utero. In the case of cord around the neck as the foetus approaches term
the chances of cord compression leading to foetal hypoxia increase and lead to
subtle and momentary changes in FHR pattern which may be early indicators of
foetal distress, and alert us to the need for timely intervention, so action
can be taken before significant foetal compromise has actually occurred. |
| |
| 6. Systemic Lupus Erythematosus And Pregnancy |
| |
| Preeti Lewis, SK Desai |
|
31 year old Rhneg G3P1L1A1 with 26.1 weeks of gestation
with c/o dyspnoea on exertion, puffiness of face, oedema
feet, Headache since 1-2 months. H/o oliguria with dysuria
and flank pain - since 10 days. Detected to be hypertensive,
Investigations were done.
Management : With the help of nephrologists, haematologist, cardiologist, immunologist
and ophthalmologist Pt was treated. Complete bed rest. UA, 1/O, BP, daily weight
charting. Injectable antibiotics.
O+ve/male child/bwt=1.2 kg. baby on ventilator for respiratory distress. On iv
maintenance and antibiotics. Details will be presented.
|
|
