Snehdeep Superspeciality Gynaecare

*खैरात रानमेव्याची*
🍏🍎🍊🍋🍉🫐🥭🍌
😋😋🥰🥰

वैद्यकीय व्यावसायिक म्हणून काम करत असताना निखळ आनंदाचे क्षण अनेकदा अनुभवायला येतात.
😌😌

त्यातलाच एक अनुभव तेंव्हा येतो जेंव्हा रुग्ण आपल्या घासातला घास काढून आपल्याला देतो.
आपल्या सुखाच्या क्षणांमध्ये तुम्हाला सामील करून घेतो.
🧀🧀...🥰🥰

रुग्ण गाव-खेड्यातून, जिल्ह्याच्या कानाकोपऱ्यातून जेंव्हा शहराकडे पोहोचतात तेंव्हा बहुतांशी इलाज करूनही गुण न आल्याने ते थकलेले असतात...
🙁🙁

त्यांच्या काही दुर्मिळ आजारांचे निदान झालेलेच नसते, काही आजारांचे इलाज गाव-खेड्यात उपलब्ध नसतात तर काहींना क्लिष्ट शस्त्रक्रिया लागणार असते.
😒😒

दहा ठिकाणी धडका घेऊन थकलेल्या रुग्णाचे जेंव्हा अचूक निदान होऊन उपचार होतात आणि रुग्ण ठणठणीत बरा होतो तेंव्हा मग तुम्ही त्या रुग्णासाठी कुठल्या देवदुतापेक्षा कमी नसता...
👩🏻‍⚕️👨🏻‍⚕️🎅🏻🧑🏻‍🎄

गावाकडील ही मंडळी पैशाने जरी गरीब असली तरी त्यांच्या मनाची श्रीमंती मात्र आभाळालाही लाजवते...
आणि मग तुमच्यावर मग राणमेव्याची खैरात होते....

अस्सल गावरान आंबे, पेरू, चिक्कू, बोरं, जांभळं, पपई, सीताफळ, द्राक्ष, खरबूज थेट शेतातून तुमच्या ओपीडीत पोहोचतात...
☺️☺️🛍️🛍️🎁🎁

लिंबू, मेथी, तांदुळचा, भोपळा मळ्यातून थेट तुमच्या किचनमध्ये हजेरी लावतात...
🥬🥦🫛🍆🍅🥝.......
वैद्यकीय व्यावसायिक म्हणून काम करीत असताना यापेक्षा सुदंर मोबदला तो काय असू शकतो...
💓💓

रुग्ण आणि डॉक्टर यांचं नातं हिंदोळे खात असताना येणारे असे प्रसंग म्हणजे वैशाख वणव्यात जणू श्रावणसरीच...
💥💥🌧️🌧️

आजाराला भावना नसते, पण आजारी माणसाला ती असते आणि जेंव्हा रुग्णाला आपण आजारापुढे जावून माणूस म्हणून बघायला लागतो तेंव्हा जादू घडायला सुरुवात होते...
⚡⚡

स्त्री आरोग्य तज्ञ म्हणून काम करताना ही गोष्ट पदोपदी जाणवते, की आपल्या समाजामध्ये माता-भगिनिंच्या भावना ह्या पोटातून ओठावर क्वचीतचं येतात...
🤫🤫🤐🤐

दमन झालेले अनेक विचार मग कधी आजार बनतात कळतंच नाही...

संवादाची पहिली पायरी ही "ऐकून घेणं" असते....
🙂‍↔🙂‍↔

अगदी बारीकसारीक गोष्टी प्रामाणिकपणे एकल्या की आजाराच्या थेट मुळाशी जाता येतं...
आणि आजाराला अगदी मुळांपासून उखडून टाकता येतं...
🙂‍↕🙂‍↕

रुग्ण समाधानाने ओपीडी बाहेर पडला की निम्मा आजार तिथंच बरा होतो आणि उरलेलं अर्ध काम मग आधुनिक उपचार करतात...
😌😌

जेंव्हा तुम्ही रुग्णांची प्रामाणिकपणे मनोभावे काळजी घेता, तेंव्हा रुग्णही तुमच्यापेक्षा कैक पटीने जास्त तुमचीही काळजी घेतात...
➕➕✖️✖️

तुमचं आयुष्य मग आशीर्वादाने भरतं...
🕉️☪️✡️✝️...

बाह्य जगात कितीही उलथा पालथ झाली तरी तुमची प्रॅक्टिसचा आलेख मात्र मग वाढतच राहतो...
📈📈

तुमची प्रॅक्टिस, तुमचं काम न राहता तुमचा श्वास बनतो...
💓💓💗💗

रुग्णाचं हित तुमचं हित बनत..
🤝🤝

समाधानी रुग्णाचं हसू तुमचं हसू बनत...आणि त्याचे आसू तुमचे आसू बनतात...
☺️☺️😢😢

तुम्ही आणि तुमचा व्यवसाय जेव्हा असे एकरूप होतात तोच खरा स्वर्ग आणि तोच खरा मोक्ष...
💓💗

स्वर्ग म्हणजे अजून दुसरं तरी काय असतं...
🥰🥰😇😇

आम्ही डॉक्टर खरचं भाग्यवान आहोत जी अश्या कामासाठी ईश्वराने आमची निवड केली...
🙏🏻🙏🏻

डॉ प्रदीप इंगळे

*Anti Ro La ने Ru La (रुला) दिया...*
😳😳😢😢

The story wherein presence of Anti Ro antibody deteriorated the prognosis in a case of fetal bradycardia ...
💞💞💓💓

Herein we describe 2 cases...

First case reported a year back ...
⏳⏳⌛⌛

She came for a second opinion
🚶🏼‍♀️🚶🏼‍♀️...

*She reported with decreased fetal movements from the last 2-3 days*
😳😳

*OH:*
G4P2L2A1 with previous 2 LSCS
34 weeks pregnancy
🤰🏻🤰🏻

*Her NST was done by her treating gynecologist showing repeatative variable decelerations till 80-90 BPM..*

Baseline variability was good and recovery was good and baseline was between 110-120 BPM..

The same pattern was obvious on repeat test..
📈📉

*O/E:*
Normotensive
PA Ut32-34 weeks
FHS +

On USG intermittent fetal bradycardia was demonstrated
EFW-1.4KG (

*When life gives you lemons, make lemonade*
🍋🍋🍹🍹☺️☺️

*The story of a challenging diagnosis and a difficult surgery... well accomplished..to alleviate the sufferings...*
🥰🥰

20 year lady came with c/o severe pain in abdomen during me**es from the last 3-4 years
😰😰😥😥

The pain was so severe that she had take injectable analgesics during each of her periods
💉💉💊💊

She got married a year back and her sufferings continued....
😣😖...

She had done multiple USGs at different centres but all of them could not find any concrete pathology..
🙁🙁

So the curative treatment could not be offered...

It is only 1 year after her marriage one of the senior radiologist could pick the pathology...
🧐🧐🙂🙂💪🏻💪🏻

On TAS there was a 2.5x3cm lesion with ground glass appearance located within the left antero-lateral myometrium

*It was lebelled as ACUM / non communicating horn with hematometra*

Patient then reports to us...
🚑🚑....

We did a TVS

*Our D/Ds were*

1) Accessary cavitated uterine malformation *(ACUM)*

2) Unicornuate uterus with a *rudimentary non-communicating horn with hematometra*

3) *Robert's uterus*
Septate uterus with non communicating half with hematometra

4) *Degenerated fibroid* with central liquefaction

The family could not afford MRI ....

She was directly posted for hystero-laparoscopy for the diagnosis as well as the definitive treatment....

We kept everything ready in view of her DD's
🧐🧐

*On hysteroscopy both the tubal ostia were located...*

So rudimentary non communicating horn and Robert's uterus were ruled out as only single tubal ostium is seen in these cases
💪🏻💪🏻

*On laparoscopy...*

There was a small bulge located at the left antero-lateral wall of the uterus..

Both tubes were normal and patent..
🚿🚿

Both the ovaries were normal so the ovarian lesions were ruled out..

*We had only 2 possibilities - ACUM vs Degenerated fibroid*

And
*Excision was the desired treatment for both...*
✂️✂️

Fundal bulge was infiltrated with dilute saline vasopressin solution
💉💉

The lesion was deep down and was extending almost upto the internal os...
😳😳

*There were multiple challenges during the surgery*

a) *The margin of the lesion was poorly defined* as it was deeply embedded inside the myometrium so optimum resection was challenging
😳😳

Herein we utilised the bluish hue of the lesion to differentiate it from the normal myometrial tissue
🏓🏓💪🏻💪🏻

b) As the lesion got punctured *incomplete resection* was the next challenge ..
😳😳

We opened the lesion and made 2 flaps of it so the base was seen and it helped in complete resection of the base..
✂️✂️💪🏻💪🏻

c) The next challenge was *avoiding injury to the uterine vascualature...*
😳😳
🩸🩸

Gentle, fibre by fibre dissection helped to avoid the uterine vascualar injury..
✂️✂️ 💪🏻💪🏻

d) *Suturing of the deeply opened cavity is highly challenging* but ambidextrous suturing helped to close the lesion appropritely...
💪🏻💪🏻

e) *To characterize the lesion on HPE was also challenging*
😳😳

Initial HPE could only pick the myometrial tissue, so further sections were processed and it revealed scanty endometrial stroma...

*Yes....it was confirmed to be ACUM...*
💪🏻💪🏻

1. Very rare cause of severe dysmenorrhoea

*Literature reports only 94 cases in the world till date*
😱😱

*We are fortunate to treat 3 cases till date...*
💪🏻💪🏻

One of our patients was lost to follow up and the other one delivered a healthy baby at term via LSCS....

We are hoping for the best obstetric outcome for this patient...
🙏🏻🙏🏻👼🏻👼🏻

2. ACUM is *NOT classified in ESHRE classification* and thus comes under U-6(unclassified category)

3. *ACUM is an embryonic developmental abnormality* wherein ectopic endometrium forms within the myometrium which fails to communicate to the va**nal canal..

4. *Surgery offers the complete cure*
✂️✂️

5. Implications of ACUM on obstetrical outcomes have not be well studied till date...

Our team was fortunate to be able to contribute to alleviate suffering of the needy....
🙂🙂🙏🏻🙏🏻

Althogh challenging to pick and treat we could finally make a sweet lemonade out of lemons thrown onto the path which led her to the cure...
🍋🍋

A lemonade...much needed one in this scorching heat...
🥵🥵🤗🤗

*And we gynecs are masters of making such lamonades day in and out ...*
🥰🥰

Cheers to you guys..

🍋🍋... 🥂 🥂 🍹🍹

Thanks
🙏🏻🙏🏻

*Vasopressin doing wonders*
💉💉

*Succesful management of cervical ectopic pregnancy in an unmarried girl...*
😳😳

21 yr unmarried girl reported with c/o continuous BPV from the last 2 months with generalised weakness...

On digging the history further she had taken *OTC MTP pills 2 months back for 6 weeks pregnancy..*
💊💊

She had h/o consensual relations which resulted in a pregnancy
👩‍❤️‍👨👩‍❤️‍👨...💕💕

USG was not done prior to intake of MTP pills..

*O/E*

She was pale
P-100BPM
Pallor+++
PA soft

*USG done s/o 5x5x6 cm gestational sac located within the cervical canal*

Gestational sac outline was irregular

Fetal pole was absent

Both internal and external os were closed..

*Hb on admission was 6.5g%*

She was admitted

*2 pints of PCV were transfused one on each day*

Detailed consent was taken involving parents
✒️🖋️🖋️✒️

There are multiple options discussed for management of the cervical ectopic in literature...
🤔🤔

1. *Intralesional or systemic methotrexate alone or MTX followed by curettage is the commonest method used*

2. *Devascualrisation folllowed by evacuation*

a) Cervical artery ligation va**nally

b) Uterine, internal iliac artery ligation or uterine artery embolisation followed by evacuation

3. *Hysteroscopic resection of RPOCs*

4. *Pericervical vasopressin with evacuation*

5. *Hysterectomy for intratractable bleeding especially when the ectopic is more than 12 weeks*

*The challenges for this case were multifold*
😳😳

1. She was unmarried, had profound anemia and continuous bleeding so the method providing quick relief must had to be chosen

2. Follow up would have been difficult so the MTX was not a viable option, as it requires frequent monitoring of the beta HCG as well as it has a failure rate of 20%

3. Systematic devascualrisation to ligate UA or IIA was too invasive as it would give scars over her abdomen which were not acceptable

4. Hysteroscopic resection was challenging as the cervix was thinned out, holding the pressure of fluid and resection of a huge chunk were a real challenge

5. Hysterectomy was out of question

*We relied upon the use of vasopressin perilesionally followed by evacuation*

*The largest study involving this modality had 100% cure rate in 11 cases*

10 units of injection vasopressin was diluted in 100cc os NS was injected around the cervical rim into substance of the cervix

*We kept everything ready*

1.Laparoscopy
2.Ballon tamponade
3.Setup of laparotomy
4.Resuscitation kit
5.Cross matched blood

But with god's grace nothing required...
🥰🥰

Cervix blanched out completely after after infiltration...the ectopic sac was detached as the cervical fibres contract..

The POCs were then evacuated using o**m forceps.
The sac was came out in toto..
🏮🏮

There was hardly any blood loss....
☺️☺️

No need of blood in post operative period
😊😊

No need of ballon tamponade
🙂🙂

No abdominal scar
😌😌

No need for follow up
😊😊

*अर्ज किया है...*
✒️✒️

*एक घाव, अनेक टूकडे*
*Cervical ectopic को सही जो पकडे*

*Vasopressin तूने कर दिया कमाल..*
*Ectopic हो गयी बेहाल...*

*Critical condition से जान बची..*
*पेशंटके चेहरे पे छायी खुशी*
😃😃

*धन्यवाद*
🙏🏻🙏🏻

*IUI causing miracles...*

This couple conceived after IUI in both the pregnancies
😃😃

A tiny correction causing mammoth difference in the lives...
💪🏻💪🏻

Let's revise few basics about IUI

1. IUI is the preferred treatment of choice for mild male factor infertility, unexplained infertility, mild endometriosis, cervical factor infertility
2. Global success rate for a given IUI cycle is between 15-20% per cycle
3. Proper selection of the case is required
4. Double IUI is NOT evidence based it doesn't add into success rate
5. Both density gradient and swim up methods do equally well
6. Ideal time for IUI is 36-42 hours post trigger
7. Soft catheters are to be preferred

This couple conceived in their first attempt both the times
🥰🥰

Magical...
😃😃

Thanks
GD nt...

*When your vigilance adds a bundle of joy into the family*
👼🏻👼🏻

The story goes,

A 23 yr lady reported with increased frequency of me**es from the last 4-6 months

Present MC 3-4d/20-22 days/ regular moderate flow

She was P1L0 with previous 1 LSCS 1.5 yrs back

Baby died after the birth owing to meconium aspiration
😥😥

They were using contraception as she was previous LSCS

*USG done s/o bilateral small sized ovaries with decreased AFC*

*AMH was 0.1...D2 FSH was 7*
😨😨

We did her natural cycle follicular monitoring and adviced her to conceive the earliest..

She had a good follicular growth in her natural cycle...

And
Boom ...she conceived naturally in next 3 months with such a LOW AMH...
🥰🥰

And delivered a healthy baby at term
👼🏻👼🏻

*Take home points*

1. Increased frequency of me**es can be an early sign of premature ovarian insufficiency(POI)

2. There is NO curative treatment for POI

3. AMH is a quantitative marker of ovarian reserve and may not represent the quality

4. Even with such a low AMH patient can conceive naturally especially in young age as the young women have a good egg quality inspite of low quantity

*Such tiny corrections offered by you create a meaningful difference in the lives of people*
🥰🥰

Couple was in depression post the previous full term loss

Went home smiling
😃😃

Thank you
GD nt
🙏🏻🙏🏻

*It's heartening when your seniors trust you*
🥰🥰

The story goes...
✒️✒️

A 23 year lady was referred by an esteemed senior with c/o on and off BPV from the last 1 1/2 months
🩸🩸

She had h/o previous 4 abortions...
😢😢

This time she had 6 weeks amenorrhea with a positive UPT...

USG was done
🔍🔍

*s/o partial molar pregnancy*
😳😳😰😰..

Beta HCG was 55k...

So the evacuation was done at the primary centre...
🧹🧹

Bleeding persisted post evacuation so repeat USG was done
🔍🔍

It was s/o RPOCs..
😥😥

Repeat evacuation was done 15 days after the primary one in view of incomplete abortion by 2 gynecologist...
🧹🧹🧹🧹

Beta HCG was 5...

On and off heavy bouts of bleeding persisted..
🩸🩸😢😢

Bleeding was torrential at times ..
🩸🩸🩸🩸

Thus a repeat USG was done
🔍🔍
It was s/o *ARTERIO-VENOUS MALFORMATION*

Patient was then referred us
🚑🚑...

TV USG was done
🔍🔍
Uterus was bulky
Multiple anechoic channels were seen inside the posterior myometrium..
🪢🪢
These channels were seen connected to the heterogeneous endometrial lesion..
🪢🪢

Turbulent colour flow was seen in this lesion with power Doppler
🔥🔥

*We had a few D/Ds*

1. Acquired AVM

2. Gestational trophoblastic neoplasm(GTN)

3. RPOCs with enhanced myometrial vascularity(EMV)

We went ahead with the third choice....

1. True AVMs are extremely rare.....

*Majority of the AVMs reported on USG are actually EMVs(enhanced myometrial vascularity)*

*AVMs can't be differentiated from the EMVs with USG, Doppler, CT or MRI scan*

*They can only be differentiated using DSA wherein true AVM demostrates an early venous filling wherein the EVMs demonstrate the late venous filling*

*EMVs can be differentiated from AVMs based on the clinical history as EMVs have h/o preceding pregnancy*

2. GTN was highly unlikely in absence of very low beta HCG

3. So this was more likely to be a case of EMV which was mistaken for the AVM...

So we went ahead with hystero-laparoscopy
🧐🧐...

Bilateral uterine arteries were coagulated at the origin...
⚡⚡

Hysteroscopy revealed a fluffy lesion arising from the posterior wall of the uterus
🪷🪷🪸🪸

It was resected using the saline bipolar resectoscope
🗡️🗡️

No torrential bleeding encountered..

Cavity was completely normal post resection...
😊😊

Post procedure USG after 15 days was absolutely normal...
😊😊

NO EMV

Absolutely normal endometrium with a good myometrial vascularity
😊😊

*HPE was s/o RPOCs*

This patient is asked to evaluate her RPL...

*Discussion*

1. *True AVMs are extremely rare*

Majority of the lesions labelled as AVMs are in fact EMVs which typically occur after a failed pregnancy...

*Therefore ISOUG-2015 recommends to replace the term AVMs with EMVs...*

2. *Although they look extremely vascular they don't bleed torrentially while resection...*

3. *EMVs disappear after the treatment of the primary pathology i.e. RPOC...*

*4. Proposed treatment modalities are*

a) Hysteroscopic resection

b) Hysteroscopic resection and uterine artery ligation at origin

c) Uterine artery embolisation

d) Evacuation

*No RCT comparing superiority of these modalities...*

We went ahead with b) hysteroscopic resection after UALO

As subsequent pregnancy prospects are better after the surgical treatment...

Only the affected area is resected ....

Almost nil damage to the endometrium when you resect under vision in a proper plane...

UALO helps to reduce the bleeding and reduce the EMV..

*Blind curettage is detrimental* as the chronically retained POCs are firm as they are hyalinised thus may not be evacuated with a blind negative suction..

Evacuation for the chronic RPOCs is the commonest thing to cause Asherman's syndrome...
🧹🧹🪢🪢

Here we could achieve normal anatomy with the surgery..

Yes..

Every imaging modality has a few limitations ..

What takes precedence is your clinical judgment...
💪🏻💪🏻🧐🧐

Here we went ahead with our clinical judgment rather than relying solely on imaging findings...

*It's a matter of a huge pride when you deliver your best when your seniors trust you the most...*
💪🏻💪🏻🥰🥰

This patient was a family member of the referring practitioner.....

It's inside the space provided by such esteemed seniors, we juniors can express ourselves...

Nd

You feel fortunate when many of your seniors trust you for their difficult cases...
🥰🥰

We the people of small cities are fortunate to have such seniors around, who provide the utmost conductive environment to flourish...

*Proud AOGSite..*
💪🏻💪🏻🥰🥰

Many thanks

Gd nt..tc
🙏🏻🙏🏻

*Wombs turning into tombs*
🤰🏻🤰🏻☠️☠️
*Never ending saga of foeticides*
👶🏻👶🏻😓😓

The story goes..
✒️✒️

24 yr lady reported with breathlessness, generalised weakness and pain in abdomen from the last 5 days
😔😧

She carried a 4 months pregnancy which according to her had aborted spontaneously 5 days back
🤔🤔

Spontaneous abortion was followed by a heavy bleeding so she visited a nearby healthcare facility
🚑🚑

Herein evacuation was done for ? RPOCs and she was discharged
🤔🤔

She was P2L2 with previous 2 LSCS

*O/E*
She was very pale
Dehydrated
Afebrile
P-120/min, BP 110/70mmHg

PA mild tenderness was elicited in left iliac fossa

No active BPV

*USG s/o around 10 × 12 cm clot within the left adnexa starting from the uterus*
🧐🧐

No free fluid was present

This hematoma was seen extending into the LUS

Uterus was empty so was the scar site

*Hb on admission was 5g%*
😨

Which during antenatal records was 11g%
😱😱

Relatives denied any other intervention..

*What it could be...??*
🤔🤔

*1. Spontaneous abortion with spontaneous uterine perforation leading to the hematoma as she was previous 2 LSCS*

*2. Spontaneous abortion with an accidental perforation while evacuation*

*3. Spontaneous abortion in a case of morbidly adherent placenta which bled during the evacuation of the adherent placenta*

*4. Primary induced abortion causing perforation*

Patient was admitted

As there was no active bleeding, no fever

She had passed urine and motion in the last 5 days

*She was stabilized first*

*4 PCVs were transfused one PCV each day under antibiotic cover*

*Relatives didn't have any complaints against anybody*
🤐🤐

MRI was then done after the stabilization to rule out any morbid adherence of the placenta ? bladder wall invasion ? adnexal invasion
🧐🧐

*MRI report* was s/o empty uterus with adnexal hematoma with intact bladder

*There was a rent over the left lateral wall of the uterus*
Nd
The large hematoma was routing from here till the pelvic brim

We went ahead with laparoscopy ro evacuate the hematoma with suturing of the perforation....

Sos need of laparotomy, hysterectomy was consented
✒️✒️

There were dense adhesions around the uterus
🪢🪢

Adhesinolysis done
🗡️🗡️

Uterus was normal with *a large hematoma in left adnexa starting from the uterus till the pelvic brim*
🩸🩸

But this hematoma also had extended beneath the whole parietal peritoneum on the left side to the right pelvic brim
😱😱😨😨

Means the dissected hematoma has created an extra cover for almost the whole abdomen..
😨😨

Our secondary ports went through this layer of hematoma..

There was no intraperitoneal bleed

Bladder was dissected down...

Oh....
*The uterus had given a way over the left lateral margin*

Left round ligament was severed, anterior leaf of the broad ligament was opened so as to access

*Hematoma was evacuated*

*And the real part of surgery started*
😨😨

As the pressure over the hematoma got released the left uterine artery started spurting like a pressure pump...
🩸🩸⛈️⛈️

The whole pelvis is filled with blood in just a few seconds..
🥶🥶😨😨

Holding the nerves tight, suctioning was done...
🧃🧃

The pressure was such that even the suction couldn't cope with the spurting blood...
🩸🩸⛈️⛈️⛈️

Finally we could grasp the bleeding pedicle ...

There was a linear tear of around 5-6 mm over the ascending branch of the uterine artery...
⚡⚡

It was coagulated and the bleeding stopped
🌫️🌫️💨💨

There was a 4-5 cm tear running parallel to the uterine vascular bundle on the left side starting from the left lateral margin of the scar
⚡⚡

Tear was sutured with vicryl number 1
🪢🪢

Broad ligament and the left round ligament closed
🪢🪢

The uterus was re-evacuated few placental bits were retrieved
🧃🧃

IP drain was kept...
🧃🧃

Post operative recovery was fantastic
🙂🙂

No blood required

Drain was removed

And the patient was discharged after 3 days of injectable antibiotics
🚶🏻‍♀️🚶🏻‍♀️🏃🏻‍♀️🏃🏻‍♀️

*Discussion*

1. Although the relatives denied it was a clear case of an induced abortion leading to such a catastrophe.

But the god was kind enough to save her

The uterus could have given a way at the end of evacuation leading to the linear tear over the uterine artery
😨😨🩸🩸

The artery spurted within the broad ligament

With the tremendous pressure hematoma got dissected beneath the whole parietal peritoneum
😨😨

And with such a strong counter pressure of the hematoma the bleeder stopped saving the mother
🙏🏻🙏🏻

*2. Such cases can be managed with laparoscopy provided the patient is vitaly stable*

3. With the primary event occurring 5 days prior the surgery was challenging

The tissues were edematous and friable

*4. Dissecting the bladder was challenging* as it was the previous 2 LSCS with obscured planes owing to gross edema

*5. And finally to control the spurting uterine was a real challenge*

But what saved us was adequate dissection of the bladder prior to the evacuation of hematoma

It created adequate space, ureters were pushed down

*In all such cases of uterine artery bleed, ureter is in real danger because of altered anatomy, edema, poor visibility and haphazard attempts to coagulate with active bleeding*

But with the grace of God everything went well
🙇‍♂️🙇‍♀️

We treated her in the best possible manner...with laparoscopy and avoided a large scar
💪🏻💪🏻

On the day of discharge husband and father in law were in tears and touched my feet...and confessed
🙏🏻🙏🏻

*" WE MADE A MISTAKE DOC"*

You treated us unbiased...

Yes ...

Whatever her past was....it was none of our business....

Just give your best every time for your patients

This family was socially well placed, highly educated and affluent..
👩🏻‍🎓👩🏻‍🎓💲💲

The doctor who did the primary mess, the person doing the imaging favour for the s*x selection and the anaesthetist giving anaesthesia for the primary surgery must be all well qualified...
👨🏻‍⚕️👨🏻‍⚕️🧑🏻‍🎓👩🏻‍🎓

Everybody forgot the Hippocratic oath they took while wearing THE WHITE COAT...
👨🏻‍⚕️👨🏻‍⚕️👩🏻‍⚕️👩🏻‍⚕️

*Is money such a strong motivation...??*
😞😞

It's shameful that numerous innocents are still killed in the womb in a nation which boasts about its rich cultural heritage....
🇮🇳🇮🇳
What a paradox.....
😞😞

Hope this mentality transforms
🙏🏻🙏🏻

Many thanks

Good day
Keep doing the best...
🙏🏻🙏🏻

*"टीम 'स्नेह'दीप" मध्ये "स्नेह"चे आगमन*
💐💐

*डॉ स्नेहल इंगळे (MBBS DGO) स्त्री रोग तज्ज्ञ म्हणून पूर्ण वेळ रुजू*
🥰🥰

८ वर्षांपूर्वी लावलेलं स्नेहदीपचं रोपटं आता चांगलंच बहरलंय,
🌿🌿🌳🌳

कित्तेक रुग्ण इथं विश्वासाने आले आणि ठणठणीत होऊन आनंदाने घरी गेले...
🚶🏻‍♀️🚶🏻‍♀️🏃🏻‍♀️🏃🏻‍♀️💃🏻💃🏻

आता स्नेहदीपच्या या गाडीला अजून एक इंजिन मिळालंय
🚆🚆😊😊...

स्नेहदीपची एक्सप्रेस गाडी आता बुलेट ट्रेन होईल यात आता काही शंका नाही.....
🚆🚆🚅🚅🚀🚀

पोस्टग्रॅज्युएशन, मुले बाळे, शासकीय सेवा यातून तरून डॉ स्नेहल आता रुग्णसेवेसाठी सज्ज आहेत...
😊😊

शासकीय रुग्णालय,अहमदनगर येथे स्त्री रोग विभागात तब्बल ४ वर्षे काम करून त्यांनी स्वतःला सिद्ध केलं आहे...
🧑🏻‍🔬🧑🏻‍🔬

आपल्या अनुभवाचा आणि कौशल्याचा रुग्णांना नक्कीच फायदा होईल...

शासकीय रुग्णालय टीमप्रती कृतज्ञता व्यक्त करून....आपण उत्साहाने "टीम स्नेहदीप" मध्ये दाखल झालात...

*Welcome to TEAM SNEHDEEP DR SNEHAL*

Rock on...the stage is all yours

💐💐🥰🥰

Post LSCS patient reported on D10
C/o pain at stitch site with h/o fever from the last 2 days

LSCS was done outside 10 days back for CPD in case of severe preeclampsia with anemia

Hb dropped from 8.5 g% to 6 g%

USG S/O around 150 cc collection below the scar

What caused this hematoma...??

*SAM/Superficial Angiomyxoma of v***a*

SAM of v***a is a very rare benign tumour with around *55-60 cases reported till date*
🤨🤨😇😇

Here we report a case of a v***al mass lesion which on HPE came out to be SAM
🎤🎤🥁🥁..

A 36 year P2L2 lady reported with a painless, progressive lump over the left l***a majora from the last 1 year...
😟😟

*O/E*
Around 4x4 cm firm, mobile and non tender mass was felt below the left l***a majora, skin over the mass lesion was normal

*USG of the mass s/o ? hemagioma ? Epidermal cyst*

Possibility of hemangioma was less likely as it developed recently, was firm and it lacked bluish red hue of a hemagioma

She was posted for the excision of the mass lesion under anaesthesia
🗡️🗡️😴😴

Although a single mass was reported in USG total 3 masses were excised in toto during the surgery😱😱...

The post operative period was uneventful...

Patient went home walking on the same day
😊😊🚶🏻‍♀️🚶🏻‍♀️🏃🏻‍♀️🏃🏻‍♀️

*Discussion:*

1. *SAMs are typically a surprise diagnosis* on HPE as in this case

2. SAMs are *benign but known to recur in 30% cases*

3. While another type of angiomyxoma is AAM (aggressive angiomyxomas)

These are *deeply invading tumours* with high chances of recurrence and are difficult to treat

4. SAMs are commonly *found in males in an age group of 11-39 years*

5. *They are commonly located over the trunk and limbs and are uncommon in v***a*

5. Exact cause is NOT known

6. *HPE of SAM shows numerous small blood vessels with a neutrophilic infiltrate*

*No IHC marker is specific*

6. *Excision is the treatment of choice*
Care must be taken to excise it completely

There may be multiple small seedlings around the large mass as found in this case

USG and clinical examination was showing a single lesion but on palpation after the excision of the large lesion, 2 more masses were palpable

7. Prognosis is good after the complete excision

*Sometimes we get such uncommon lesions over an uncommon location in an uncommon gender*
😇😇😄😄
*So uncommon*
🤓🤓

*Such surprises make medicine challenging, interesting and worth practising...*
🥰🥰

Thanks
Gd day
🙏🏻🙏🏻

*Keyhole surgery doing wonders*
🥰🥰

A 46 yr old lady reported with progressive abdominal distention and heavy flow during me**es from the last 6 months

*O/E*
Around *28-30 weeks size, firm, globular, non tender mass palpable*

The lower pole of the mass could not be reached

*USG s/o large fibroid*

*Hb on admission was 6g%*

2 PCV transfused

*Total laparoscopic hysterectomy done*

A specimen of around 1.4 kg was delivered out through the va**na with va**nal morcellation
🗡️🗡️

It's like removing a 1.5 kg pumpkin through the 5 cm window
🍈🍈🛟🛟🗡️🗡️

Difficult for the surgeon but best for the patient
😵‍💫😵‍💫🥰🥰

She walks her home back on d3
🚶🏻‍♀️🚶🏻‍♀️🏃🏻‍♀️🏃🏻‍♀️

Keyhole surgery doing wonders for the benefit of the patient
🥰🥰🙏🏻🙏🏻