|
A Rare Case of
VVF due to McDonald Encerclage: Its unusual presentation and
its repair concurrently with subsequent LSCS
By Dr.
Somshekhar Patil (Miraj)
Mrs. S.S.P. aged 22 years presented on 22nd
August 2005 with term pregnancy and premature rupture of
means. There was h/o Mc Donald’s encerclage done in 5th
month in another hospital.
This was her presentation to us.
Obs. History
:- G4 P1 L0 D1 A2
·
1st Pregnancy --
Spontaneous abortion at end of 2nd month
·
2nd Pregnancy --
Spontaneous abortion at end of 3rd month
·
3rd Pregnancy -- PT delivery at 8th
month and that was FSB.
·
4th Pregnancy --
Present Pregnancy
O/E –
Patient was not in labour, she had frank
leak. The stitch was removed. And the labour was induced.
Ultimately she required LSCS for PROM with failed induction.
CS was technically uneventful. Baby cried immediately. She
had an uneventful post op recovery and discharged on 7th
post op day and had no complaints at the time of discharge.
There was no follow up in puerperal period.
She comes to us again after a gap of 1½
years with 3 ½ months amenorrhea and continuous leak of
urine for last 15 days. The leak started spontaneously and
there was the smell of urine. In a week’s time it increased.
She stopped passing urine from urethra and the whole urine
was leaking through the vagina. In interval period of 1½
years, she did not have significant urinary symptoms except
for mild frequency and dysuria. A KUB sonography and
obstetrics sonography was undertaken and clinically, she was
diagnosed as a pregnancy of 18 weeks with a small VVF.
Diagnostic cystoscopy was undertaken and confirmed it as VVF
arising from posterior wall. Ureteric opening and trigone
were normal.
O/E
·
G.C. - Satisfactory
·
Uterus - Corresponding
to 16 – 18 weeks size.
·
Perineum - Wet and smelling of urine
·
P/S - When Cervix was little displaced both
there was a jet of urine seen coming from the anterior at
the level of Cervix vaginal in.
·
P/V - Cervix closed and
normal in and the fistula palpated.
It was decided to allow her undergo a
routine ANC and a perineal hygiene. At term – She came to us
in labor and she required LSCS after a short trial for
previous LSCS with soft tissue dystocia. It was planned
before hand that if she required LSCS this time, we would
take a chance to repair the VVF during LSCS since it was the
small VVF and had no much fibrosis around it.
2nd LSCS was performed as a
routine fashion and after uterine incision was closed the
bladder was dissected and separated further from the lower
uterine segment till we reached the fistula tract. That
tract was excised. The edges in bladder opening were
freshened and it was noted that the bladder opening was away
from both the ureters. The bladder opening was closed in 3
layers vertically with 3 – 0 PGA sutures. Bladder was
catheterized before hand with 18 Foley’s catheter.
The vaginal opening of the fistula could
not be approached easily from the abdominal route. The
abdomen was closed and the patient was given the lithotomic
position. The vaginal opening could be easily visualized.
The edges of opening were freshened and closed transversely.
Post operatively indwelling catheter was kept for 10 days
and the leak had stopped completely. Catheter was removed
and patient was discharged and had a follow up after 1 ½
months. During that time there was no leak and the repair
was successful.
Discussion:
This case was rare and interesting because
the etiology of VVF appears to be the previous Mc Donald’ s
Encerclage and the fistula presented after a gap of
1 ½ years in next pregnancy was also unusual and we could
repair VVF during LSCS successfully which was also a rare
event.
We attribute fistula to be due to
encerclage.
1)
By exclusion of other causes (trauma, TB
etc.)
2)
By its anatomical situation with was
corresponding to the Mc Donald’s encerclage.
3)
It was a small VVF with not much of
fibrosis may be because of the non-irritant suture material
used.
Its unusual presentation with gap of 1 ½
years is likely to be due to the fat that the tract might
have been small and direction of tract might have been
oblique which might have acted as a flap mechanism during
non-pregnant state and when she conceived again the uterus
started enlarging and bladder also started ascending and at
one patient of time the tract might have got straightened
and stretched, thereby nullifying the flap mechanism and the
leak started there onwards.
-- In literature, we found one
case of an uretero vaginal fistula due to Mc Donald’s
encerclage. Hence it is a very rare etiology of VVF.
-- We did not find much in
literature about the repair of VVF with LSCS. In fact books
advise against such repair. But in this case it was feasible
and hence we did it with a favorable result. |
