Background: Postmenopausal bleeding (PMB)accounts for 5% of gynecology visit. All with unexpected uterine bleeding should be evaluated for endometrial carcinoma since this potentially lethal disease is the cause of bleeding in approximately 10 percent patients (range 1 to 25 percent, depending upon risk factors). The aim of the study was to evaluate endometrial causes of postmenopausal bleeding (PMB) with it's correlation with endometrial thickness (ET)and hysteroscopy findings and endometrial tissue histopathology.Methods: A total 50 consecutive cases of PMB fulfilling the inclusion and exclusion criteria and giving informed consent were selected. Each patient was subjected to transvaginal sonography (TVS) in which uterus, adnexa and endometrial thickness (ET) was assessed. Then hysteroscopy and/or dilation and curettage was scheduled at subsequent visit. Endometrial sample was sent for histopathological examination. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy was calculated for ET by TVS and hysteroscopy findings, considering histopathological diagnosis as the gold standard.Results: Most common endometrial cause of PMB was atrophic endometrium (44%). The other causes were endometrial carcinoma (18%), endometrial hyperplasia (18%), endometrial polyp (12%), endometritis (4%), and leiomyoma (4%). The diagnostic accuracy of ET by TVS at a cut-off point of 5 mm was 94% with sensitivity 89.3%, specificity 100%, PPV 100% and NPV 88%. The diagnostic accuracy of hysteroscopy was 98% with sensitivity 96.4%, specificity 100%, PPV 100% and NPV 95.7%.Conclusions: Being relatively cheap, easily accessible, non-invasive, TVS with ET measurement should first line investigation in the evaluation of women with postmenopausal bleeding with suspected endometrial pathology. Although hysteroscopy is more specific and sensitive, in poor resource settings it should be limited to cases with ill-defined endometrial lining, recurrent/ persistent bleeding and cases with endometrial thickness greater than 5 mm irrespective of endometrial echotexture.
An ectopic pregnancy is the development of an embryo outside the uterus, a major cause of maternal morbidity and mortality. Heterotopic pregnancy is when an intrauterine implanted embryo develops simultaneously along with an extra uterine implantation. With rising incidence of assisted reproductive technology (ART), incidence of ectopic pregnancy is on a rise. We report a case of an elderly patient, conceived by in vitro fertilization and embryo transfer (IVF-ET), who had a catastrophe of events following conception, where she had an intrauterine twin gestation and an ectopic gestation in the left fallopian tube. She presented with vomiting and on ultrasound scan, we found a twin intra uterine gestation, with demise of one twin with no sign of ectopic implantation. Initially we decided to continue pregnancy. However, she had persistent spotting per vagina, and on a repeat ultrasound scan there was intrauterine demise of the other foetus also. Her uterus was then evacuated under anaesthesia. Post operatively, she became hemodynamic ally unstable and ultrasound was inconclusive of the cause. So, we subjected her to an MRI which showed a left adnexal ruptured ectopic pregnancy with hemoperitoneum. She was immediately taken up for exploratory laparotomy and left salpingectomy was done hemoperitoneum evacuated. Due to timely intervention and use of advanced techniques for diagnosis, she recovered successfully. Thus, heterotopic pregnancy can be a rare, life threatening complication of IVF, a vigilant eye and not shying away from the use of novel and advanced techniques for diagnosis, can help in early diagnosis and timely intervention and thus prove to be lifesaving.
Non puerperal uterine inversion is a very rare clinical scenario with very few gynaecologist actually managing it in their lifetime. Acute variety of non-puerperal inversion is even rarer and thus possess diagnostic and management challenges. Case study of a rare case of a 45 years old female who was admitted for an elective surgery and had sudden acute inversion of uterus which was clinically diagnosed. Patient was managed by debulking of tumour which turned out to be large leiomyoma, followed by total abdominal hysterectomy. Rarity of the disease, atypical symptoms and less clinical exposure to such cases pose diagnostic as well as surgical challenges as in our case.
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