Journal of South Asian Federation of Obstetrics and Gynaecology

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2019 | January-February | Volume 11 | Issue 1

Guest Editorial

Mohamed AM AboEllail, Megimi Ito

Advances in Color Doppler in Obstetrics

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:12] [Pages No:1 - 12]

Keywords: 3D/4D ultrasound, Color Doppler, HDlive flow, HDlive flow silhouette, Obstetrics, Radiant flow, Superb microvascular imaging

PDF  |  DOI: 10.5005/jp-journals-10006-1641  |  Open Access |  How to cite  | 

Abstract

With the latest advances in color Doppler such as superb microvascular imaging (SMI), radiant flow, HDlive flow, and HDlive flow silhouette, we can obtain more comprehensive blood flow information compared with conventional color Doppler. Radiant flow, HDlive flow, and HDlive flow silhouette are appropriate for assessment of the fetal cardiac anatomy and prenatal diagnosis of a congenital heart anomaly. SMI is superior for the precise evaluation of fetal peripheral blood vessels and placental vasculature. In this review article, we present the latest state-ofthe- art SMI, radiant flow, HDlive flow, and HDlive flow silhouette features of normal and abnormal fetal hearts, fetal peripheral vessels, and placentas. We also discuss the present and future applicability of advanced color Doppler to assess fetal and placental circulations.

ORIGINAL ARTICLE

Linda Varghese, Pooja J Prakash

A Study to Identify the Menstrual Problems and Related Practices among Adolescent Girls in Selected Higher Secondary School in Thiruvananthapuram, Kerala, India

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:4] [Pages No:13 - 16]

Keywords: Adolescent girls, Menstrual problems, Practices

PDF  |  DOI: 10.5005/jp-journals-10006-1642  |  Open Access |  How to cite  | 

Abstract

Background: Menarche and menstruation are important aspects of female life. Even though the menstruation is a normal physiological process, adolescent girls have difficulty to handle menstruation. The main objective of this study was to identify the menstrual problems and related practices among adolescent girls. Methodology: A descriptive survey approach was adopted for the study. The sample consisted of 350 adolescent girls selected by proportionate stratified random sampling from the 9th, 10th, 11th and 12th standards of Government Girls Higher Secondary School, Thiruvananthapuram. A semi-structured questionnaire was used to collect data regarding background information, menstrual characteristics, menstrual problems, and related practices. Biophysical measures such as weight, height, and body mass index (BMI) were taken along with the data. Results: Most of the adolescent girls had irregular menstruation (24%), 12.6% had polymenorrhea, 6.3% had scanty menstruation and only 4% adolescent girls had menorrhagia. The majority (79%) were experiencing dysmenorrhea during menstruation. The menstrual symptoms experienced were abdominal pain (74%), backache (42.9%) and fainting (8.9%). Conclusion: Menstrual problems form an important domain of adolescent health and because of these problems are unreported, it is necessary that adequate attention and care is provided. The consequences of the neglect of menstrual problems result in impaired reproductive and sexual health in older women.

ORIGINAL ARTICLE

Mahvash Zargar, Farideh Moramezi, Sarah Zarepeyma

Comparing Hysterosalpingographic Findings with Laparoscopic and Hysteroscopic Results in Infertile Patients: A Southwestern Iranian Study

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:6] [Pages No:17 - 22]

Keywords: Hysterosalpingography, Hysteroscopy, Infertility

PDF  |  DOI: 10.5005/jp-journals-10006-1643  |  Open Access |  How to cite  | 

Abstract

Aim: This study aimed to compare the hysterosalpingographic findings with laparoscopy and hysteroscopy findings in infertile patients referring to Ahvaz Imam Khomeini Hospital. Materials and methods: This retrospective study was conducted on patients referred to infertility clinics of Imam Khomeini Hospital in Ahvaz for hysterosalpingography (HSG) during 2 years from March 2014 to February 2016. Our subjects were married women with different years of infertility. Results: Of 200 patients, six cases were excluded from the study due to the lack of information, and 194 patients were included in the study. In this study, 71 women (36.6%) had secondary infertility. On average, the women examined had 5.19-year infertility. Less than 10% of women have been suffering from infertility for more than 10 years. The most common uterine findings (50.5%) in uterine hysteroscopy were normal. The most cervical findings (97.9%) in cervical hysteroscopy were normal. The most laparoscopic finding (54.6%) was the normality and openness of both fallopian tubes. The highest hysteroscopy findings (76.3%) were the normality of the endometrial cavity and cervix and the openness of both fallopian tubes. The hysterosalpingographic findings (54.6%) were consistent with laparoscopic findings, and in 75.2% of the cases were consistent with the hysteroscopy findings. Conclusion: Considering the results of the study and the ease of using ultrasound in all medical diagnostic fields, in particular, consideration of the issues surrounding the reproductive system of women, the adaptation of transvaginal sonography and other diagnostic methods, such as hysterosalpingography, laparoscopy and hysteroscopy in future studies is recommended.

ORIGINAL ARTICLE

Lakshmidevi Muralidhar, Lopa M Pradhan, Shreedhar Venkatesh

Study on Pattern of Primary Amenorrhea at Tertiary Care Center—A Retrospective Analysis

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:4] [Pages No:23 - 26]

Keywords: Adolescent gynecology, Gonadotropins, Gynecological endocrinology

PDF  |  DOI: 10.5005/jp-journals-10006-1644  |  Open Access |  How to cite  | 

Abstract

Introduction: Primary amenorrhea is defined as lack of attainment of menarche by the age of 15 years in a patient with appropriate development of secondary sexual characteristics and 13 years in the absence of secondary sexual characters. The present study is undertaken to study the etiological features, associated anomalies and treatment options for patients with primary amenorrhea. Objectives • To determine the incidence of etiological factors of primary amenorrhea. • To determine the association of various anomalies with primary amenorrhea. Methodology: It is a retrospective study planned to be conducted from Jan 2011 December 2015, in the Department of Obstetrics and Gynaecology, Vydehi Institute of Medical Sciences and Research Centre. Results: In our study group I, i.e., eugonadotrophic group consists of 34 patients (77.2%), group II, i.e., hypergonadotrophic group has 9 (20.45%) patients and 1 patient in hypergonadotrophic group, i.e. group I. In group I mean FSH, LH estradiol, prolactin and TSH values are 6.89 miu/mL, 8.8 miu/mL, 45 pg/mL, 20.8 ng/mL, and 3.05 iu/mL. In group II mean values of FSH, LH, estradiol, prolactin, and TSH are 51.82 miu/mL, 13.3 miu/mL, 12.7 pg/mL, 22.1 ng/ mL and 5.4 iu/mL. Conclusion: Primary amenorrhea is an extremely stressful situation for young girls and needs psychological counseling to prevent long term sequelae. The feeling of defeminization and underdevelopment of secondary sexual characters is the major concern in patient and attendees is the major concerns which has to be addressed with careful counseling.

ORIGINAL ARTICLE

Ramesh Chandran Jyoti, Sumangala Devi D, Sarah N Gorhatti

Epidemiology of Gestational Trophoblastic Disease at a Tertiary Hospital in India over Last 8 Years

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:3] [Pages No:27 - 29]

Keywords: Gestational trophoblastic disease, Gestational trophoblastic neoplasia, Methotrexate

PDF  |  DOI: 10.5005/jp-journals-10006-1645  |  Open Access |  How to cite  | 

Abstract

The incidence of gestational trophoblastic disease (GTD) varies all around the world, highest being in Asian countries. This study provides a hospital-based incidence of GTD in a tertiary institution.

RESEARCH ARTICLE

Nalini Mishra, Meera Baghel, Alka Gupta, Shipra Shrivastava, Hemant Chandrawanshi

Use of Innovative Low Cost Drape for Assessment of Blood Loss during Delivery: A Case Report

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:5] [Pages No:30 - 34]

Keywords: Blood collection drape, Low resource settings, Post partum hemorrhage

PDF  |  DOI: 10.5005/jp-journals-10006-1646  |  Open Access |  How to cite  | 

Abstract

Aim: Routine quantification of blood loss (QBL) during childbirth by CG drape. Background: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality in South East Asia and needs early diagnosis and prompt intervention. A calibrated drape is the fundamental requirement for routine QBL. The commercially available drape is not cost-effective, and therefore authors have prepared an innovative low cost calibrated drape named CG drape. Conclusion: CG drape is an ideal device for the direct measurement of blood loss during delivery. It does not require manufacturing and distribution. It is practical and easy to use. Clinical significance: CG drape by virtue of its very low cost (approximately ₹ 20 each) allows routine QBL during childbirth and results into increased vigilance, early diagnosis and prompt intervention of PPH and may be lifesaving for the already anemic women of South East Asia.

RESEARCH ARTICLE

Syed A Hussain, Jagadeesan G Mani

Comparison of Neoadjuvant Chemotherapy Followed by Radical Hysterectomy and Neoadjuvant Chemoradiation Followed by Radical Hysterectomy with Concurrent Chemoradiation in Locally Advanced Carcinoma Cervix (FIGO Stages IB2, IIA2, IIB): Interim Results of a Randomized Control Study

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:9] [Pages No:35 - 43]

Keywords: Brachytherapy, Locally advanced cervical cancers, Preoperative chemoradiotherapy, Randomized control trial, Toxicity profile, Quality of life

PDF  |  DOI: 10.5005/jp-journals-10006-1647  |  Open Access |  How to cite  | 

Abstract

Objectives: To investigate the therapeutic efficacy, toxicity profile and quality of life in locally advanced cervical carcinoma treated with concurrent chemoradiation therapy (CCRT), preoperative chemoradiation (PCRT) and preoperative chemotherapy (PCHEMO) followed by surgical implications Materials and methods: A total of (N = 100) locally advanced cervical cancer patients (FIGO stages IB2, IIA2 and IIB) was treated between June 2014 to March 2018, Out of 100 patients, 33 patients treated with CCRT arm (50Gy EBRT and 21Gy brachytherapy), 33 patients treated with PCRT arm (50Gy EBRT) followed by radical hysterectomy, 34 patients with PCHEMO arm followed with radical hysterectomy using 3 weekly cisplatin (75 mg/m2 and paclitaxel (175 mg/m2). Patient\'s Quality life was recorded with a standard questionnaire. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 22. Results: The median follow-up period was found to be 28 months. However less statistical significance was obtained between various parameters such as age, FIGO stage, performance status, perioperative morbidities, and symptoms scales among three arms (p > 0.05). 97%, 94%, 88% of overall response rates noted in CCRT, PCRT and PCHEMO arm patients respectively. But 55% and 24% of PCRT and PCHEMO arm patients had pathological complete responses with the significance of p = 0.0016. CCRT arm patients had a larger amount of symptom expertise, difficulties in sexual functioning and sexual agony Conclusion: We observed equivalent therapeutic response, better toxicity profile and better quality of life among the patients treated with PCRT arm than the standard CCRT arm patients. Clinical significance: This approach could be feasible in developing countries wherein brachytherapy resources are scarce.

RESEARCH ARTICLE

Mona Asnani, Shipra Kunwar, Ajay Kohli, Ayesha Ansari, Kumkum Srivastava, Tamkeen Rabbani

Premenstrual Dysphoric Disorder: Prevalence, Predictors and Challenges in Diagnosis

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:6] [Pages No:44 - 49]

Keywords: Predictors, Premenstrual syndrome, Prevalence

PDF  |  DOI: 10.5005/jp-journals-10006-1648  |  Open Access |  How to cite  | 

Abstract

Introduction: Premenstrual syndrome (PMS) is a cluster of mood, behavioral and physical symptoms occurring during the late luteal phase of the menstrual cycle that are all relieved after the onset of menstruation. A severe form of PMS is known as a premenstrual dysphoric disorder (PMDD). Aim and objectives: The study was aimed to assess the prevalence of PMS and PMDD among young Indian Medical undergraduate students and also to analyze predictors of PMS and PMDD in terms of health status and health-behavioral factors, family history, increased physical and mental stress, body mass index (BMI), age at menarche and duration of menstrual flow Materials and methods: The study was conducted at Era\'s Lucknow Medical College between July and September 2011, a total 73 students were analyzed for with the help of premenstrual symptoms screening tool and presence and severity of PMS were assessed the results were analyzed by Chi-square test taking p value <0.05 as significant. Results: The mean age of the students was 21.71 years with a standard deviation (S.D) of ±1.3.Mean age of menarche was 13.16 years with S.D ± 1.21 years. Analysis revealed around 97.2% of students had at least one symptom of PMS (86.3%– mild PMS; 9.6%–moderate-severe PMS). One student qualified for PMDD. Conclusion: Premenstrual syndrome (PMS) is a common problem with young urban women which may be debilitating both at work and in interpersonal relationships in its severe form. The premenstrual screening tool is an easy and simple way of diagnosis of clinically significant premenstrual syndrome so that they can be managed appropriately improving their quality of life.

RESEARCH ARTICLE

Rekha G Daver, Muskaan Chhabra

Multidrug Regimen for Prevention of Mother-to-child Transmission in Human Immunodeficiency Virus-positive Mothers in India—From Prevention toward Elimination

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:8] [Pages No:50 - 57]

Keywords: Antenatal, Human immunodeficiency virus, Multidrug regimen, Neonatal outcome, Prevention of mother-to-child transmission

PDF  |  DOI: 10.5005/jp-journals-10006-1649  |  Open Access |  How to cite  | 

Abstract

Objectives: To study the incidence, demographics, and course till delivery of HIV positive women on multidrug regimen for prevention of mother-to-child transmission (PMTCT). To study the efficacy of this regimen, neonatal outcome and human immunodeficiency virus (HIV) status in infants of these women to detect transmission. Design: Prospective observational study. Duration: 20 months (01/03/2014–31/10/2015). Setting: Department of Obstetrics and Gynaecology at a Tertiary Health Care Center in Mumbai, Maharashtra, India. Population or sample: The HIV-positive antenatal women attending outpatient department (OPD) or admitted in wards. Sample size: 93. Materials and methods: All HIV positive pregnant women were, after consent and counseling, started on tenofovirlamivudine- efavirenz (TLE) regimen for HIV prophylaxis. Those women who were already on ART were continued on the same regimen. Post-delivery syrup nevirapine was given to the baby for 6 weeks. Main outcome measures: To study transmission of HIV to the baby by testing at 6 weeks, 6 months, 12 months and 18 months. Results: Of the 93 babies,13 babies were lost to neonatal death and stillbirth. Of the 80 live-born infants, 6 were lost to follow-up. Hence, 74 infants were tested at 6 weeks, 6 months, 12 weeks and 18 months of age. All the 74 tested babies were seronegative. Conclusion: The use of multidrug regimen (as per WHO B+), even in resource-limited settings gives astonishing results with no baby found to be seropositive thus showing us the way forward from prevention to elimination.

RESEARCH ARTICLE

Rohan Palshetkar, Nandita Palshetkar, Hrishikesh Pai, Biswanath G Dastidar, Jiteeka Thakkar, Nikita Lad

Analysis of In Vitro Fertilization—Intracytoplasmic Sperm Injection Results from Fresh Day 2 and Day 3 Embryo Transfers at a Tertiary In Vitro Fertilization Center

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:3] [Pages No:58 - 60]

Keywords: Clinical pregnancy rate, Day 3, Embryo transfer, In vitro fertilization

PDF  |  DOI: 10.5005/jp-journals-10006-1650  |  Open Access |  How to cite  | 

Abstract

Embryo transfers (ET) on day 2 or day 3 following fertilization have been the standard of practice since the initial days of human in vitro fertilization (IVF). Recent advances in culture media, as well as embryo culture techniques, have prompted in a shift in strategy to day 5 blastocyst transfers following IVF. However blastocyst transfers, although resulting in slightly better pregnancy rate, are known to be associated with certain disadvantages, such as higher costs, higher cycle cancellation rates, and in vitro damage to embryos. Thus we reviewed our results with day 2 and day 3 ETs to see whether outcomes were adequate to justify a return to day 3 embryo transfer policy. Our data shows a 46% clinical pregnancy rate and 1.9% incidence of multiple pregnancy rate with cleavage transfers. Thus in our setting with a lot of poor resource patients, we feel day 2 or 3 transfer provides a good strategy for IVF cycles.

RESEARCH ARTICLE

Lynsel Texeira, Nischith D\'souza, V Jeevan Kumar, Lavanya Raghu, Vineet K Singh, Altaf Khan, T Mujeeburahiman

Robot-assisted Management of Urological Injuries Following Gynecological Surgeries: Our Experience

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:4] [Pages No:61 - 64]

Keywords: Gynecological injuries, Robot-assisted surgery, Ureteric reimplantation, Ureterovaginal fistula repair, Vesicovaginal fistula repair

PDF  |  DOI: 10.5005/jp-journals-10006-1651  |  Open Access |  How to cite  | 

Abstract

Background and objectives: Robot-assisted minimally invasive surgeries have rapidly increased during the last decade. The objectives of the present study were to report our initial experience on robot-assisted management of urological injuries following gynecological surgeries, i.e., vesicovaginal fistula (VVF) repair and ureteric reimplantation for ureterovaginal fistula (UVF) and posthysterectomy ureteric strictures, using the da Vinci robotic system. Materials and methods: We performed robot-assisted surgeries in 12 such cases from February 2016 to September 2018. These include 7 cases of VVF repair, 2 cases of ureterovaginal fistulas and 3 cases of post-hysterectomy ureteric strictures requiring re-implantation. Results: All 7 patients who underwent VVF repair had no requirement of analgesics from 3rd day onwards and early convalescence, with only 1 having delayed recovery, The patients who underwent ureteric reimplantation for ureterovaginal fistula and ureteric strictures recovered well, with no hydroureteronephrosis or reflux of urine in any of the patients during follow-up. Conclusion: Our study concludes that, robot-assisted VVF repair and ureteric reimplantation for ureterovaginal fistula and ureteric stricture are safe and feasible and provides all the advantages of minimally invasive surgery, with additional benefit of enhanced precision, range of motion, visualization and access to pelvis and patient-related benefits of less pain, faster recovery, shorter hospital stay and early return to normal activity.

RESEARCH ARTICLE

Chinthika P Gunasekara, Irangi Karunanayake, Nirasha Premathilake, Nawashika H Senarathna, Ishanka Udayangani, Manjula M Weerasekara, Ramya Pathiraja, Neluka Fernando

Women's Perceptions and Practices on Human Papillomavirus Infection and Human Papillomavirus Vaccine in Sri Lankan Community

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:5] [Pages No:65 - 69]

Keywords: Attitudes, Cervical cancer, HPV vaccine, Human papillomavirus, Knowledge, Practices, Sri Lanka

PDF  |  DOI: 10.5005/jp-journals-10006-1652  |  Open Access |  How to cite  | 

Abstract

Aim: This study investigated the knowledge, perceptions, and practices regarding human papilloma virus (HPV) infection among women attending gynecology clinic and antenatal clinic at a teaching hospital in Sri Lanka. Materials and methods: A cross-sectional survey was conducted of 400 women attending gynecology and antenatal clinics at a teaching hospital between September 2015 and December 2015. A pretested self-administered questionnaire was used to collect data. A score of ≥ 75% was considered as good while 74.50% was considered as moderate and < 50% as poor. Results: Out of 400 women who participated in this study, the percentage of respondents who had heard of HPV, cervical cancer (CC) and genital warts were 23%, 80%, and 41% respectively. However, only 16% knew that there is an association between HPV and CC. Although 48% believed that CC is common in Sri Lanka, only 6.8% considered themselves at risk. Overall knowledge of risk factors, symptoms, transmission and diagnosis was 44% (CC) and 14% (HPV infection) respectively. Only 14.3% was aware of the availability of the HPV vaccine in Sri Lanka. None of the participants in the study group had received the HPV vaccine. Conclusion: This population had poor knowledge, attitudes, and practices with regard to HPV infection. Clinical significance: Therefore substantial effort should be made to educate the society regarding HPV infection, complications, and preventive measures.

CASE REPORT

Ramesh Chandran Jyoti, D Sumangala Devi

Growing Teratoma Syndrome

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:3] [Pages No:70 - 72]

Keywords: Growing teratoma syndrome, Immature teratoma, Malignant germ cell tumor

PDF  |  DOI: 10.5005/jp-journals-10006-1653  |  Open Access |  How to cite  | 

Abstract

Growing teratoma syndrome is seen in young women following surgery for immature teratoma of the ovary. It needs management with adjuvant chemotherapy following debulking procedures for residual disease.

CASE REPORT

Angelito Magno, Quenny MDA Alas, Chen-Ai Sung

False-positive Positron Emission Tracing/Computed Tomography Secondary to Suture Granuloma Formation in Early-stage Endometrial Cancer

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:4] [Pages No:73 - 76]

Keywords: Endometrial cancer, False-positive PET/CT, Silk suture, Suture granuloma

PDF  |  DOI: 10.5005/jp-journals-10006-1654  |  Open Access |  How to cite  | 

Abstract

Suture granuloma formation can cause abnormal radiotracer uptake of 2-deoxy-2-[18F] fluoro-D glucose (FDG) in positron emission tracing/computed tomography (PET/CT) scan. It can be formed secondary to usage of silk suture during surgery as part of delayed host inflammatory reaction to a foreign body. Here, we report a case of a 61-year-old woman diagnosed with endometrial cancer who underwent tumor debulking surgery secondary to abnormal radiotracer uptake in PET/CT suspected as tumor recurrence which on histology revealed suture granuloma.

CASE REPORT

Hansa Dhar, Palankezhe Sashidharan, Yasser A Razek

Gossypiboma (Textiloma) in the Abdominal Preperitoneal Space Following Cesarean Section: A Case Report with Literature Review

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:4] [Pages No:77 - 80]

Keywords: Cesarean, Fistula, Gossypiboma, Migrating sponge, Retained foreign body, Textiloma

PDF  |  DOI: 10.5005/jp-journals-10006-1655  |  Open Access |  How to cite  | 

Abstract

Retention of surgical items is a preventable complication. The foreign body may be symptomless or migrate in and around the abdomen causing fistula formation, bowel obstruction and perforation. Some major causes responsible for this complication are emergency, prolonged, difficult surgeries associated with obesity, poor communication with an error in sponge and instrument counting. Frequency being 1/1000 to 1/32672 surgeries in the recent review of the literature. Definitive treatment for this condition is surgical removal either by laparotomy or laparoscopically. We report a case whose cesarean section was done in a secondary care hospital for brow presentation and later referred to us after two months with complaints of pain and swelling in the abdomen. Entrapment of a surgical sponge in the preperitoneal space of the abdomen was noted and later removed surgically. This case highlights the need for all health care professionals to be vigilant and cautious intraoperatively as any lapse in mop and instrument counting may be disastrous for both the patient as well as the healthcare team. There is a growing need for patient safety hospital initiation to avoid such errors by surgical teams. The aim of presenting and reporting this case is to increase awareness among healthcare workers to avoid such lapses causing great medical morbidity with medicolegal complications.

CASE REPORT

Kinza Younas, Benjamin Chisholme, Joshy Neelankavil, Euan Kevelighan

A Rare Case of Nonpuerperal Uterine Inversion Managed by a Combined Laparoscopic and Vaginal Approach

[Year:2019] [Month:January-February] [Volume:11] [Number:1] [Pages:3] [Pages No:81 - 83]

Keywords: Hypovolumic shock, Nonpuerperal, Uterine inversion

PDF  |  DOI: 10.5005/jp-journals-10006-1656  |  Open Access |  How to cite  | 

Abstract

A nonpuerperal uterine inversion is a rare occurrence clinically. It is usually associated with uterine fibroids or tumors. We report a case of 47 years old nulliparous women who presented with sudden onset of severe abdominal pain and heavy vaginal bleeding. Speculum examination revealed a 6 cm bleeding mass presenting in the vagina. The case was managed by performing hysterectomy using combined laparoscopic and vaginal routes.

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