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A Case of Vaginal Tear During A Speculum Examination While Performing Laparoscopic Tubal Ligation
Parul S Shah*, Binti R Bhatiyani*, Shashank V Parulekar**
 
A case of vaginal tear during a speculum examination while performing laparoscopic tubal ligation is reported. This is a first case in English Literature.
 
Case Report

Mrs. MMK, a 24 year old P2L2 was referred to KEM Hospital for bleeding per vaginum immediately after a laparoscopic tubal ligation. She had two vaginal deliveries; last one was one and half year back. She had an interval laparoscopic tubal ligation done at a peripheral maternity hospital under local anaesthesia and intravenous sedation and was found to have bleeding per vaginum to the extent of soaking one fullsheet four hours post tubal ligation. No vaginal procedure was done other than insertion of Vitoon’s manipulator for uterine manipulation.

The patient was Day 8 of menstrual cycle and past menstrual cycles were regular. She was lactating. There was no medical, surgical or drug history, contributing to the case.

Vaginal exploration was attempted at peripheral maternity hospital but the bleeding site was not seen and so the patient was transferred to KEM Hospital for further management after packing the vagina with two roller packs.

On examination, patient’s general condition was fair, peripheral pulse was 120/min, good volume. Blood pressure - 100/70. She had pallor. Systemic examination revealed no abnormality, patient was uncooperative and did not allow examination without anaesthesia.

Under general anaesthesia two packs soaked with blood were removed. Per speculum examination revealed a transverse tear in the posterior fornix, 5 cm in length from one lateral fornix to another with the culde-sac peritoneum exposed (Fig. 1).

The tear was sutured by interrupted sutures with No 1-0 chromic catgut.

Patient was given one pint blood transfusion intraoperatively. Post operative period was uneventful; speculum examination done 3 weeks after surgery showed satisfactory healing.

 
Discussion

Oestrogenisation of vagina is less in lactating women so vagina is susceptible to injuries.

During lactation due to increased prolactin, gonadotropin levels are low so oestrogenisation of vagina is poor, so vagina is thin and can be traumatized easily.1

In this case it was traumatized during vaginal manipulation, possibly by the edge of Sim’s vaginal speculum.

 
References
1. Sir Norman Jeffcoate. Breast function and its disorders. In Principles of Gynaecology, 4th edition. Butterworth World Student Reprints. Reprinted 1982: 119-26.