Successful pregnancy following acquired gynatresia.

Acquired gynatresia is a common gynecological condition in developing countries where puerperal complications and unskilled interventions prevail. A 23-year-old primipara who had spontaneous vaginal delivery complicated by gynatresia had vaginoplasty that failed due to erectile dysfunction in the spouse. She subsequently developed secondary amenorrhea and was relieved with dilatation and evacuation. She was planned for definitive surgery, however,she incidentally conceived with q pin-hole vagina. She was delivered of a live fetus at term via an elective cesarean section. This case is peculiar as spontaneous conception occurred with a pinhole opening. There is a need to adequately evaluate cases before definitive management to maximize success.

INTRODUCTION

Birth trauma is one of the causes of acquired gynatresia.[1] Other causes could be due to female genital mutilation, chemical vaginitis, pelvic radiotherapy, or colpocleisis.[12] Congenital form more common than acquired gynatresia in the developed world.[3]

In Lagos, the most common cause was herbal pessaries while birth injuries accounted for 15.4%.[2] In Ibadan, chemical vaginitis was the major cause.[3] A case from Jos was due to insertion of herbal concoctions to the terminate pregnancy.[4] In Arabian countries, the most common cause was the insertion of rock salt into the vagina in the puerperium to tighten it.[5]

CASE REPORT

A 23-year-old P1+0 not alive whose last childbirth was 7 months and the last menstrual period was 3 weeks before presentation. She presented with a history of absent vaginal cavity following repair of a broken down perineal laceration 5 weeks postdelivery. The labor was prolonged and she reported to a peripheral hospital where she had spontaneous vaginal delivery of a fresh stillbirth. The delivery was complicated by perineal laceration and postpartum hemorrhage. She had primary repair, but it became septic and broke down after 5 weeks and had secondary repair in the same hospital which subsequently led to her condition.

She menstruated normally for 5 days in a 28-day regular cycle with associated dysmenorrhea. There was no cyclical lower abdominal pain, urinary, or fecal incontinence. However, there was a history of difficulty in coital penetration.

Overall, examination revealed normal findings. However, pelvic examination revealed severely stenosed introitus.

All requested investigations were normal. She had an examination under anesthesia which revealed a thick membrane covering the vaginal introitus with a small opening around the fourchette as well as cervical stenosis. There was a deficient perineal body and laxed anal sphincter.

She had vaginoplasty, and subsequently vaginal dilatation, and intracervical catheter insertion for 10 days. She was discharged and advised on vaginal dilatation using plastic dilators. She was seen 6 weeks later, and the vaginal introitus admitted two fingers with ease, and vaginal depth was 6 cm. She was encouraged to resume coitus.

Coitus was inadequate due to erectile dysfunction in the spouse. She menstruated normally for few months and subsequently developed amenorrhea for 1 year with associated cyclical lower abdominal pain and managed as a case of recurrent gynatresia. She had vaginal dilatation and evacuation to relieve menstruum, while being worked up for definitive surgery. However, she incidentally conceived spontaneously. It was confirmed by ultrasound at about 9 weeks gestational age. She was booked and planned for elective cesarean section. The pregnancy was carried to term uneventfully until she reported for admission. General and systemic examination were normal as well as investigation results. She had elective cesarean section and was delivered of a live male baby that weighed 3.2 kg. Operative findings are as presented on Figures 1–4. They both did well and were discharged home in satisfactory condition.

Figure 1

Pregnant uterus preoperatively

Figure 4

Postoperative after cesarean section

Stenosed vagina

Pinhole vaginal opening

DISCUSSION

Acquired gynatresia due to genital trauma is an under-reported condition which could have impact on the quality of life and reproductive career of a woman. Most reported cases of acquired gynatresia in the developed world are due to the complication of pelvic radiation or surgeries.[2] However, the most common reported cause in developing countries is the use of herbal substances that result in the chemical vaginitis and healing by fibrosis.[26] The case presented had a history of genital laceration during her delivery that became septic, coupled with a poor surgical technique that led to healing by fibrosis and partial obliteration of the vaginal cavity. Birth trauma is not a common cause of gynatresia, especially when conducted by the skilled birth attendants. However, in this case presented birth injury was repaired at a peripheral hospital probably by an unskilled attendant and resulted in gynatresia.

Kaur et al.[7] reported a case of postpartum gynatresia due to chemical vaginitis from vaginal packing with clothe soaked in caustic soda. Anzaku et al.[4] reported the use of herbal concoction to achieve abortion. Birth trauma was found to be a cause of acquired gynatresia in 15.4% of cases over 7 years at Lagos, Nigeria.[2]

The treatment of gynatresia due to dense adhesions is mainly surgical.[8] The use of dilators is inadequate, because devascularized and scarred vagina are devoid of elasticity for fibers to be severed.[8] Surgical management could be in the form of simple excision or complete vaginal reconstruction and that depends on the extent of the damage.[8] Surgical procedures for reconstruction include McIndoe vaginoplasty in which space is created in the connective tissue between rectum and bladder with the use of split thickness skin graft from the patient's anterior thigh or buttocks.[89] Others include use of myocutaneous, peritoneum, intestinal segment, and graft to create the new vagina.[89]

The use of dilators or molds in the postoperative period helps in reducing the stenosis or scarring of the vagina, and they are important contributors to the success of the reconstructive surgery.[810] The case presented was not able to sustain the use of vaginal dilators postoperatively which lead to the development of more fibrous tissue that caused amenorrhea. However, the second surgery resulted in pregnancy despite the pinhole opening.

CONCLUSION

Deliveries by unskilled birth attendants should be discouraged. The improper repair by an unskilled birth attendant was the cause of morbidity in the case presented.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.