Umbilical cord prolapsed through urethra: An unusual presentation of a vesico-uterine fistula
A 31-year-old woman, gravida 3, para 2, was referred to a tertiary care hospital with fetal demise and umbilical cord prolapse through the maternal urethra at 21 weeks of gestation. She was admitted to the referring hospital with complaints of on-and-off watery vaginal discharge and mild vaginal bleeding. Laboratory investigations showed hemoglobin of 9 gm/dl, white blood cell count of 11.3 × 109/μl, urine analysis yielding WBC >100/HPF and blood group A+.\nAt the tertiary care facility, initial patient assessment revealed a pulse rate of 111/min, blood pressure of 138/74 mmHg, respiratory rate of 22/min and temperature of 37.5 degrees centigrade. There was no history of any associated medical disorders, no prior history of contraception, hematuria or urinary incontinence. Her first pregnancy ended 6 years ago, at term, by emergency cesarean section (CS) for non-reassuring fetal heart tracing. The outcome was male weighing 2.3 kg, alive and healthy. Her second pregnancy ended, 2 years ago, in CS at 24 weeks of gestation due to antepartum hemorrhage. Outcome was early neonatal death of a male baby. Intraoperatively, bladder injury was identified and repair was performed by a urologist. She received two units of blood and remained in the intensive care unit for 3 days. After the second CS, she had symptoms of lower urinary tract infection for which she received treatment on an outpatient basis, but no hematuria. In the current encounter, the uterus was enlarged to 20-weeks size and was tender to palpation. The uterine contour was normal and there were no palpable contractions. On local examination of the vulva, a 4-inch-long thin loop of umbilical cord was seen coming through the maternal urethra. On speculum examination, there was no leakage of liquor or bleeding through the cervix. Urgent ultrasound scan confirmed fetal demise and one small defect was seen in the posterior wall of the bladder (1.26 cm) through which the cord emerged and traversed the bladder []. Impression was scar dehiscence with vesico-uterine fistula.\nManagement plan was discussed with the patient and her husband. The couple refused for any images to be taken during the procedure. Laparotomy was carried out. There was no free fluid in the peritoneal cavity. Uterus appeared normal. Uterovesical pouch was obliterated with dense adhesions. Adhesions were released by sharp and blunt dissection. On dissection, a 1.5 cm connection was found between the dome of the bladder and the anterior uterine wall. Fetus and membranes were evacuated from the uterus through a low transverse uterine incision. Uterus was repaired in two layers. Bladder repair was carried out in two layers after adequate mobilization of the tissue planes. Foley's catheter was retained for 10 days. Successful repair was confirmed on post-operative cystourethrogram.