Sunday, January 24, 2010

The Lady with No Vagina

(Disclaimer: This story may be considered gross by many of you out there. But it's so interesting, I had to post. It talks about vagina a lot, as well as tearing caused at delivery.)

MIDWIFE: Doctor, we have this lady. She has this abnormality.

ME: What is the abnormality?

MIDWIFE: She has no vagina.

ME: Ok....

MIDWIFE: She is in labor.

ME: What? I don't understand. How did she get pregnant?

MIDWIFE: It happens. What do you call it? Vaginal atresia?

ME: What?? Is she full term? How could she be pregnant?

MIDWIFE: It happens. We have seen it before.

This makes no sense to me. I head to labor ward to see the woman. She is 16 years old, and this is her first pregnancy. At first, I wonder if she really just has an abdominal tumor that they are mistaking for pregnancy. She insists she feels the baby moving. I palpate the abdomen - it sure feels like a baby.

I do a vaginal exam. My fingers go in about 1-2 centimeters, then stop. I can feel the baby's head very low, but there is no palpable opening, and no cervix. In some places, it feels almost like very dense adhesion the way you would feel in an abdomen that had had previous surgery. I am so confused. I palpate and palpate, try to lyse some adhesions bluntly, but I can't do anything. She is already bleeding a little from several exams.

I get the ultrasound and take a look, and sure enough, there is a full-term pregnancy inside. The fluid looks low, but the baby is alive.

I consider the possibilities. First, when did this occur? If she has been like this from birth, how on earth did she get pregnant? To put it bluntly, how did the penis get in? And how did the sperm get up into her uterus if there is no cervix? Could this have happened after she got pregnant?

Second, what is the diagnosis? She is pregnant, so she must have a uterus and ovaries - so it can't be androgen insensitivity. It could be congenital vaginal atresia. It could also be an injury that occurred after pregnancy. She is only 16 - maybe she tried to abort, they injured the vagina, and the wound healed like that? Maybe she put inside something caustic. It could be a vaginal septum or imperforate hymen. The anatomy is distorted from the very low fetus, and impossible to examine with a speculum. And why would it feel so adhesed? Still I've never seen either one, so it's possible.

Third, what to do? If it is congenital vaginal atresia or some kind of injury, then attempting a vaginal delivery would hurt the fetus and likely the mother. If it is a septum or imperforate hymen, then I could just make an incision and the rest of the anatomy (including the cervix) would be normal. But if it isn't either of those, and I make an incision, I could hit bowel or bladder or do some serious damage.

I make a couple of panicked phone calls - the first is to a respected Obstetrician in Kampala. He has probably seen this before. He doesn't answer. The second is to a friend from residency working in Rwanda. She recalls that in Benin, women would put some sort of herb in their vagina that would cause a terrible burn injury and lead to a fistula.

I go back to the patient and grill her. Did you put something in there? To make the baby come? Any herbs, any instruments, anything? She denies anything.
(As an aside, all of this discussion is far from private - the labor ward consists of 6 uncomfortable delivery "beds" in one big room, separated only by chest-high walls. There are some curtains, but they are not great. Everyone can hear everything, and for the most part see everything. One of the midwives has to chastise the patient and family in the next bed who are peering over curiously at the goings on with this patient.)

I decide that cesarean is the only option, which is what the midwives have been pushing for. I tell them to organize the operating theatre. One of our highly motivated study doctors volunteers to do the cesarean with me - I will probably need an extra set of hands to examine the anatomy, so I agree. He had examined her as well, and he was a stumped as I was.

No surprise, there is a delay in theatre. They have called the anesthetist, but can't locate the theatre nurse. They will call us when theatre is ready. The Obstetrician in Kampala calls me back, and explains that there is probably a pinpoint cervix (which allowed her to get pregnant) but it is congenitally abnormal and will not dilate. He says there is no use of caustic herbs known in Uganda. He agrees with my decision to section.

We go back to the clinic and wait. We tell the other doctors about the case, and they are also dumbfounded. "But how did she get pregnant??" they all ask. I'm glad I'm not the only one.

A short while later, I realize I have left something on Labor Ward, and, I return briefly to retrieve it.

MIDWIFE: Doctor, the patient has delivered!

ME: Which patient?

MIDWIFE: The same one.

ME: The one with no vagina?? How did she deliver?

MIDWIFE: But she did!

I walk over to her, and lo and behold, there is a baby between her legs, and an umbilical cord still leading up into her body.

ME: What? How? What??

MIDWIVES: She is ok.

Two elderly women come up and hug me exuberantly three times each. They are her family members. They raise their hands up to the sky and embrace me.

MIDWIFE: They are thanking you for the miracle.

ME: Did you tell them I didn't do it? I was going to cesar her.

It doesn't matter. I get many sequential hugs. I ask the midwives to call me when the placenta is out so I can examine the damage. They do, and I go with the other study doctor to examine her.

There are two large tears on either side of her vagina, what we call "sulcal lacerations." At the anterior aspect, there is a thin film of epithelium hanging, which apparently used to be attached posteriorly as well. This is what was blocking entry into her vagina, which she did have. We also see a normal cervix beyond that. We try to identify whether it is a vaginal septum or an imperforate hymen, but we can't because of the distortion from the delivery.

I review the anatomy with the study doctor. We identify the entire hymenal ring, the normal tissue, the cervix and the rectum. There is no damage to the rectum at all. I show him how we are going to repair each side. The tear on the right side will require the tissue from the torn septum.

Suddenly, I am called to a phone meeting I can't miss. The study doctor says he is comfortable starting the repair without me. He injects Lidocaine and starts. I run to the meeting. By the time I am done, he is back in the clinic, having finished the repair. I return with him to examine her, and find that his repair is excellent. We caution her that she must stay until Monday to be sure that the vagina does not re-heal shut, but remains open. Not surprisingly, she insisted on leaving the next day, and went home. Let's hope she heals well.

And thus, the lady with no vagina had a vaginal delivery. Nature fooled us yet again.

6 comments:

Francie said...

HOLY... ? This is amazing.

Kate said...

That settles it. Scott is having the next one!

danengber said...

I read this twice and still don't understand what happened. How did that think epithelium get there? How did she get pregnant? You need to come home.

Rachel (you know, malakum) said...

Man, you need to turn these stories into a book; they're absolutely fascinating. I'd read them before Atul Gawande's stuff, and I *love* Atul Gawande's stuff.

Unknown said...

I am dumbfound about this..how could this be possible??!!

Unknown said...

I am dumbfound about this..how could this be possible??!!