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222c#2222���������������������������������������������������������������������'222222222�	�:	TITLE: POST CAESAREAN SECTION UTEROCUTANEOUS FISTULA: A CASE REPORT
AUTHORS:              *Aniekan  M   Abasiattai   WACS, FICS
                                  * Godwin J   Ibanga            MBBS
                                   *Anietifon      Akpan          MBBS
                                  **Kinsley    U  Ume         MBBS, FWACS
INSTITIUTION: * Department of Obstetrics/Gynaecology, University of Uyo Teaching 		 `      Hospital  Uyo, Nigeria
                         ** Department of Surgery, University of Uyo Teaching Hospital, Uyo, Nigeria
CORRESPONDING AUTHOR:
Dr Aniekan M Abasiattai
Department of Obstetrics/Gynaecology
University of Uyo Teaching Hospital
Uyo-Akwa Ibom State
Nigeria
Email:  HYPERLINK "mailto:animan74@yahoo.com" animan74@yahoo.com
Phone: +2348023174734


ABSTRACT
Uterocutaneous fistula is a very rare clinical entity that usually follows abdominal or pelvic surgery. We report the first case of uterocutaeous fistla that presented in our center. This report aims to remind practicing clinicians about this rare complication of caesarean section and discuss our experience with its management.
Key words: Uterocutaneous fistula, postcaesarean section, Uyo











INTRODUCTION 
A fisula is an abnormal communication between two epithelial surfaces of two different organs1.  They are usually lined by granulation tissue, but can become epithelized 1.Though fistulas involving the urinary and genital tracts are relatively common, uterocutaneous fistulas however are rare. This report presents the first case managed in our center. It aims at discussing our experience with the management of this condition and also reminding practicing clinicians about this rare complication of caesarean section.
CASE HISTORY
A 26 year old primiparous lady presented at the Gynaecological clinic of the University of Uyo Teaching Hospital on the 23rd of April 2013 with recurrent oozing of blood from her abdominal scar of five months duration. The patient experienced the bloody discharge only during her menstrual periods. At other times, she occasionally noticed a colourless offensive discharge exuding from the same site. 
In her last confinement seven months prior to presentation, she had an emergency lower segment caesarean section  in a private clinic at a neighboring Local Government Area after prolonged labour for four days, and was delivered of a male stillborn. The operation was performed by a General Medical Practitioner in his private clinic after the patient was brought to him by her relatives from the traditional birth attendant�s place where she had laboured. Following delivery, she was hospitalized for two months during which she was treated for wound sepsis. She had received several forms of treatment from private medical practitioners and local herbalists before presentation at the Teaching Hospital. Her menstrual cycles were regular and there were no gastrointestinal or urinary symptoms. She had no chronic medical illness.
On examination, her general condition was satisfactory. The pulse rate was 86/minute and the blood pressure 120/70mmHg. The abdomen was full with a puckered midline sub-umbilical scar. Blood was observed to be oozing through a pin point opening on the inferior aspect of the scar.  Pelvic examination revealed a normal vulva/vagina. The cervix was healthy; the uterus bulky and anteverted with limited mobility and the adnexa were normal. A tentative diagnosis of post caesarean section uterocutaneous fistula was made.
 Full blood count showed a haemoglobin of 12.1grams/deciliter; white blood cell count of 5.6x109 /L and a platelet count of 309x109 /L. Endocervical swab for microscopy, culture and sensitivity revealed no growth of pathogens. Urea creatinine and electrolytes levels were normal. Hysterosalpingography showed an elongated cervix with the uterine cavity located around L4 and L5. The uterine cavity had a surrounding contrast smudge despite no tubal demonstration (figure I).
A decision to perform a laparotomy was made and the patient consented. Intra-operative findings included a thick fibrotic fistulous tract measuring about 6cm in length, extending from beneath the umbilicus to the fundus of the uterus (figure II). There was also an opening on the uterine fundus measuring about 0.5x 0.5cm with thick granulation tissue surrounding it (figure III). The fallopian tubes were bound down by adhesions and both ovaries were normal.
The fistulous tract was then completely excised while the edges of the opening in the uterine wall were excised and the uterine wall repaired in two layers. The patient�s post operative course was uneventful and she was discharged on the tenth postoperative day after the wound had healed satisfactorily and skin sutures had been removed. At review six weeks and two months following discharge, she remained symptom free and was menstruating normally. The abdominal scar was intact. She was advised to book early for antenatal care in a specialized unit in all subsequent pregnancies. Histopathologic sections (microscopic) showed a fistula tract lined with benign stratified squamous epithelium superficially and granulation tissue deeply. There was an area of ulceration of the skin with sub-epithelial inflammation, neovasculization and endometrial type glands. 
DISCUSSION 
Uterocutaneous fistula is an extremely rare entity as only few cases have been reported over the past 200 years in world literature4. Spontaneous uterocutaneous fistula is extremely rare and aetiology is usually Surgery, Obstetric, infection or tumour related1,2. Reported risk factors include previous abdominal and pelvic surgeries, incomplete closure of uterine incisions during cesaerean sections, post operative sepsis, septic abortion, migration of intrauterine devices and laminaria tents, chronic genital infections such as genital tuberculosis, ruptured appendix associated with Crohn�s disease, endometriosis, abdominal pregnancy leading to perforation of the anterior wall of the uterus and long maintenance of abdominal drains1-5. 
Our patient had prolonged obstructed labour and subsequently had caesarean section which was complicated by sepsis. Most uterocutaneous fistulas are reported to originate from some type of infective process that disrupts the continuity of tissues involved 2.In addition, poor surgical technique may have contributed to the development of the fistula in our patient as most General Medical Practitioners who offer maternity care in our  environment do not have any additional training in Obstetrics. As seen in our patient, the major symptom of uterocutaneous fistula is bloody discharge from an opening on the skin which occurs simultaneously with menstrual period6. 
Uterocutaneous fistula may be confused with other clinical conditions such as scar endometrosis. Hence, demonstration of the fistulous tract is necessary for definitive diagnosis and this can be done with a fistulogram, or use of contrast enhanced  computed tomography (CT) scan as well as magnetic resonance imaging (MRI) or hysterosalpingography (HSG)1-3, 6. In our patient, HSG was performed but could not demonstrate the entire fistulous tract probably due to the high resistance of the contrast media within the narrow tract. Though contrast CT scan and MRI could have demonstrated the tract, they were not available in our center at the time the patient was managed. In addition to their unavailability in most Nigerian centers, the costs of performing such test are very dear. Thus, the diagnosis of uterocutaneous fistula in the patient was made based on a high index of suspicion due to the typical clinical presentation coupled with the demonstration on hysterosalpingogram of a smudge of contrast medium around the uterine cavity in the absence of tubal demonstration. 
Though spontaneous healing of the fistula is possible4, treatment is usually by laparotomy with hysterectomy and/or fistula excision1, 4-6.  Hysterectomy is the treatment of choice where pregnancy is no longer desired4, 6. Successful treatment of uterocutaneous fistula with gonadotropin releasing hormone agonists has been reported6. Our patient was primiparous with no living child hence a fistulectomy and repair of the rent in her uterus was performed with  good outcome as she has remained asymptomatic since surgery.
With the rising caesarean section rates particularly in low resource settings such as ours 7, it becomes imperative for General Medical Practitioners who offer maternity care to have additional training in conventional caesarean section techniques with emphasis on infection prevention. A uterocutaneous fistula should be suspected in any patient who presents with cyclical bloody discharge from a surgical scar. Timely diagnosis with appropriate surgical care led to a favorable outcome in our patient.

REFERENCES
Loue V, Koffi A, Adjoby R, N�Guessan K, Alla C, Gbary E, Abauleth R. Postmyomectomy uterocutaneous fistula. J Gynecol Surg. 2013; 29(1): 36- 38.

Eldem G, Turkbey B, Balas S, Akpinar E. MDCT diagnosis of uterocutaneous fistula. European Journal of Radiology extra 67. (2008); e129 � e130.

Shukla D, Pandey S, Pandey LK, Shukla VK. Repair of uterocutaneous fistula. Obstet Gynecol 2006; 108: 732 � 3


Baggish M, Bhaki A. Uterocutaneous fistula: A complication of ruptured appendix and Crohn�s disease during pregnancy. J Gynecol Surg. 2010; 26: 163.

Sonmezer M, Sahincioglu O, Cetinkaya E, Yazici F. Uterocutaneous fistula after surgical treatment in an incomplete abortion: Methylene blue test to verify diagnosis. Arch Gynecol Obstet. 2009; 279:225.

Seyhan A, Ata B, Sidal B, Urman B. Medical treatment of uterocutaneous fistula with gonadotropin- releasing hormone agonist administration. Obstet Gynecol. 2008; 111: 256-8.

 . Abasiattai AM, Utuk NM, Inyang-Etoh EC, Akaiso OE. Outcome of labour after previous caesarean delivery in Uyo, Southern Nigeria. The Nigerian Medical Practitioner 2012; 61: 68-23.
























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