INTERESTING CASE STUDY

 Mrs. Minimalar  24year old Primi from Villukuri  Admitted with complaints of lower  abdominal pain since 2 days.  She is a primi with 4 months amenorrhoea  LMP 17/09/2012  EDC 24/06/2013

H/O Presenting Complaints  Patient was referred from local hospital, as a Primi – 16 weeks gestation with a/c abdominal pain 2 days.  Diffuse pain  Associated with vomiting  Regular ANC and was immunized

Past & family H/O  No similar illness in past  Congenital anomalies present in family Marital H/O  Married since 7 months  Non consanguinous marriage Menstural H/O  Regular cycle  LMP – 17/09/2012

Examination O/E- Thin built - Conscious & well oriented - Afebrile - No pallor / No oedema - Speech stammering - Mouth – uvula absent - hands & feet – congenital wasting + deformity of hand & feet Vitals – stable CVS RsNAD

Per Abdominal Examination  Tenderness  iliac fossa  swelling left inguinal region  3x2cm  Non – reducible  No cough impluse  Transilluminant Uterus 16 weeks FH good

Investigation  All Haematological investigations – WNL USS Revealed – single viable foetus - 16 weeks - NL for date

USS of inguinal region  A large thinwalled simple cyst containing clear fluid in left inguinal region.  It extended from level of deep inguinal region to superficial inguinal ring just lateral to symphysis pubis.  Right ovary enlarged with  vascularity  Left ovary seen separate from the cyst.

What can this be ?

Differential Diagnosis  Inguinal Hernia  Femoral Hernia  Enlarged lymphnodes  Soft tissue tumour  Lipoma  Leiomyoma  Endometriosis of round Ligament  Vascular abnormality like – Arterial + venous aneurysms  Rarely – hydrocoele of canal of nuck  Ganglion cyst  Para spinal abscess

Discussion  Rare cause of inguinal swelling in women  Only 400 reported cases  Female counterpart of hydrocoele of spermatic cord  Rare developmental disorder

Anatomy  In male foetus an evagination of the parietal peritoneum The processus vaginalis accompanies the testis as it descends into the scrotum  The same finger like processus vaginalis named the canal of Nuck follows the round ligament of uterus as it passes through the female inguinal canal  Normally this peritoneal evagination undergoes obliteration soon after birth in both sexes or within 1 year  Failure to achieve complete obliteration  Partial proximal obliteration leaves the distal portion of processus vaginalis open  cyst of canal of Nuck

Diagnosis  Based on clinical findings Painless swelling Moderately fluctuant inguinal mass Irreducible Transilluminant No A/c abdominal symptoms

Investigation  Choice  Ultra sound scan  MRI

Treatment of choice  Surgical resection of hydrocoele, and ligation of neck of processus vaginalis  Sonographically guided aspiration temporarily  Risk of contralateral inguinal hernia

Conclusion  Rare developmental disorder  DD for groin tumour in females  USS – investigation of choice  Concomitant inguinal hernia may be there  Surgical excision curative  Temporary cure – USS guided aspiration.

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