Dr. Jyoti Ramesh Chandran is an aluminus of Government Medical College Jabalpur. She is the president of Calicut O&G Society 2018, 2019 and 2020. She is the corresponding editor of JOGI (2017–2020). She is also member of Institutional Research Committee of GMC Kozhikode. Her areas of interest include high-risk obstetrics, endoscopy and fetal medicine.
Cloacal anomalies are rare anorectal malformations usually affecting girl child. It needs surgical correction in childhood and may have significant bearing on the reproductive outcome in later life. We are presenting a case report of such a case posing obstetric challenge and complications.
Cloacal anomalies are a type of anorectal malformation in which the rectum, urethra and vagina fail to separate. It is an extremely rare disorder, incidence being 1 in 50,000 births [1]. It usually affects girl child. There may be only a single opening in the perineum. There may be co-existent anoma-lies of GIT, cardiac, renal, uterine, skeletal and limbs. Great surgical expertise is required to correct both anorectal and urogenital malformations in the childhood with significant bearing on the reproductive outcome in later life.
Mrs X, 26-year-old primigravida, a booked case in our institution with last menstrual period on 19 April 2016 and expected date of delivery on 26 January 2017, was admitted at 36 weeks for safe confinement. She was mar-ried for 2 years and had coital difficulty but had conceived spontaneously.
Her antenatal history was uneventful.
Past history revealed a corrective surgery in the newborn period for anorectal malformation. She was born with a sin-gle opening in the perineum, and a colostomy was done on the 1st day of life. Subsequently, a definitive surgery was done at 9 months of age followed by closure of colostomy at 18 months. She developed stricture at the anal opening for which an anoplasty was done at 5 years of age. She was having regular bowel and bladder habits.
On general examination, she had rocker bottom foot (Fig. 1). Her vitals were stable, and her systemic examina-tion was within normal limits. Her obstetric examination revealed a single intrauterine gestation in breech presenta-tion with adequate growth and normal liquor and fetal heart sounds.
Examination of external genitalia revealed normal labia majora and labia minora fused in the midline; there was a dimple in the midline at the region of introitus which admit-ted tip of little finger (Fig. 2). Urethra was not visualised, and the anal opening was scarred.
Investigations: a pelvic ultrasound taken at 19 years of age revealed uterus didelphys, ovaries, adenaxae normal and both kidneys and ureters were normal. Her 1st trimester antenatal UGS was showing disparity in dates of 2 weeks, and her last USG at 37 weeks showed abnormal lie (breech presentation) in the last trimester. Urology consultation was done as urethral opening was not seen. They performed a cystoscopy, and urethra was identified through the vaginal dimple and bladder catheterised under cystoscopic guid-ance (Fig. 3) Obstetric management was a planned elective caesarean at 39 weeks due to mistaken dates in I trimester ultrasound, but patient went into labour at 38.2 weeks, and an emergency caesarean section was performed on 15th January at 8 am.
Operative findings and procedure: Subumbilical mid-line incision was planned due to previous scar on the abdo-men, and difficult abdominal entry was anticipated, and as expected, there was difficulty in entering the peritoneal cav-ity, inadvertent bladder injury of about 5-cm anterior bladder wall (Fig. 4).
Lower segment caesarean section performed and deliv-ered a male baby 2700 gm as breech, Apgar 1’9. Uterus was didelphys (Fig. 5) with pregnancy in the right horn; bilateral tubes and ovaries were normal.
Bladder rent repaired by urologist whose assistance was sought initially anticipating complications; suprapubic cath-eter (SPC) and intra-peritoneal drain were kept. Urethral
catheter was removed after 2 weeks and SPC after 3 weeks with normal voiding. Otherwise, post-operative period was uneventful.
Cloacal anomaly is a complex problem, best dealt at a spe-cialist centre and needs a team work [2].
The aim of definitive reconstruction is to create three separate channels. Although corrected in neonatal life, if not followed up, it can pose challenges during obstetric carrier. Due to stricture formation in created openings, there can be cryptomenorrhoea, difficult coitus or difficulty in defecation [3]. Due to associated uterine anomalies, there are chances of development of hematometra, endometriosis, early mis-carriage, preterm labour, malpresentation and rupture uterus
[4]. The mode of delivery in such cases would be by caesar-ean section with high chance of bowel and bladder injuries due to altered pelvic anatomy.
A study by Hendren et al. [5] of 195 women with cor-rected cloacal anomalies reached adulthood, 17 experienced coital difficulties and 7 delivered by caesarean section except one who had vaginal birth.
Conflict of interest The authors declare that they have no conflict of interest.
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