Gynaecological Catastrophe: Acute on Chronic Uterine Inversion − Can We Prevent It? A Case Report and Review

Tanuja Muthyala; Yedla Manikya Mala; Asmita Rathore; Sonia Goswami

doi:10.4103/mamcjms.mamcjms_7_20

CASE REPORT

Year : 2020 | Volume : 6 | Issue : 1 | Page : 47-49

Gynaecological Catastrophe: Acute on Chronic Uterine Inversion − Can We Prevent It? A Case Report and Review

Tanuja Muthyala¹, Yedla Manikya Mala², Asmita Rathore², Sonia Goswami²
¹ Department Of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
² Department Of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh; Maulana Azad Medical College, New Delhi, India

Date of Submission	04-Feb-2020
Date of Decision	20-Feb-2020
Date of Acceptance	04-Mar-2020
Date of Web Publication	30-Apr-2020

Correspondence Address:
Assistant Professor Tanuja Muthyala
Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Guntur, Andhra Pradesh-522503
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/mamcjms.mamcjms_7_20

Abstract

In a non-obstetric patient, uterine inversion is a rare complication of intrauterine tumors. Till date, only 200 cases have been reported worldwide. The typical presentation is with features of haemorrhagic shock. Delay in diagnosis and management deteriorates the general health and future reproductive potential of the patient. We present a 30 year old multiparous lady, a diagnosed case of submucosal fibroid who had acute uterine inversion and was managed by performing a laparotomy with Haultains procedure. The case is bring presented as it is a rare gynaecological emergency, which requires immediate resuscitative and definitive procedures. Uterine conservation is a feasible option in selected cases of uterine inversion; chronic and neglected cases are a challenge for both conservative surgery and hysterectomy. High index of suspicion for malignancy should be a consideration irrespective of age, parity, previous benign conditions to optimize outcome.

Keywords: Leiomyoma, non-puerperal, uterine inversion

How to cite this article:
Muthyala T, Mala YM, Rathore A, Goswami S. Gynaecological Catastrophe: Acute on Chronic Uterine Inversion − Can We Prevent It? A Case Report and Review. MAMC J Med Sci 2020;6:47-9

How to cite this URL:
Muthyala T, Mala YM, Rathore A, Goswami S. Gynaecological Catastrophe: Acute on Chronic Uterine Inversion − Can We Prevent It? A Case Report and Review. MAMC J Med Sci [serial online] 2020 [cited 2023 Jun 4];6:47-9. Available from: https://www.mamcjms.in/text.asp?2020/6/1/47/283509

Introduction

Non-puerperal uterine inversion is so rare that incidence rates of it are unknown. Around 200 cases are reported worldwide. It is most commonly associated with intrauterine tumors. Clinical presentation of uterine inversion varies depending on the degree of inversion and whether the onset is acute or chronic. Complications like hemorrhage, sepsis, coagulopathy, embolism, fistula formation, and mortality occur, especially in neglected cases. We report a case of acute on chronic uterine inversion in a young multiparous lady presented to our emergency in shock. She was resuscitated and managed by Haultain’s procedure. We report this case because of rarity of this gynecological emergency, to review its varied clinical presentations, diagnostic challenges and treatment options of non-puerperal uterine inversion.

Case Report

A 30-year-old multiparous lady presented to our outpatient department with complaints of irregular and excessive menstrual flow from last one year. She had moderate pallor and on abdomino-vaginal examination, uterine size was corresponding to 12–14 weeks gravid uterus, fornices were clear and cervix healthy. Ultrasonography suggested a submucosal fibroid of 6*8 cm with a broad base. Contrast-enhanced computed tomography (CECT) of whole abdomen with pelvis ruled out features of malignancy. Serum Lactate dehydrogenase levels were normal. She was advised admission, but she did not follow the advice and presented again in emergency four months. She was symptomatic from last four months with on and off bleeding, vaginal discharge and lower abdominal pain. On emergency visit, she was disoriented, gasping and pale with pulse rate of 150/minute, blood pressure 60 mmHg systolic. Examination revealed dark red solid mass of 12×10 cm protruding out of vagina with degenerative changes and ongoing bleed [Figure 1]A. It was filling vagina and cervix was not visualized. Per-rectal examination confirmed findings of inversion. Pallor was out of proportion to the ongoing bleed. Ultrasonography suggested inversion. Trachea and she was intubated, resuscitated inside the operation-theatre with four units’ blood transfusion.

Figure 1 (A) Complete uterine inversion with fibroid through vagina in the index case. (B) Haultain procedure: Picture showing traction given over round ligaments

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Myomectomy was attempted vaginally, but tumor was friable, bleeding and stalk could not be reached, so decision for laparotomy was taken. Intraoperative findings were suggestive of complete uterine inversion giving typical flower-vase appearance [Figure 1]B. Haultain’s procedure was performed using vertical midline incision of 3 cm on posterior uterine wall with gentle traction on the round ligaments. The stalk was avulsed and myoma delivered vaginally. Hysterotomy incision was repaired in layers and bilateral tubal-ligation was performed. Post-operatively the patient was transferred to ICU, inotropes were tapered gradually and she was off ventilator 36 hours post-operatively. Histopathology reported leiomyoma.

Discussion

Non-puerperal inversions represent about one-sixth of all inversions.^[1] Intrauterine tumors are commonest predisposing cause. Risk factors are fundal origin with broad base or a thick stalk, large size of the tumor, weakened uterine wall and dilated cervix.^[2] Mwinyoglee et al.^[3] reported around 97% of inversions had intra-uterine tumors as etiology, one-fifth of these were malignant. Submucosal leiomyoma is the commonest etiology. Submucosal fibroids are usually symptomatic with metrorrhagia or menorrhagia and require treatment. Even asymptomatic patients with submucosal leiomyomas need monitoring and large size may mandate excision due to the risk of malignancy or inversion.

Literature search from 1887 to 2019 reported around 60 cases of uterine malignancies associated with uterine inversion. Of which, 22 had unspecified sarcoma, seven Leimyosarcomas, four Endometrial stromal sarcomas, two Adenosarcoma, one Fibrosarcoma and 14 malignant mixed Mullerian tumors. Other associations are rhabdomyosarcoma, teratoma, endometrial polyps, chronic raised intra-abdominal pressure due to liver cirrhosis and ascites which lead to inversion.^[4] In an acute and complete uterine inversion, features of shock prevail with severe pain and hemorrhage. With chronic or incomplete inversion, symptoms are pelvic discomfort, unhealthy vaginal discharge, and non-cyclical bleeding per vagina. Necrotic areas in dependent parts predispose to infection making tissues friable, congested with loss of surgical planes. Depending on the degree of inversion, bimanual palpation suggests absence/dimpling of uterine fundus at its anatomical position. On a recto-abdominal examination, the vagina is occupied by the inverted uterus.

On Ultrasonography, inverted mass appears hyper-echoic while uterine cavity is seen as central hypo-echoic H-shaped area in transverse view, and in sagittal view, a U-shaped longitudinal groove from fundus to center of inverted area. Magnetic Resonance Imaging (MRI) findings: on T2-weighted images, a U-shaped cavity (Target sign) with inverted fundus on sagittal view and a ‘bulls-eye’ configuration on axial view are suggestive of uterine inversion.^[5] Moulding and Hawnaur proposed, the key features to identify uterine inversion on MRI are bulging round ligaments and fallopian tubes centrally and on top of uterus. Both these are pulled downwards and medially by inverted fundus. MRI can also define cavity details and tumor characteristics.^[6]

The diagnosis in our patients is acute on chronic inversion as she had features of incomplete inversion from past 4 months before she presented in emergency with vaginal mass and bleeding. Unlike postpartum uterine inversion, manual reposition of the uterus is rarely successful following inversion due to gynecological causes, as the lower uterine body and cervix form a constriction ring due to chronic congestion and edema which makes surgical correction inevitable. It can be done by vaginal (Tew’s and Kustners’s techniques) or abdominal route (Haultain or Huntington procedures) by laparotomy or laparoscopy.^[7] Uterus is reposited after tumor excision. Once reposition is successful, whether the patient requires hysterectomy or radical surgery depends on the patient’s future reproductive prospects, intra-operative findings, histopathology results and vitals on admission. In the index case, Haultain’s procedure with bilateral tubal ligation was performed.

Conclusion and Recommendation

Non-puerperal uterine inversion is a rare gynecological catastrophe. This differential must be considered as a possibility in a non-pregnant woman presenting with bleeding or mass per vagina with or without hypotension. It can very rarely present as postmenopausal bleeding. Associated malignancy is to be ruled out in every case of uterine inversion irrespective of age or parity, pre-operatively or intra-operatively. Prognosis depends on prompt diagnosis and timely intervention. Broad-spectrum antibiotics are recommended to prevent sepsis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Gomez-Lobo V, Burch W. Nonpuerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent. Obstet Gynecol 2008;112:708-9.
2.	Lupovitch A, England ER, Chen R. Non-puerperal uterine inversion in association with uterine sarcoma: case report in a 26-year-old and review of the literature. Gynecol Oncol 2005;97:938-41.
3.	Mwinyoglee J, Simelela N, Marivate M. Non-puerperal uterine inversions. A two case report and review of literature. Central African J Med 1997;43:268-71.
4.	Salameh AEK, Loay M, Aljaberi RM, Almarzooqi DR, Khloof SA, Rasa A, Tabanja R. Non-puerperal uterine inversion associated with adenosarcoma of the uterus: a case report. Case Reports in Women’s Health 2019;22:e00107
5.	Veli M, Fahrettin K, Soner P, Aydin K, Ahmet K. Magnetic resonance imaging of non-puerperal complete uterine inversion. Iran J Radiol 2015;12:e9878.
6.	Moulding F, Hawnaur JM. MRI of non-puerperal uterine inversion due to endometrial carcinoma. Clin Radiol 2004;59:534-7
7.	Zhang X, Sun L, Chen X, Hua K. Uterus preserving reposition of non-puerperal uterine inversion under laparoscope: a case report and literature review. Gynecol Obstet Invest 2015;79:206-9.