Journal of Clinical Sciences

CASE REPORT
Year
: 2021  |  Volume : 18  |  Issue : 1  |  Page : 69--72

Non-puerperal uterine inversion: An uncommon presentation - A case report


Francis C Ezenwankwo1, Osemen E Okojie2, Adaiah P Soibi-Harry1, Babasola O Okusanya3,  
1 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
2 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria; Women and Childrenfs Health, Maidstone and Tunbridge Well NHS Trust, Kent, Englad
3 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital; Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria

Correspondence Address:
Dr. Osemen E Okojie
Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Idi-Araba, Lagos

Abstract

Spontaneous nonpuerperal uterine inversion is an exceedingly rare gynecological event. When it occurs, it is often due to an intrauterine polypoid mass attached to the uterine fundus, eventually pulling the uterus inside out over time as the mass increases in size. We present a case of nonpuerperal uterine inversion in a 32-year-old female who presented with heavy vaginal bleeding and vaginal protrusion of a fleshy mass. A clinical diagnosis of chronic uterine inversion due to a pedunculated submucous fibroid was made and was surgically managed with a vaginal myomectomy combined with an exploratory laparotomy and surgical reduction under general anesthesia. Good clinical acumen and surgical skills are invaluable for accurate diagnosis and appropriate treatment of nonpuerperal uterine inversion.



How to cite this article:
Ezenwankwo FC, Okojie OE, Soibi-Harry AP, Okusanya BO. Non-puerperal uterine inversion: An uncommon presentation - A case report.J Clin Sci 2021;18:69-72


How to cite this URL:
Ezenwankwo FC, Okojie OE, Soibi-Harry AP, Okusanya BO. Non-puerperal uterine inversion: An uncommon presentation - A case report. J Clin Sci [serial online] 2021 [cited 2021 Apr 11 ];18:69-72
Available from: https://www.jcsjournal.org/text.asp?2021/18/1/69/308601


Full Text



 Introduction



Uterine inversion is the telescoping of the fundus of the uterus to or through the cervix so that the uterus is in effect turned inside out. Although more of an uncommon life-threatening obstetric complication of the puerperium, it is a rarer gynecologic complication in the nonpregnant woman.[1],[2],[3] Postpartum uterine inversion is acute when it occurs within 24 h of childbirth, subacute when it occurs between 24 h and 4 weeks of childbirth, and chronic when it occurs after 4 weeks of childbirth.[2] Furthermore, uterine inversion not related to pregnancy is regarded as chronic uterine inversion.[2] Uterine inversion is further categorized as complete or incomplete depending on whether the prolapsed fundus of the uterus has passed through the cervix to the vagina or not.[2],[4] Total uterine inversion is when the vagina lies alongside the uterus.[5] The incidence of puerperal uterine inversion is 1 in 20,000 (1 in 2000–1 in 100,000).[2] Its occurrence depends on the quality of care of the third stage of labor.[2] Nonpuerperal invasion is much rarer and accounts for 17% of all cases of uterine inversion;[4] only about 150 cases were reported between 1887 and 2006.[4],[5] Nonpuerperal uterine inversion is often due to a fundal submucous uterine fibroid (78.8%–85%) as was seen in the case being reported.[4],[5],[6],[7] Other risk factors include endometrial polyp, uterine sarcoma, endometrial carcinoma, and mixed mesodermal tumors.[5],[6],[8]

 Case Report



A 32-year-old para 2 female presented with a 10-month history of heavy, prolonged menstrual bleeding and protrusion of a mass from her vagina of 4-day duration. She had a passage of blood clots, episodes of dizziness, easy fatigability, and palpitations. There was a history of dysuria, increased urinary frequency and intermittency, constipation, dyspareunia, and postcoital bleeding but no abnormal vaginal discharge. There was no vomiting, no cough, no weight loss, and no bleeding from other orifices. She sought care at a peripheral health facility, where she was transfused with three units of blood, and attempts to reduce the vaginal mass were unsuccessful, prompting the referral

She attained menarche at 14 years, her menstrual period had changed from 4 to 7 days in a regular 28-day cycle, she was not aware of Pap smear, and she used emergency contraceptives occasionally. There was no history of dysmenorrhea.

She had no chronic medical illness, was not a smoker, and did not consume alcoholic beverages.

Her physical general examination and breast and abdominal examination findings were essentially normal. Vital signs recorded were heart rate: 88 bpm, blood pressure: 124/70 mmHg, and respiratory rate: 22 cpm.

On pelvic examination, she had an inverted uterus with a submucous fibroid nodule of 6 cm × 8 cm attached to the uterine fundus. The cervix was thinned out around the mass, the fundus of the uterus was not palpable per abdomen, the adnexa was free, and there was contact bleeding.

A diagnosis of pedunculated submucous fibroid complicated by uterine inversion was made. Evaluation of the patient was done simultaneously with initial care. An intravenous access was secured with wide bore cannula; blood samples were obtained for investigations and grouping and crossmatching of two units of blood, in preparation for the surgical procedure. Preoperative packed cell volume (PCV) was 32%; renal function test and all other hematological investigation results were normal. The findings and management options were explained to the patient. She was counseled for an emergency examination under general anesthesia (EUA), vaginal myomectomy, and reduction of uterine inversion.

Furthermore, she was counseled on the possibility of an exploratory laparotomy and surgical reduction, with/without hysterectomy should the need arise. An informed consent was obtained from her.

At examination under anesthesia, with general anesthesia using fluorinated hydrocarbons, a vaginal myomectomy was carried out for the prolapsed submucous fibroid. There was an unsuccessful attempt to manually replace the uterus through the vagina digitally. She was repositioned in the supine position, the abdomen cleaned and draped, and an exploratory laparotomy was performed still under general anesthesia. A combination of Huntington's and Haultain's operation was employed to achieve the restoration of the uterus to its premorbid anatomy. The Huntington's procedure involved grasping the round ligaments with a pair of Alice forceps and the uterus below the area of the inversion and gradually pulling up, till reinversion of the uterus had been achieved, whereas the Haultain's procedure involved incision of the posterior aspect of the formed cervicovaginal ring and lifting up the posterior wall of the uterus until restoration to its normal anatomy had being achieved. A size 8 Foley's catheter was placed in the uterus and inflated with 3 ml of normal saline. This was retained for 5 days postoperatively. Findings at surgery include an inverted uterus with submucous fibroid (6 cm × 8 cm), denuded endometrium with contact bleeding [Figure 1], classic flowerpot appearance of the uterus [Figure 2], and fallopian tubes, ovaries, and round ligament telescoping into the uterine tunnel and extending beyond the constriction ring which was tight and about 2 cm thick, grossly normal ovaries and fallopian tubes [Figure 3]. Her estimated blood loss was 700 ml.{Figure 1}{Figure 2}{Figure 3}

Her immediate postoperative condition was satisfactory, with a postoperative PCV of 30%. The managing team of doctors discussed the intraoperative findings with her when she was stable, and she was discharged home on the 5th postoperative day. She was followed up at 6 weeks; she remained well, after which she was discharged from the clinic.

Histology report of submucous fibroid:

Macroscopy: specimen consists of one piece of firm fibrous tissue about 6 cm ×7 cm in diameter. Cut section showed nodules of whorled gray-to-white fibers, with focal hemorrhagesMicroscopy: sections showed a myometrial tissue with smooth muscle cell proliferating focally. These appear as nodular areas, with fibers in whorled fashion, and compressing adjacent normal smooth muscle cellsConclusion: uterine fibroid.

 Discussion



The pathogenesis of chronic uterine inversion has not been clearly defined.[4] The most plausible explanation seems to be a large submucosal mass in the fundus, usually attached to the uterus through a thin pedicle. Our patient presented with acute vaginal bleeding and protrusion of a pedunculated submucous fibroid through the vagina. The walls of the uterus may become thin and weak due to the presence of the mass or due to pressure effect and necrosis and may be pulled down by the weight of the mass.[4],[5] Subsequent distension of the uterine cavity may lead to a dilation of the cervix and expulsion of the mass.[4],[5] It has been suggested that conditions that raise intra-abdominal pressure including chronic cough, sneezing, and straining may be involved in the development of uterine inversion.[4] Patients with this condition may present in an acute state characterized by vaginal bleeding, protrusion of a fleshy mass per vagina, and severe pain as was seen in our patient.[4],[5],[6] The presentation may also be insidious with irregular bleeding, vaginal discharge, urinary dysfunction, and anemia.[4],[5] Diagnosis based on only clinical examination alone may be challenging. However, a detailed history and clinical examination would be sufficient to make a diagnosis.[4],[5] Ultrasound scan findings of uterine inversion have been described as a hyperechoic mass in the vagina with a central hypoechoic H-shaped cavity.[9] Magnetic resonance imaging (MRI) and computerized tomography (CT) scan are useful diagnostic tools. A U-shaped uterine cavity and a thickened and inverted uterine fundus on a sagittal image and a “bull's-eye” configuration on an axial image are signs indicative of uterine inversion on MRI.[4],[5],[6],[7],[10]

However, only hemodynamically stable patients can undergo radiographic imaging. Since our patient was clinically unstable and the diagnosis had been clinically made, there was no further need for radiological imaging. Various surgical techniques have been described in the management of uterine inversion. These include Huntington's and Haultain's abdominal procedures and Kustner and Spinelli vaginal procedures.[2],[5],[7] For the case being reported, we used a combination of Huntington's and Haultain's procedure to achieve uterine reduction following vaginal myomectomy. Usually, a vaginal myomectomy or polypectomy is done, and an attempt is made to replace the uterus with adequate uterine relaxation, achieved by the use of general anesthesia with fluorinated hydrocarbons or by acute tocolysis with nitroglycerin is often required.[2] General anesthesia with fluorinated hydrocarbons was used for index patient. In the case under review, initial attempts to reduce the inverted uterus by the Huntington's procedure alone yielded little success. The Haultain's procedure was ultimately used to revert the uterus successfully to its anatomic position.

 Conclusion



Nonpuerperal uterine inversion is a rare gynecological condition. An extremely high index of suspicion and good clinical acumen is needed to make a diagnosis. When the circumstance permits, MRI is the imaging modality of choice to confirm the diagnosis. Good knowledge of the pathophysiology and the surgical procedures for its correction is expedient to having a good prognosis.

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.

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