Non puerperal total uterine inversion:
An unusual gynecological case managed with
vaginal hysterectomy.
INTRODUCTION
DEFINITION :
Uterine inversion is a rare clinical condition in which the
fundus of the uterus descends into or through the cervix
resulting in an inside out telescoping of the uterus out of the
pelvis into the vagina or even outside the body.
Inversion of uterus may be puerperal or non puerperal.
Puerperal inversion is a rare complication of poorly managed third stage of
labor and accounts for 1 in 3500 deliveries.
However the incidence for non-puerperal uterine inversion remains
unclear with just more than 100 cases reported worldwide.
Non gravid uterine inversion is associated with uterine pathology with 80-
85% of them being associated with uterine leiomyomas
Inversion of fibroid uterus is due to thinning and weakening at the seat of
tumors implantation which is more marked in larger tumors that are
fundal in location.
Clinical presentation
Most women present with abnormal uterine bleeding that can
be significant enough to result in anemia requiring blood
transfusion or even hypovolemic shock.
There might be associated abdominal pain, discomfort, fullness
in vagina or even mass coming out of vagina.
Detailed history taking and examination along with
complementary imaging tests such as ultrasonography are key
tools for diagnosing as well as for the plan of management.
Staging of uterine inversion :
Stage 1 : Intrauterine/incomplete inversion-fundus remains within
the cavity.
Stage 2 : Complete inversion of uterine fundus into the cervix.
Stage 3 : Total inversion where by the fundus protrudes through the vulva.
Stage 4 : The vagina is also involved with complete inversion through the
vulva along with an inverted uterus.
Case Report
A 47-year-old woman (gravid 1, para 1) was admitted
to our hospital because of profuse vaginal bleeding.
On examination , she looked pale with cold and
clammy extremities and was hemodynamically
unstable with a heart rate of 114 beats per minutes
and a blood pressure of 90/54 mmHg.
Her oxygen saturation was 96% on room air and
respiratory rate was 18 breaths per min and she was
pale.
There was a large, firm hemorrhagic mass filling the
vagina and protruding to 15 cm beyond the introitus.
The mass formed an inverted pyriform swelling. It was
smooth, dark red in color, and bleeds on palpation.
Bimanual palpation revealed the absence of uterus and a
constricting ring is felt surrounding the neck of the
swelling.
Massive hemorrhage protocol was activated and two
wide bore cannulas were inserted.
Blood samples were sent off while she was being
resuscitated.
Her hemoglobin was 5 g/dl, platelets 1.2lacs, normal
PT (15.8), and INR(1.2) and normal urea and
electrolytes.
The pregnancy test was negative.
Blood was crossed matched and blood transfusion
commenced.
Continuous bladder drainage with foley’s catheter done.
Broad spectrum intravenous antibiotics was started.
Blood transfusion was done to improve her anemic status
preoperatively.
Local dressing using the antiseptic solution of povidone iodine
and hygroscopic action of magnesium sulphate was done daily
for 5 days.
Ultrasound revealed absent uterine fundus in pelvis
with the lower segment of uterus visualized with
echogenic content showing vascularity with a pseudo
endometrial stripe of the inverted cervix.
After stabilization of the condition (Hb: 7.5 g/dL and Ht: 38%), with volume
expansion of crystalloids and blood transfusion with 3 units of packed cell
volume, with antibiotic coverage for 5 days, she was taken for a emergency
surgical procedure on the 6th Day.
The patient and relatives were counselled for surgery and a well informed
written consent taken.
Proposed surgery: Vaginal
hysterectomy.
Patient in lithotomy position, under spinal anesthesia, under all aseptic
precautions.
Surgical findings:
Uterine prolapse, with inverted uterus.
Intraoperatively, the uterus was found to be completely inverted with the
endometrial surface of the fundus visible.
There were multiple submucosal fibroids on the fundus of the inverted
uterus with significant necrosis.
After painting and draping was done, transverse incision taken on
cervix and anterior colpotomy similarly posterior colpotomy also
done.
The antero-posterior extent of cervix palpated.
A single clamp applied laterally including the uterine vessels and
uterosacral ligaments, cut and ligated.
Specimen was excised and sent for histopathology examination.
Vaginal vault closure done. Hemostasis checked and
conficonfirmed.
Patient was shifted out in good condition.
Post operatively patient had good recovery, with prophylactic
antibiotics the postoperative period was uneventful and afebrile
and was discharged on postoperative day 8.
