Case Report: Young Nulligravid with Chronic Non-Puerperal Uterine Inversion Secondary to a Prolapsed Myoma with Malignant Histopathology

Abstract

<h3>Study Objective</h3> To present an interesting case report of a 23-year-oldnulligravid with a 5-month history of heavy and prolonged vaginal bleeding with intermittent hypogastric pain. Examination showed a necrotic mass measuring 7 × 8 × 5 cm occupying the vaginal vault with no palpable cervix and uterus. Ultrasound confirmed a prolapsed submucous myoma with uterine inversion. Admitting diagnosis was chronic and complete non-puerperaluterine inversion secondary to prolapsed infected submucous myoma with secondary anemia. The patient was anemic with leukocytosis and she was given intravenous antibiotic and transfused with packed RBC, properly typed and crossmatched. Biopsy of the prolapsed mass revealed an infarcted polyp. Surgical plan was to preserve fertility and perform a hysteroscopic- and laparoscopic- guided vaginal myomectomy followed by uterine repositioning. On diagnostic hysteroscopy, there was no identifiable cervix, the prolapsed mass was too large and surgical landmarks were not identified. Concurrent laparoscopy revealed the uterus was inverted into a constricted "flower-pot" cervical ring towards the vaginal canal at the level of the round ligaments and bilateral ovaries and fallopian tubes were grossly normal. Proceeded with amputation of the prolapsed mass in a piecemeal fashion followed by attempts at uterine repositioning by Huntington's and Hultain's maneuvers but were not successful. The remaining vaginal mass was too large to pass through the cervix hence decision was to proceed with laparoscopic total hysterectomy with bilateral salpingectomy. Histopathology revealed Malignant Spindle Cell Neoplasm. <h3>Design</h3> N/A. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Uterine inversion is rare in the non-puerperal period and is often difficult to diagnose and manage. There should be high index of suspicion in the setting of a mass protruding from the vagina, non-palpable uterus, and pelvic organs not visualized on ultrasound. When inversion is chronic, reverting maneuvers may prove difficult rendering fertility-sparing techniques implausible. In the setting of fertility preservation, malignancy must be ruled out.