Inversion of uterus due to prolapsed submucous fundal fibroid

Non Puerperal Uterine Inversion (NPUI) is a very uncommon condition. The incidence of puerparal uterine inversion make an estimate of 1/30,000 deliveries and NPUI approximately 17% of all uterine inversion. The most common cause which leads to uterine inversion is a submucous myoma attached to the fundus but diagnosis can be difficult to make. The management of uterine inversion is always challenging for a surgeon. In the present case a 38-year-old woman, presented with significant anaemia because of menorrhagia. She used to feel mass occasionally into the vaginal canal which never comes out of the introitus, the mass was elucidated as a fibroid polyp. On investigation, her haemoglobin was 6.6 gm%, with continous bleeding per vaginum, patient was transfused with three units packed red blood cells and planned for surgery. A diagnosis of incomplete uterine inversion secondary to a submucous fibroid was made at exploratory laparotomy. Total abdominal hysterectomy, right salpingectomy with left salpingo-oophorectomy was performed. The patient was discharged under satisfactory condition.

Nonpuerperal uterine inversion is a rare entity. Diagnosis is difficult because of the rarity of the condition and is often made at the time of surgery (1). A case of acute complete nonpuerperal uterine inversion with successful operative management is presented. A 41-year-old woman was referred to our hospital for lower abdominal pain and profuse vaginal bleeding of 8 h duration, palpation of a vaginal mass and anemia [hemoglobin (Hb) = 6.1 mg/dL]. She had already been transfused with four units of blood. Her medical history consisted of two previous cesarean sections, 14 and 12 years ago, and a uterine leiomyoma of size approximately 5 cm diagnosed 9 months ago after an episode of menorrhagia, but she had had no symptoms or complaints since then. Initial examination confirmed these findings and we found an Hb concentration of 8.4 mg/dL. The patient was immediately transferred to the operating theatre, suspecting that the cause was an expelled leiomyoma. Attempts at vaginal excision of the mass protruding into the vagina were unsuccessful and bleeding was heavy. Furthermore, neither the cervix nor the uterus could not be palpated. An immediate laparotomy was performed, revealing a complete inversion of the uterus. The bladder fundus, the adnexal structures, such as the fallopian tubes and round ligaments, accompanied the inversion and the ovaries were barely visible in the opening produced by it. Numerous attempts at bimanual reversion of the uterus were unsuccessful and a Haultain procedure was performed, making a midline incision of the posterior uterine inversion ring between the uterosacral ligaments, and performing gradual reversion of the uterus with the fundal leiomyoma. A total hysterectomy was performed to stop the bleeding. The patient received another three units of whole blood and had an Hb concentration of 7.8 mg/dL by the end of the operation. The postoperative period was uneventful and she was discharged on the fifth postoperative day in good condition. Nonpuerperal uterine inversion is a rare entity and its incidence has not been estimated in the literature (2, 3). It is classified as acute or chronic and subclassified as incomplete (fundus protrudes into the uterine cavity but not through the external cervical os), complete (fundus protruding through the external cervical os) or total (inversion of the uterus and part of or the entire vagina) (4). A previous cesarean section has been implicated as a risk factor for puerperal uterine inversion (5). Nonpuerperal inversions occur due to a tumor or an idiopathic event. Most tumors are reported to be uterine leiomyomas and the mechanism involved is thought to be the distension of the cavity, weakening of the uterine walls and the expulsive contractions of the uterus and weight of the tumor itself (4). In idiopathic cases the condition is usually abrupt, accompanied by pain and shock, while in tumor-produced cases it is mostly associated with chronic vaginal discharge and irregular vaginal bleeding (4). This, however, was not the case in our patient in whom a tumor-produced inversion caused the acute onset of lower abdominal pain and profuse vaginal bleeding leading to significant blood loss. Diagnosis can be difficult and two criteria must be applied on clinical examination: 1) nonvisualization of the cervix after excision of the vaginal mass; and 2) nonpalpation of the uterine corpus in bimanual examination with an empty bladder (3). Sonographic characteristics for incomplete inversion are the poor delineation of the endometrial stripe with a Y-shaped configuration (3). Computed tomography diagnosis may be difficult, but nonvisualization of the uterus in the pelvis and visualization of edematous endometrium and myometrium in the middle pelvis are suggestive of the condition (3). Magnetic resonance imaging (MRI) has been used recently for the diagnosis of uterine inversion where the U-shaped cavity may be seen (1). Four surgical procedures (two vaginal and two abdominal) have been used for the treatment of this condition (1, 4). The abdominal Haultain procedure, which consists of incising the constriction ring posteriorly followed by reversion of the uterus, was used successfully in our case. This procedure seems to be safe and effective in reducing the risks of bladder and ureter injury, and is also the procedure of choice in the case of malignant tumors causing the uterine inversion (1).

Uterine inversion which commonly occurs during the puerperium is the descent of the fundus of the uterus into or through the cervix thereby keeping the uterus in an ‘inside out’ position. Other structures such as the ovaries and fallopian tubes may also be displaced from the pelvis and restricted within the inverted uterus. However, non puerperal uterine inversion is very rare and represents about one-sixth of all inversion. The most common implicating factor in non-puerperal inversion is prolapsed fibroid with occasional reports of endometrial polyp and uterine neoplasia. Diagnosis of non-puerperal uterine in version may pose a major problem and treatment in women of reproductive age who desire future fertility may involve conservative surgeries. Case Report: We report a case of a 35 year old nulliparous woman with complaints of sudden protrusion of a mass from her vagina with associated cramping lower abdominal pain and vaginal bleeding. A diagnosis of non puerperal uterine inversion due to sub mucous uterine fibroid was made. Surgical interventions done included excision of fibroid and rectification of the uterus through Haultain’s procedure. Histology confirmed uterine fibroid and patient had resumed normal menstrual flow. Conclusion: High index of suspicion is essential for proper diagnosis of non-puerperal uterine in version. In the setting of fertility sparing surgeries, malignancy need to be ruled out, and the woman must be counseled on interval to next pregnancy and risks associated with different modes of delivery.

HomeRadioGraphicsVol. 43, No. 6 PreviousNext Cases from the Cooky JarFree AccessUterine InversionKaitlin M. Zaki-Metias , Melina Hosseiny, Fardad Behzadi, Patricia BalthazarKaitlin M. Zaki-Metias , Melina Hosseiny, Fardad Behzadi, Patricia BalthazarAuthor AffiliationsFrom the Department of Radiology, Trinity Health Oakland Hospital/Wayne State University School of Medicine, 44405 Woodward Ave, Medical Education, Pontiac, MI 48341 (K.M.Z.M.); Department of Radiology, University of California San Diego, San Diego, Calif (M.H.); Department of Radiology, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass (F.B.); and Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (P.B.).Address correspondence to K.M.Z.M. (email: [email protected]).Kaitlin M. Zaki-Metias Melina HosseinyFardad BehzadiPatricia BalthazarPublished Online:May 18 2023https://doi.org/10.1148/rg.230004MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Uterine inversion, or uterine intussusception, is a rare, potentially life-threatening entity characterized by inversion of the fundus into the uterine cavity, which often manifests as an acute complication of childbirth (1,2). Less commonly, uterine inversion is nonpuerperal, occurring as a result of an endometrial or myometrial mass (2,3). Patients typically present with symptoms that include vaginal bleeding and pelvic pain.At MRI, uterine inversion appears as a U-shaped uterus with loss of the normal convex fundal contour on sagittal images (Fig 1A, 1B) (2). A target configuration may be visualized on axial images, representing the concentric serosa, myometrium, and endometrium (Fig 1C, 1D) (2). MRI is also useful in assessing the cause in patients with nonpuerperal uterine inversion, including submucosal leiomyomas, uterine leiomyosarcomas, and endometrial malignancies. There are four grades of uterine inversion, which are characterized by the degree of inferior bowing of the fundus relative to the cervix and/or vaginal introitus (Fig 2).Figure 1. Uterine inversion in a previously healthy premenopausal female patient with acute onset of pelvic pain and vaginal bleeding. A bleeding vaginal or cervical mass was suspected on physical examination, and pelvic MRI was performed for further evaluation. Sagittal T2-weighted (A) and contrast-enhanced fat-suppressed T1-weighted (B) MR images of the pelvis demonstrate a U-shaped uterus (U) with loss of the normal fundal contour, with protrusion of the fundus into the distended vaginal canal (V), consistent with grade III uterine inversion. The cervix (C) is located superior to the inverted fundus. At the fundus, there is an ill-defined rounded lesion (arrow in A and B) with heterogeneous T1 signal intensity and enhancement with irregular margins, with adjacent heterogeneous T2 signal intensity and increased T1 signal intensity. The findings are most consistent with a hemorrhagic submucosal uterine leiomyoma. Axial T2-weighted (C) and contrast-enhanced fat-suppressed T1-weighted (D) MR images of the pelvis show concentric rings of signal intensity indicating the serosa, myometrium, endometrium, and vagina.Figure 1.Download as PowerPointOpen in Image Viewer Figure 2. Illustration depicts the normal anatomic position of the uterus (A) and the various grades of inversion. Grade I uterine inversion (B) is characterized by inferior bowing of the fundus up to but not beyond the cervix. In grade II uterine inversion (C), the inverted fundus protrudes through the cervix and into the vagina. The uterus is fully inverted and protrudes out of the vagina in grade III uterine inversion (D).Figure 2.Download as PowerPointOpen in Image Viewer Disclosures of conflicts of interest.—K.M.Z.M. Meeting attendance and travel reimbursement from Trinity Health Oakland Hospital. P.B. Editorial board member of RadioGraphics, Association of University Radiologists GE Radiology Research Academic Fellowship, meeting travel reimbursement from the American College of Radiology.K.M.Z.M and P.B. have provided disclosures (see end of article); all other authors have disclosed no relevant relationships.

INTRODUCTIONUterine inversion is an un-common complication of parturition which often occurs in the immediate postpartum period. The chronic (non-puerperal) uterine inversion is rarer and most times tumour associated. PRESENTATION OF CASEA 51-year old grand multiparous lady presented with a month history of abnormal vaginal bleeding associated with offensive vaginal discharge, lower abdominal pain and dizziness. The initial evaluation suggested severe anaemia secondary to advanced cervical cancer. Examination under anaesthesia (EUA), staging and biopsy was attempted but this was however inconclusive due to profuse haemorrhage. A repeat EUA revealed chronic uterine inversion secondary to fundal submucous uterine leiomyoma. Myomectomy was done with tissue histology confirming benign uterine leiomyoma. Two weeks later, a modified Haultain's procedure was done followed by simple hysterectomy and posterior colpoperineorrhaphy. She had satisfactory recovery. DISCUSSIONThis is the first reported case of chronic non-puerperal uterine inversion in our hospital. When it occurs, it is usually tumour associated with the commonest tumour being prolapsed myoma and leiomyosarcoma. The diagnosis is based on high index of suspicion. CONCLUSIONChronic uterine inversion is a rare gynaecological condition and can be misdiagnosed as advanced cervical cancer or other causes of severe genital haemorrhage in women. A high index of suspicion is needed for its proper diagnosis. Sometimes, an EUA and biopsy was required to determine the cause here and conveniently it could be described as a “gynaecolological near miss”.

Complete non-puerperal uterine inversion caused by uterine hemangioma: A case report

Background Multidisciplinary simulation training in the management of acute obstetric emergencies has the potential to reduce both maternal and perinatal morbidity. It is a valuable tool that can be adapted for targeted audiences of different specialities at all experience levels from medical students to senior consultants. Methods In this study, pre- and post-course questionnaires of learners with varying levels of clinical experience from Obstetrics and Gynaecology (O&G), Anaesthesia, Neonatology, Emergency Medicine, midwifery, and nursing who undertook two simulation courses (namely the Combined Obstetrics Resuscitation Training course, CORE, and the CORE Lite), which comprised lectures and simulation drills with manikins and standardized patients, between 2015 and 2023 were compared. This also included a period when training was affected by the coronavirus disease 2019 (COVID-19) pandemic. Results The results showed that both simulation courses increased confidence levels amongall learners in the management of obstetric emergencies. Pre-course, participants were most confident in the management of neonatal resuscitationand severe pre-eclampsia, followed by postpartum haemorrhage.They were least confident in the management of vaginal breech delivery, uterine inversion, and twin delivery. Post-course, participants were most confident in the management of neonatal resuscitation and shoulder dystocia, followed by postpartum haemorrhage. They were least confident in the management of uterine inversion and maternal sepsis, followed by vaginal breech delivery and twin delivery. Whilst we saw a huge improvement in confidence levels for all obstetric emergencies, the greatest improvement in confidence levels was noted in vaginal breech delivery,twin delivery,and uterine inversion. Conclusion The simulation courses were effective in improving the confidence in the management of obstetric emergencies. While it may be difficult to measure the improvement in clinical outcomes as a result of simulation courses alone, the increase in confidence levels of clinicians can be used as a surrogate in measuring their preparedness in facing these emergency scenarios.

Non- puerperal uterine inversion is a rare clinical condition which most often occurs with tumor implanted of the fundus of the uterus. Leiomyoma is the commonest cause as a leading point for non-puerperal uterine inversion to occur. Unusual case report of non-puerperal uterine inversion caused by sub mucous leiomyoma is reported to 38 years old para 5 presented with vaginal bleeding and protruding mass per vagina with anemia and offensive discharge. Uterine inversion was corrected abdominally by Haultain's procedure after vaginal myomectomy followed by abdominal hysterectomy. Both the ovaries were conserved. Key words : uterine inversion, non-puerperal , leiomyoma

Uterine inversion is turning of uterus inside out and upside down. Serosal layer becomes innermost layer, the endometrium outermost layer and uterine fundus becomes most dependent part, if it is complete inversion. It’s rare but dreadful condition. Exposed, enlarged endometrium may produce excessive vaginal bleeding and are more prone for infection. These cases usually present with severe anemia. It most commonly occurs following delivery and is termed as ‘puerperal uterine inversion’. It may present without pregnancy with sub mucus fundal fibroid and termed as ‘non-puerperal uterine inversion’. Inversion is termed acute when it is within 24 hours, sub-acute when it is presents after 24 hours but less than four weeks postpartum and chronic when more than 4 weeks postpartum. In time span of 25 years, we encountered 4 cases of acute inversion and 4 cases of chronic inversion. Out of 4 cases of acute inversion, 3 cases were reposed successfully, and one died within few minutes of arrival. Out of 4 cases of chronic inversion of uterus, one was of gynecological origin in a young nulliparous lady with big sub mucus fibroid. Fibroid was excised out vaginally and inversion was corrected by Haultain’s method. Another case of chronic inversion of puerperal origin was reposed successfully by Kustner’s method vaginally. Later, she delivered a baby normally. Again, one was an obstetric case, operated by Haultain’s method by abdominal route. None of them reported later with relapse. One case of chronic inversion refused admission and absconded. All cases were within 20-30 years of age. All cases were severely anemic and needed blood transfusion prior to surgery. Acute inversion, which occasionally occurred during cesarean section and reposed immediately, has not been included in the study.

Incomplete Nonpuerperal Uterine Inversion in an Adolescent Girl: A Case Report.

The probability of rhabdomyosarcoma occurring in the cervix is less than 0.5% and may be associated with a pathogenic dicer 1, ribonuclease III (DICER1) gene variation. Tumour-induced hypercoagulability and high levels of cancer antigen (CA) 125 are risk factors for cerebral venous sinus thrombosis (CVST). In addition, although nonpuerperal uterine inversion is very rare and is usually caused by leiomyomas from the uterus, large cervical masses can also be the cause. This case report describes a 24-year-old woman with uterine inversion caused by an embryonic cervical rhabdomyosarcoma that presented with CVST as her first symptom. The patient underwent laparoscopic total uterus and bilateral salpingectomy, during which the uterus was found to be completely inverted. Postoperative pathology confirmed embryonic cervical rhabdomyosarcoma. The patient quickly developed lung and para-aortic lymph node metastases. Two months later, the patient died of complications. When coagulation indices in patients with tumours are abnormal, especially when the levels of D-dimer and CA125 increase, it is recommended that anticoagulant therapy is administered in a timely manner to prevent the occurrence of CVST. Furthermore, for large cervical tumours, physicians should also be alert to the occurrence of uterine inversion.

Non-puerperal uterine inversion is an extremely rare entity, which many gynaecologists would never come across in their lifetime. Diagnosis can be difficult. Our patient was a 91-year-old lady who presented with profuse vaginal bleeding. Hysteroscopy was unsuccessful as the cervix was completely replaced by a friable growth. A total abdominal hysterectomy and bilateral salpingo-oophorectomy was planned as a palliative measure to stop bleeding. Uterine inversion was suspected for the first time at laparotomy and confirmed after dissecting the hysterectomy specimen, which revealed both tubes and ovaries lying inside the inverted uterus. Histology showed a malignant mixed mullerian tumour of the uterus.

Uterine inversion is a rare condition that refers to the collapse of the fundus into the uterine cavity and occurs in puerperal and non-puerperal conditions. Non-puerperal uterine inversion is particularly infrequent. Diagnosing non-puerperal uterine inversion is often challenging because it resembles vaginal or cervical tumors and pelvic organ prolapse. Furthermore, this condition alters the anatomical structure of pelvic organs, thereby complicating diagnosis and treatment, and potentially leading to misdiagnosis with grave consequences. We report a case of a postmenopausal woman who presented with irregular vaginal bleeding and dysuria for 2 months. Preoperative enhanced pelvic magnetic resonance imaging suggested a benign tumor combined with uterine inversion, which was subsequently confirmed during surgery. A laparoscopic attempt to reposition the uterus failed, leading to successful repositioning via an abdominal incision and subsequent total abdominal hysterectomy with bilateral salpingo-oophorectomy. A histopathological examination showed a submucosal leiomyoma, which was smaller than that typically reported in other cases. We also conducted a review of previous cases to offer empirical guidance for the diagnosis and treatment of this rare condition.

Uso del balón intrauterino en caso de inversión uterina recurrente

Background: Uterine inversion is a rare but serious complication wherein the uterus is partially or completely turned inside out. It can either be acute or chronic. Unlike acute uterine inversion which occurs as a complication during parturition, which can be promptly managed, chronic uterine inversion poses a diagnostic difficulty even for an experienced gynecologist. We, herein, report a patient who was managed and followed up at our institution for chronic uterine inversion. Case presentation: A 30-year-old female, P4L4 previous all vaginally delivered, presented with complaints of something coming out of her vagina, per vaginal bleeding and foul-smelling discharge. On Physical examination, the patient was severely anaemic and revealed a bleeding, necrotic mass on inspection and the entrance of the cervix felt high up on per speculum and per vaginal examination. The patient was diagnosed as having chronic uterine inversion. The patient was admitted and was made hemodynamically stable with intravenous fluids and three units of blood. Manual reduction using vaginal procedure to reposition the uterus wasn’t successful, hence she was taken up for surgery. Fibroid was resected vaginally. Then Haultain rectification procedure was performed and then the definitive procedure of hysterectomy was done. Postoperatively, the patient was kept under observation and was vitally stable. Histopathology reported leiomyoma. Conclusion: Though non-puerperal uterine inversion is rare, a few cases will still have to be managed without any previous experience. This differential has to be considered as a possibility in a non-pregnant woman presenting with bleeding or mass per vagina with or without hypotension and can very rarely present as postmenopausal bleeding. Irrespective of age or parity, pre-operatively or intra-operatively, associated malignancy is to be ruled out in every case of uterine inversion. The prognosis depends on prompt diagnosis and timely intervention. Keywords: Fibroid, chronic, non-puerperal, uterus, inversion.