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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 99-102

Acute uterine inversion complicating medical abortion in a young girl: A rare obstetric emergency


1 Department of Obstetrics and Gynaecology, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of Medicine, King George Medical University, Lucknow, Uttar Pradesh, India
3 Department of Physiology, Career Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication29-Oct-2018

Correspondence Address:
Prof. Rekha Sachan
Department of Obsteterics and Gynaecology, King George Medical University, Lucknow - 226 024, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_32_17

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  Abstract 


Uterine inversion in young girls as a complication of medical abortion is a rare obstetric emergency, and it is very difficult to diagnose. Often inversion is associated with massive hemorrhage and shock; sometimes, it can lead to maternal death. Here, we are reporting a case of 21-year-old unmarried girl who was admitted with complete uterine inversion and shock after taking treatment for medical abortion. Initially patient's vitals were stabilized by resuscitative measures, and after that she was shifted to an operation theatre for the reposition of inversion. The manual reposition of uterine inversion was attempted under general anesthesia, but it failed. Then she was planned for correction by abdominal route. Huntington procedure was done to correct uterine inversion, and 2 units of packed red blood cells (PRBC) were transfused. She was discharged on 8th postoperative day in good condition. Early recognition and appropriate management give successful outcome in this life-threatening obstetric emergency.

Keywords: Medical abortion, shock, uterine inversion


How to cite this article:
Sachan R, Singh M, Patel ML, Sachan P. Acute uterine inversion complicating medical abortion in a young girl: A rare obstetric emergency. Arch Int Surg 2017;7:99-102

How to cite this URL:
Sachan R, Singh M, Patel ML, Sachan P. Acute uterine inversion complicating medical abortion in a young girl: A rare obstetric emergency. Arch Int Surg [serial online] 2017 [cited 2020 Jul 11];7:99-102. Available from: http://www.archintsurg.org/text.asp?2017/7/3/99/244405




  Introduction Top


Uterine inversion is an obstetric emergency, the fundus of the uterus protrudes within endometrial cavity, and sometimes it protrudes outside the cavity. There are two types of inversion puerperal (obstetric) and nonpuerperal (gynecological). Puerperal inversion usually is seen just after the birth of a baby and is associated with the mismanaged third stage of labor or large submucous fundal fibroid pulling the uterus down.[1] Nonpuerperal uterine inversion is uncommon; only 150 cases published between 1887 and 2006.[2],[3],[4],[5] The incidence of uterine inversion ranges from 1 per 1,584 deliveries[6],[7] to 1 in 20,000 deliveries in a population-based study. Mortality because of uterine inversion has been reported up to 15%.[8]

The exact etiology of uterine inversion is not very clear, but probable etiological factors are thin uterine wall, rapid growth of the tumor, large tumor size, fundal location of the tumor, which might be responsible for inversion.[7] Nonpuerperal uterine inversions usually present after 45 years of age.[2] Most nonpuerperal inversions in young age are usually associated with fundal fibroid or sometimes tumors such as leiomyosarcoma and endometrial carcinoma, rhabdomyosarcoma, malignant mixed mullerian tumor, and endometrial stromal carcinoma.[9],[10],[11],[12] Four cases of rhabdomyosarcoma in young girls were reported in PubMed. Uterine inversion in women of reproductive age is associated with malignancy.[13] Here, we are reporting a case of 21-year-old unmarried girl, who came in emergency with complete uterine inversion and shock after medical abortion.


  Case Report Top


A 21-year-old unmarried girl came in emergency at Queen Mary's hospital, with chief complaints of continuous bleeding per vaginum and persistent lower abdominal pain. She had amenorrhea of 2 months with history of sexual contact and some abortifacient drug intake few days back with no history of any surgical intervention. On examination, her pulse rate was feeble, blood pressure was nonrecordable, and she was in a state of shock.

The patient was conscious but agitated; her pulse rate was 140 beats/min and feeble. Her blood pressure was nonrecordable, and extremity was cold. She was extremely pale. On examination, the abdomen was soft and nonender. On speculum vaginal examination, a fleshy mass of 10 × 8 cm was seen in the vagina, and active bleeding was coming out from the inverted fundus of the uterus. On digital vaginal examination, same mass was felt protruding into the vagina. Cervical lip was not felt around the mass, and at the place of fundus of uterus, cupping was felt. On investigation, hemoglobin was 4.5 g%; platelet count was 20,000 and prothrombin time was 30 seconds; prothrombin concentration was 50%. Viral markers—hepatitis B, C, and HIV—were negative, and blood group was O+.

Initial resuscitative measures were carried out. Nonpneumatic anti-shock garment was applied, and vasopressor support was started. After resuscitation, she was shifted to the operation theatre for the reposition of uterus. Nonsurgical Johnson's method was first tried followed by O Sullivan's hydrostatic technique, but it was unsuccessful. Therefore, laparotomy was done. Peroperatively, classic flowerpot appearance was seen, in which the cupping of uterus, along with tubes, ovaries, round, and ovarian ligaments, was seen inside the cupped uterus [Figure 1] and [Figure 2]. We implemented Huntington's procedure to correct inversion. Gentle upward traction was applied by Allis forceps on each side of the round ligament and fundus of the uterus until the inversion was corrected. Uterus was pale and flabby; so, uterotonics were given and hemostasis had been achieved. The plication of both sides of the round ligament was done and either side of infundibulo–pelvic ligament was tied to lateral pelvic wall to prevent further re-inversion of uterus [Figure 3] and [Figure 4]. Peroperatively, 2 units of PRBC and 3 units of fresh frozen plasma (FFP) were transfused. The patient was transferred to trauma ventilatory unit and was kept there for 72 h. A total of 6 units of PRBCs, 5 units of FFP, and 6 units of platelets were transfused; broad spectrum antibiotics were administered. Stiches were removed on the 7th postoperative day, and the patient was discharged on 8th postoperative day in good condition.
Figure 1: Flower pot appearance of inverted uterus with absence of fundus of uterus and pulling of round ligament and  Fallopian tube More Detailss and ovarian ligaments

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Figure 2: Inversion of uterus with cupping of fundus

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Figure 3: Correction of inverted uterus with fallopian tubes and round ligaments

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Figure 4: Good contracted uterus after correction and treatment with uterotonics

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  Discussion Top


Uterine inversion is a rare, life-threatening obstetric emergency. In acute uterine inversion, main signs are sudden appearance of a vaginal mass, bleeding, and pain with or without shock. Similarly, in our case, symptoms were acute in onset, and the patient was in a stage of shock with active bleeding per vaginum. Acute inversion is seen mostly in immediate post-partum period, but in our case, it was observed after medical abortion. Inversion after medical abortion is very rare. Though the MRI and CT scans are useful in the diagnosis of inversion, but it was not done because the patient required immediate intervention. Lewin et al. reported T2-weighted MRI scans, a U shaped uterine cavity and a thickened and inverted uterine fundus on a sagittal image and a “bulls-eye” configuration on an axial image are signs of uterine inversion.[14] On the basis of per speculum finding, the suspicion of pedunculated large fibroid polyp, product of conceptions, and inversion of uterus was assumed, but after per vaginal examination because of the presence of cupping or the absence of fundus, the diagnosis of inversion of uterus was made. Nonsurgical Johnson's method should be tried first; if it fails then hydrostatic O'Sullivan (nonsurgical method) can be tried; surgical options could be used as the last resort.[15] Huntington and Haultain techniques are commonly used for abdominal operations. We implemented Huntington procedure in our case. In the Haultain procedure, incision is to be given posterior to the cervico-vaginal ring to increase the size of the ring, so that the reposition of the uterus becomes easy.[16],[17] Another option through vaginal approach, Kustner and Spinelli procedures can be used. In the Kustner procedure, entry to the pouch of Douglas is made from posterior aspect and split the posterior aspect of the uterus and the cervix for re-inverting the uterus. In the Spinelli technique, an incision is made on the anterior aspect of the cervix, and then the uterus is reposited.

Chronic inversion is usually difficult to diagnose, and mostly, patients present with spotting, discharge per vaginum, and low-back pain. Chronic inversion is mostly seen in old women. Robotic surgeries have been recently used for the correction of chronic uterine inversion. Bimanual uterine compression and massage are very helpful to maintain the uterus in well-contracted state. These maneuvers should be carried out as soon as possible to minimize the blood loss. The longer the time between the occurrence of inversion and beginning of the maneuvers, lower the success rate. This is explained by the involution of the cervix that causes closer of cervical os, and a rigid ring is formed that prevents the restoration of normal position of the uterus. One author reported a case where the acute inversion of the uterus was managed under laparoscopic guidance, but for laparoscopic correction, a patient must be hemodynamically stable.[18] To prevent recurrence, the judicious use of uterotonic agents such as oxytocin or misoprostol is recommended. Broad spectrum antibiotic is also recommended to prevent endometritis or sepsis.[19]


  Conclusion Top


This case is unusual because the inversion of uterus occurred because of the complication of medical abortion, even in young girls, and corrected by a conservative surgery. Thus, the uterus was saved.

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 Top

1.
de Vries M, Perquin D. Non-puerperal uterine inversion due to submucous myoma in a young woman: A case report. J Med Case Rep 2010;4:21.  Back to cited text no. 1
    
2.
Gomez-Lobo V, Burch W, Khanna PC. Non-puerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent. Obstet Gynecol 2007;110:491-3.  Back to cited text no. 2
    
3.
Lupovitch A, England ER, Chen R. Non-puerperal uterine inversion in sarcoma: Case report in a 26-year-old and review of the literature. Gynecol Oncol 2005;97:938-41.  Back to cited text no. 3
    
4.
Sims-Steward D, Frederick S, Fletcher H, Char G, Mitchell S. Postmenopausal uterine inversion treated by subtotal hysterectomy. J Obstet Gynaecol 2008; 28:116-7.  Back to cited text no. 4
    
5.
Folie CO, Baffoe P. Non-puerperal uterine inversion: A case report. Chana Med J 2010;44:79-81.  Back to cited text no. 5
    
6.
Auber M, Darwish B, Lefebure A, Ness J, Roman H. Management of nonpuerperal uterine inversion using a combined laproscopic and vaginal approach. Am J Obstet Gynecol 2011;204:e7-9.  Back to cited text no. 6
    
7.
Hussain M, Jabeen T, Liaquat N, Noorani K, Bhutta SZ. Acute puerperal uterine inversion. J Coll Phys Surg Pak 2004;14:215-7.  Back to cited text no. 7
    
8.
Witteveen T, van Stralen G, Zwart J, van Roosmalen J. Puerperal uterine inversion in the Netherlands: A nationwide cohort study. Acta Obstet Gynaecol Scand 2013;92:334-7.  Back to cited text no. 8
    
9.
Krenning RA, Dorr PJ, de Groot WH, de Goey WB. Non-puerperal uterine inversion. Case report. Br J Obstet Gynaecol 1982;89:247-9.  Back to cited text no. 9
    
10.
Chen YL, Chen CA, Cheng WF, Huang CY, Chang CY, Lee CN, et al. Submucous myoma induces inversion. Taiwan J Obstet Gynecol 2006;45:159-61.  Back to cited text no. 10
    
11.
Oywang SB, Rana F, Sayed S, Aruasa WK. Embryonal rhabdomyo sarcoma with uterine inversion: Case report. East Afr Med J 2006;83:110-3.  Back to cited text no. 11
    
12.
Cormio G, Loizzi V, Nardelli C, Fattizzi N, Selvaggi L. Non-puerperal uterine inversion due to uterine sarcoma. Gynecol Obstet Invest 2006;6:171-3.  Back to cited text no. 12
    
13.
Ueda K, Okamoto A, Yamada K, Saito M, TakakuraS, Tanaka J, et al. Non-puerperal inversion of the uterus associated with endometrial cancer: A case report. Int J Clin Oncol 2006;11:153-5.  Back to cited text no. 13
    
14.
Lewin JS, Bryan PJ. MR imaging of uterine inversion. J Comput Assist Tomogr 1989;13:357-9.  Back to cited text no. 14
    
15.
Johnson AB. A new concept in the replacement of the inverted uterus and a report of nine cases. Am J Obstet Gynecol 1949;57:557-62.  Back to cited text no. 15
    
16.
Huntington J. Acute inversion of the uterus. Boston Med Surg J 1921;184:376-80.  Back to cited text no. 16
    
17.
Haultain F. The treatment of chronic uterine inversion by abdominal hysterectomy with a successful case. BMJ 1901;2:974-6.  Back to cited text no. 17
    
18.
Vijayaraghavan R, Sujatha Y. Acute postpartum uterine inversion with haemorrhagic shock: Laparoscopic reduction: A new method of management? BJOG2006;113:1100-2.  Back to cited text no. 18
    
19.
Adesiyun A. Septic postpartum uterine inversion. Singapore Med J 2007;48.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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