JOURNAL OF CASE REPORTS 2014;4(1):13-16

Management of Acute Non-puerperal Complete Uterine Inversion

Girija BS, Sudha TR
From the Department of Obstetrics and Gynecology, Hassan Institute
of Medical Sciences, Hassan- 573201, Karnataka, India.

Abstract:

Non-puerperal uterine inversion is a rare clinical problem, which usually results from a tumor on the fundus of
the uterus. A rare case of acute non puerperal complete inversion of uterus with leiomyomata and carcinoma
of cervix (incidental diagnosis) in a 50 year old woman is reported here. She presented with sudden onset
of pain abdomen, mass per vaginum on lifting heavy weight and profuse vaginal bleeding. This case is
reported for the safe surgical management of acute non-puerperal complete inversion of huge necrotic
uterus by combined abdomino-perineal approach. Patient recovered within 24 hours after surgery without
any evidence of pelvic peritonitis.

Key words: Uterine Inversion, Uterine Hemorrhage, Submucus leiomyoma, Peritonitis, Hysterectomy,
Carcinoma Squamous cell, Ovary.

Introduction

Inversion of uterus is an unusual entity and may acute non-puerperal complete inversion of uterus
be classified as puerperal or obstetric and non- with huge myomas with severe infection and necrosis
puerperal or gynecologic inversion [1-4]. Puerperal threatening to fall off by auto-amputation.
uterine inversion occurs with an incidence of 1 in
3,500 to 1 in 1,00,000 deliveries [5]. But non- Case Report
puerperal uterine inversion is very rare and many
gynecologists are unlikely to encounter such a case A 50 year old woman para2, living2 got admitted
during their life time [6], this fact gives a clue as to as an emergency case with history of sudden onset
its infrequent nature [7]. of pain abdomen, mass per vaginum on lifting
heavy weight and profuse vaginal bleeding. She
We report a case of acute non-puerperal complete gave history of foul smelling vaginal discharge
inversion of the uterus with huge fundal myomas and since last one year. She attained menopause 3
carcinoma cervix (incidental diagnosis). This case is years back and was alcoholic since 1 year. On
being reported for the safe surgical management examination she was anaemic, cachexic with
with combined abdomino-perineal approach for normal vitals. Abdomen was soft and nontender.

Corresponding Author: Dr. Girija BS

Email: [email protected]
Received: November 7, 2013 | Accepted: December 31, 2013 | Published Online: January 10, 2014
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(creativecommons.org/licenses/by/3.0)
Conflict of interest: None declared | Source of funding: Nil | DOI: http://dx.doi.org/10.17659/01.2014.0004

13 Journal of Case Reports, Vol. 4, No. 1, Jan-June 2014

Vulval examination revealed large irregular, firm,
hemorrhagic mass covered with necrotic areas
measuring approximately 15x20 cms seen outside
the introitus. There were two masses measuring 5x6
cm and 6x7 cm at the tip of the vulval mass [Fig.1].
Copious purulent foul smelling vaginal discharge
was present and cervix was not visualized. On
per vaginal examination, vagina was filled with
mass, rent was felt in the posterior fornix and
induration was present. On per rectal examination,
uterus was not felt in position. Her hemoglobin was
5.8 gm%, other investigations were within normal
limit. Ultrasound and CT scan could not be done. Fig.1: Acute non puerperal complete inversion of
Patient could not walk due to threatening auto- huge uterus.
amputation. She was given supportive treatment.

The mass was necrotic, hemorrhagic and because

of the rent in the posterior fornix, auto amputation
of the mass was anticipated. Patient was posted
for the emergency surgery. Under combined
epidural spinal anesthesia patient was placed in
frog position. Abdomen was opened in layers. On
laparotomy typical ‘flower pot appearance’ was
noticed [Fig.2]. Ovaries, fallopian tubes and round
ligaments were found in the cup shaped depression
of uterine inversion. Infudibulo-pelvic ligaments and
round ligaments were clamped, cut and ligated.
Utero-vesical fold of peritoneum was cut and Fig.2: Laparotomy picture showing flower pot
bladder mobilized downwards. To prevent pus appearance in pelvis.
entering the peritoneal cavity a perineal approach
for incising the infected, necrotic mass at the level
of the isthmus after ligating the descending cervical
branch of uterine artery was done. Amputated
stump was sutured with intermittent stitches for
hemostasis and it was pushed inside the vagina and
vagina was packed. Through abdominal approach
cervical stump was pulled up, uterine vessels were
visualized, clamped, cut and ligated, followed by
uterosacral and Mackerodt ligaments and vaginal
angles. Cervical stump was delivered out [Fig.3].
Biopsy was taken from the necrotic tissue in the
posterior fornix. Peritoneal cavity, abdomino-pelvic
organs and pelvic lymph nodes were palpated Fig.3: Specimen of amputated uterus and cervix.

14 Journal of Case Reports

which were normal. The purpose of amputating
the uterus by perineal approach was to avoid
contamination of the peritoneal cavity. Usual
surgical procedures for inversion would expose
the peritoneal cavity to infection. The amputated
mass weighed about 3 kgs. Specimen was sent
for histo-pathological examination. This patient
recovered within 24 hours without any evidence
of pelvic peritonitis and she had uneventful post-
operative period. Histopathology report came as
poorly differentiated squamous cell carcinoma
cervix grade III [Fig.4]. Three weeks later she was
referred for radiotherapy.

Discussion Fig.4: Histopathology suggestive of poorly

differentiated squamous cell carcinoma cervix
Most cases of uterine inversion are puerperal. Non- grade III.
puerperal uterine inversions are extremely rare.
From 1887 to 2006, 150 cases of non-puerperal and urinary disturbances. MRI and CT scan have
inversions have been reported [8]. Their etiology been found to be useful diagnostic tools. MRI can
in order of frequency was submucus leiomyoma show the characteristic image of uterine inversion.
(71.6%), endometrial carcinoma (6.8%) and Lewin et al. reported that in T2-weighted MRI scans,
unspecified etiology (8%). a U shaped uterine cavity and a thickened and
inverted uterine fundus on a sagittal image and
Takano et al summarized 88 reported cases of non- a “bulls-eye” configuration on an axial image are
puerperal uterine inversion. 81(92%) of these were signs indicative of uterine inversion [11]. In this case,
associated with uterine tumors, of which 20% were because symptoms were acute in onset and patient
malignant. This emphasizes the need to perform was in extreme agony due to necrosis, bleeding and
biopsies prior to definitive treatment [9,10]. In this threatening auto amputation requiring emergency
reported case, biopsy was done from the growth intervention, we could not get either ultrasound
in the posterior fornix and from the uterine tumor, or CT scan done to have accurate pre-operative
but we could not wait for the histopathology report diagnosis. However, with clinical findings and high
before definitive treatment because emergency index of suspicion patient was taken for surgery.
surgery had to be done due to threatening auto
amputation. Most surgeons use abdominal approach for
hysterectomy. We used combined abdominal
Non-puerperal uterine inversion can also be and perineal approach for surgery. Initially at
classified into acute and chronic based on the onset laparotomy to prevent an embolus due to pelvic
and evolution. Usually non-puerperal inversions congestion, both the infundibulo-pelvic ligaments
are chronic but 8.6% are presented as sudden were clamped and divided as the first step as
onset. Symptoms of acute non puerperal uterine suggested by Kopal [12]. Since the mass was
inversion are sudden onset of mass protruding ischemic and necrotic, we avoided myomectomy
through vagina, pain abdomen, vaginal bleeding from perineal route and reposition of the uterus
15 Journal of Case Reports
as an usual procedure, to avoid intra-peritoneal Gynecol Surv. 2000;55:703-707.
infection. Instead we planned for amputation of 3. GrischKe EM, Wallwiener D, Bastert G.
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4. Krenning RA, Dorr PJ, de Groot WH, de Goey
S Uludag et al. demonstrated posterior hemi- WB. Non puerperal uterine inversion: Case
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inversion using combined laparoscopic and vaginal 6. M Winyoglee J, Simelela N, Marivate M. Non
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Conclusion 8. Bertrand S, Randriamarolahy A, Cucchi JM.
Uterine inversion caused by a submucus
Non-puerperal uterine inversion is an unusual leiomyoma. Clinical Imaging. 2011;35:478-479.
condition that most gynecologists will never 9. Takano K, Ichikawa Y, Isunoda H, Nishida M.
encounter and thus has to be managed based upon Uterine inversion caused by uterine sarcoma: a
little or no previous experience. In the presence of case report. Jpn J Clin Oncol. 2001;31:39-42.
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consider uterine inversion. Non puerperal uterine Mimicking as an Ectopic Pregnancy. Journal of
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Acknowledgments 12. Kopal S, Seckin NC, Turhan NO. Acute uterine
inversion due to growing submucus myoma in
We would like to thank the patient and her relatives an elderly woman: a case report. Eur J Obstet
for giving us the permission to publish this case report. Gynecol Reprod Biol. 2001;99:118-120.
13. Uludag S, Gezer A, Erkon S. Posterior
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16 Journal of Case Reports