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Ann. Pak. Inst. Med. Sci. 2016 41

Late Puerpeural Uterine Inversion Secondary to Submucous Fibroid: Rare Event

Sidra Gilani1, Syeda Batool Mazhar2, Arfa Tabassum3, Misbah Hanif4

A u t h o r ` s A f f i l i a t i o n

1,4Postgraduate Resident 2Assistant Professor 3Professor & Head of Dept. Maternal and child health centre, Pakistan Institute of Medical Sciences , Shaheed Zulfiqar Ali Bhutto Medical University , Islamabad

A r t i c l e I n f o Received: May 11, 2016 Accepted: May 29, 2016

H o w t o C i t e t h i s M a n u s c r i p t

Gilani S, Batool SA, Tabassum A, Hanif M. Late Puerpeural Uterine Inversion Secondary to Submucous Fibroid: Rare Event.Pak. Inst. Med. Sci. 2016; 12(1):41-43.

Address of Correspondence Dr. Sidra Gilani sid_gilanii@yahoo.com

A B S T R A C T Puerperal uterine inversion due to fibroid uterus is an uncommon event. Non puerperal uterine inversion secondary to fibroid accounts for 80-85% of cases. Diagnosis of incomplete late puerperal uterine inversion can be difficult. Case: We report a referred case of puerperal uterine inversion diagnosed on 27th postnatal day. Uterine inversion could not be reversed manually so laparotomy assisted replacement was done along with myomectomy. It was followed by balloon temponade of uterine cavity for control of haemorrhage and risk of recurrence. Key Words: Uterine inversion, Submucous, Fibroid.

Case Report

A 26 year old woman p2+0, presented on 27th postnatal day with lower abdomen pain, urinary retention, foul smelling vaginal discharge and episodic heavy vaginal bleeding. She had a vaginal delivery of a male baby, with average birth weight and good Apgar scores at Jalalpur government hospital by a Dai (untrained birth attendant). According to the patient delivery of placenta was difficult requiring manual removal. She did not give history of postpartum hemorrhage and she was discharged home after three hours of delivery. On the 4th postnatal day she developed heavy vaginal bleeding which settled but episodic heavy bleeding continued off and on. On the 10th postnatal day, she observed copious amount of foul smelling vaginal discharge but she did not visit any health facility. Her condition further deteriorated when she developed lower abdominal pain and difficulty in passing urine for which she went to the Dai (untrained

birth attendant) who proceeded with evacuation and curettage after examination due to suspected retained products of conception. Her symptoms did not improve and she went to a local private radiologist for ultrasound. Suspicion of a foreign body uterus and a large amount of blood clots in cervical and vaginal canal were detected on ultrasound. The radiologist referred her to PIMS hospital. When the women presented in emergency, she was well oriented in time , place and person .On General physical examination she had mild pallor, blood pressure 100/60mm ,pulse 110/min, temperature 99o F and respiratory rate of 18/min. Her systemic examination was unremarkable. On per abdominal examination; abdomen was soft and non-tender; uterus was subinvolutedpalpable and 16 weeks size. On per vaginal examination; offensive vaginal discharge and a mass with shred of tissue protruding from dilated cervical Os, reaching the

Case Report

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Ann. Pak. Inst. Med. Sci. 2016 42

introitus. Its upper limit was not reachable. Baseline Investigations were normal. Provisional diagnosis of late puerperal uterine inversion was made. A Manual replacement was planned. On examination under anesthesia manual reduction of uterus was attempted but unsuccessful. On laparotomy the anterior lower segment of the uterus had a dimple. Per-op dimpling seen at anterior uterine wall .A longitudinal incision was given just below indentation. Myomectomy of 10x8 cm large submucous fibroid with necrotic and ulcerated surface was done and inversion corrected. Cervical Foleys passed and balloon inflated up to 40 cc retained for 24 hours. Patient was fine in postoperative period and discharged on 6th post op day .She did not return for follow up visit.

Discussion Uterine inversion is a rare life threatening emergency which can be puerperalandnon puerperal. Incidence of puerperal uterine inversion varies from 1 in 550 to 1 in several thousand deliveries. Maternal mortality associated with this condition can be as high as15 %.2 Non puerperal uterine inversion is a very rare condition. Gomez –lobo et al reported 150 documented cases from 1887-2006.3

Uterine inversion can be complete, incomplete or prolapsed. Complete uterine inversion occurs when the fundus protrudes through external Os whereas incomplete uterine inversion occurs when fundus lie within endometrial cavity.4 In prolapsed inversion thinverted uterine fundus extends beyond introitus.6 Uterine inversion is classified as acute if inversion has occurred without cervical contraction, subacute if cervical contraction is present and chronic if more than 4 weeks have elapsed since inversion and cervical contraction.5On this basis the index case is subacute incomplete uterine inversion. Various risk factors for uterine inversion include fetal macrosomia , short umbilical cord, excessive traction on cord, fundal pressure prior to placental separation, uterine relaxants, uterine anomalies, placenta accreta and manual removal of placenta. Non puerperal uterine inversion is usually associated with uterine pathology among which leiomyoma accounts for 80-85 % of cases.1,4,5 Chronic uterine inversions typically present with anemia due to irregular bleeding, vaginal discharge, pelvic pain, and a protruding mass in the vagina4

Diagnosis is based on signs, symptoms and clinical examination; however diagnosis in vitally stable patients

A: laparotomy image showing indentation at anterior lower uterine segment and longitudinal incision beneath it

B: Myomectomy

C: 10x8 cm Submucous fobroid

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can be aided with imaging modalities. MRI findings are more distinct than ultrasound.6

Successful treatment depends on prompt recognition and correction of inversion. Reduction can be conservative(non-surgical) or surgical. Johnson first described manual reduction of inversion which consists of pushing inverted fundus through cervical ring with pressure directed towards umbilicus.‘O’ Sullivan described hydrostatic pressure technique.5 Resuscitation should begin immediately and discontinuation of uterotonic drugs. Attempt to remove placenta should not be done until uterus has been replaced. For pressure technique, hydrostatic balloon placement should be used.4

Ogueh and ayida described hydrostatic replacement with use of sialisticventous cup inserted vaginally.5 Thechronic cases being more likely to require surgical correction; surgical techniques for reduction of inversion are Huntington7, Haultain8and Spinelli 9 procedure. In our case myomectomy of submucous fibroid was done and incomplete uterine inversion corrected.

Conclusion A rare case of late puerperal uterine inversion secondary to submucousfibroid not previously reported in Pakistani literature. Presence of submucous fibroid with morbid

placental adherence was the likely cause in this case. There should be high index of suspicion for uterine inversion in women presenting with puerperal prolapse, urinary retention and secondary PPH.

References 1. Shivanagappa M, Ambarisha Bhandiwad MM. A case of acute

on chronic uterine inversion with fibroid polyp. Journal of clinical and diagnostic research: JCDR. 2013 Nov;7(11):2587.88

2. Minakshi S, Shivani A, Arshad A. Neglected puerperal inversion of the uterus: ignorance makes acute a chronic form. Pan African Medical Journal. 2012 Jul 27;12(1).

3. De Vries M, Perquin DA. Non-puerperal uterine inversion due to submucous myoma in a young woman: a case report. Journal of medical case reports. 2010 Jan 24;4(1):1.

4. Pieh-Holder KL, Bell H, Hall T, DeVente JE. Postpartum prolapsed leiomyoma with uterine inversion managed by vaginal hysterectomy. Case reports in obstetrics and gynecology. 2014.

5. E Antonelli,a O Irion,a P Tolck,b M Moralesa Subacute uterine inversion: description of a novel replacement technique using the obstetric ventouse BJOG 2006; 113:846–847.

6. Dawn R. Hostetler, MD, and Michael F. Bosworth, DO Uterine Inversion: A Life-Threatening Obstetric Emergency J Am Board Fam Praet 2000;13:120-3.

7. Huntington JL. Abdominal reposition in acute inversion of the puerperal uterus. Am J ObstetGynecol 1928;15:34–40.

8. Haultain F. The treatment of chronic uterine inversion by abdominal hysterotomy. Br Med J. 1901;2:974–80.

9. Spinelli PG. Inversioneuterina. RivGinecContemp Napoli 1897;17: 567–70