Nonpuerperal uterine inversion caused by an adenosarcoma: A case report

INTRODUCTION

Eighty-five per cent of uterine inversions are puerperal. Non-puerperal uterine inversion is usually caused by tumours that exert a traction force on the fundus of the uterus. This causes the uterus to be partially or completely inverted. It is commonly related to benign tumours like submucosal leiomyomas. Nevertheless, malignancies are an infrequent association.

CASE PRESENTATION

We report a case of a 35-year-old female patient, medically and surgically free, gravida0 para0, complaining of menometrorrhagia associated with pelvic pain for 2 years. A suprapubic ultrasound scan showed an enlarged, globular uterus with a heterogeneous, undefined mass of 49 mm in size. MRI scan showed the appearance of a U-shaped uterine cavity and a thickened inverted uterine fundus with an endometrial infiltrating mass of 25 mm. Intraoperative exploration showed uterine inversion involving the ovaries; the fallopian tubes and the round ligaments and a necrotic intracavitary mass. The malignancy of the tumor was confirmed through anatomopathological examination as Adenosarcoma.

CONCLUSIONS

Uterine inversion is rare outside the puerperal period, and malignant etiology must not be overlooked. Therefore, comprehensive care with meticulous etiological investigation is crucial.

Non-Puerperal Chronic Inversion of Uterus Due to Big Fibroid Uterus in a Post-Menopausal Woman

Uterine inversion occurs in puerperal and non-puerperal conditions; non-puerperal uterine inversion (NPUI) may run acute and chronic clinical course. Most on the NPUI are chronic variety while a few are acute variety. NPUI occurs if there is long standing big sub-mucosal fibroid and it is very rare to present in acute setting. Here we report a case of acutely presented NPUI. A 58-year-old widow of lower socioeconomic status presenting to the emergency center of Chittagong medical college Hospital with complaints of sudden protrusion of a big mass through introitus in an attempt of passing out hard stool during defecation on the day of admission with a history of per vaginal watery discharge for a long time and severe anemia. Anemia was corrected and a broad-spectrum antibiotic was given prior to operative management. Under general anesthesia vaginal myomectomy followed by vaginal hysterectomy was performed in the same sitting. Pathological examination revealed a fibroid uterus. Postoperatively patient recovered without any residual problem. Infection should be suspected and treated with appropriate broad-spectrum antibiotics before planning surgery. Vaginal route restoration of NPUI is very difficult but possible with careful attempt. During a vaginal hysterectomy, care to locate and salvage the bladder and distal urinary collecting system is warranted. So, a high index of suspicion is the key to limit morbidity and approach for proper management of such rare clinical condition.

Laparotomic reposition of acute postpartal uterine inversion

Acute uterine inversion is a rare but one of the most serious complications of childbirth. This condition is defined as the collapse of the fundus into the uterine cavity. Maternal mortality and morbidity are reported to be 41%. In the management of uterine inversion, early dia-gnosis, anti-shock measures and attempting manual repositioning as soon as possible are important. If the initial manual repositioning fails, it is necessary to proceed with surgical intervention. Administration of uterotonic agents is recommended after successful reposition. This recommendation helps uterine contraction, thereby preventing recurrence of the inversion. If reposition is repeatedly unsuccessful, then a hysterectomy may be necessary. The aim of this paper is to present a case report from our department.

Non-puerperal Uterine Inversion with endometrial polyps in an 11-year-old girl: A Case Report

BACKGROUND

Non-puerperal uterine inversion is a rare condition with diagnostic and surgical challenges. Clinically, the inverted uterus appears as a mass protruding from the vagina and is often misdiagnosed as a malignant tumor and surgically removed.

CASE

An 11-year-old girl was admitted to the emergency room due to spontaneous vaginal mass protrusion. The pudendum examination showed an irregular and dark red neoplasm protruding from the vagina. The final diagnosis was non-puerperal uterine inversion with an endometrial polyp.

SUMMARY AND CONCLUSION

MRI is the key to the diagnosis of uterine inversion. Our review confirmed that the 11-year-old girl was the youngest in the world to suffer from non-puerperal uterine inversion.

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

Uterine inversion is a rare postpartum complication. It is a rare condition in which the internal surface of the uterus protrudes through the vagina. Non-puerperal uterine inversion (NPUI) is extremely rare. In most instances, it is linked to uterine tumors. Among these tumors, leiomyoma is the most frequent cause reported in data. This condition may not be noticed until time of surgery. Malignancy is suspected in most cases. Nevertheless, uterine inversion can be diagnosed preoperatively using radiology. Difficulties in diagnosing NPUI makes this clinical case a challenge in gynaecology and not commonly reported in literature. We report our experience in the diagnosis and treatment of a complete non-puerperal uterine inversion associated with uterine angioleiomyoma. The patient's age was 44, gravida 2 para 1 presented with intermittent vaginal bleeding for four months and an acute abdominal cramping pain. On examination, a large mass lesion was observed which occupies the vaginal cavity and the contour of the uterine cervix could not be reached. Biopsies and Immunohistochemistry matched with an angioleiomyoma. She underwent a transvaginal surgical reposition technique: Spinelli’s. It is important to diagnose accurate non-puerperal uterine inversion. Surgery provides good prognosis and it is necessary. We report a case of NPUI caused by angioleiomyoma. Nevertheless, malignancy must be eliminated in first place.

Uterine Inversion as a Result of a Large Prolapsed Carcinosarcoma of the Uterus

BACKGROUND

Uterine inversion is most commonly seen in labour and delivery. However, it can be associated with uterine tumours, including gynaecologic malignancy.

CASE

In a 66-year-old woman, uterine inversion identified at laparotomy that was found to be associated with uterine carcinosarcoma (malignant mixed mesodermal tumour) represents an unusual presentation. Surgical approach necessitated a vertical hysterotomy to amputate and deliver the uterine tumour.

CONCLUSION

Uterine inversion in gynaecologic oncology may be associated with sarcoma or malignant mixed mesodermal tumour. This can represent a diagnostic and surgical challenge and should be considered.

Non-puerperal uterine inversion due to submucous myoma in a woman: a case report

Uterine leiomyomas are the most common benign tumor of the female reproductive tract. Their incidence during pregnancy is approximately 2 percent and they are associated with some complications such as preterm labor, placental abruption, fetal malpresentation, obstructed labor, cesarean delivery, and postpartum hemorrhage. They may develop anywhere within the muscular wall of the uterus, including submucosal, intramural, or subserosal areas. Some of the submucous myomas may be pedunculated and eventually may protrude through the cervical canal to the vagina. They later become necrotic and sometimes infected. Vaginal myomectomy is recommended as the initial treatment of choice for a prolapsed, pedunculated myoma except when other indications require an abdominal procedure. Inversion is a condition in which the uterus turns inside out with prolapse of the fundus through the cervix. It is seen in acute and chronic forms. Chronic inversion may follow an incomplete obstetric inversion unnoticed or left uncared. Herein, we present, a case of infected non-puerperal uterine inversion due to submucous leiomyoma that was originating from fundus and the diagnostic dilemma it presents in the after puerperal stage.

Non-puerperal uterine inversion in a patient with intracranial sigmoid sinus thrombosis and facial palsy

Non-puerperal uterine inversion and cranial nerve palsies in patients with sigmoid sinus thrombosis are both extremely rare. We report a case of a patient who presented with both simultaneously. The symptoms of sigmoid sinus thrombosis resolved with subcutaneous enoxaparin, and an abdominal dissection with removal of the uterus vaginally resulted in a successful outcome for the patient.

Sonographic diagnosis of complete uterine inversion: an unusual case

Complete puerperal uterine inversion is an uncommon but potentially life-threatening obstetric emergency. It generally occurs as an obstetrical complication in the postpartum period and can present in acute, subacute, and chronic forms depending on the time interval after delivery. Maternal mortality has been reported to be as high as 15%, mainly because of life associated threatening blood loss and shock. Early diagnosis and treatment are essential, but diagnosis of this is not simple. This is a report of unusual case of complete uterine inversion diagnosed by accurate ultrasound leading to prompt potentially life-saving treatment.

Acute postpartum uterine inversion: a case report

The case described is that of an African 24 year old and Para 2. She had a normal vaginal delivery at a local clinic and sustained an acute uterine inversion and postpartum haemorrhage. Resuscitative measures were done and she was referred to the central hospital. At the central hospital and under general anaesthesia attempts to manually replace the uterus were unsuccessful. The uterine inversion was successfully corrected at laparotomy after which an area of gangrene and perforation was noted on the uterine fundus. A decision to perform total abdominal hysterectomy was taken. The patient had an uneventful post-operative recovery. A discussion of acute postpartum uterine inversion is presented.

Non-puerperal uterine inversion caused by malignant mixed mullerian sarcoma

Non puerperal uterine inversions resulting from mixed mullerian uterine sarcoma are rare. We present a case of a postmenopausal woman with a large mixed mullerian tumour presenting as a huge abdominopelvic mass. It required a challenging surgical procedure to remove the tumour which is also described along with the review of literature.

Chronic postpartum uterine inversion treated by abdominal replacement and cerclage

BACKGROUND

Chronic uterine inversion is a potentially dangerous condition that often requires abdominal surgical reduction of the uterine inversion. Uterine inversion can recur after successful uterine replacement.

CASE

A young primagravida presented with chronic recurrent uterine inversion 5 weeks after spontaneous vaginal delivery. The uterus was replaced abdominally and an abdominal cervical cerclage was placed to prevent recurrent inversion.

CONCLUSION

Abdominal cervical cerclage can be utilized after treatment of chronic recurrent uterine inversion to prevent future recurrence of uterine inversion.

Non puerperal uterine inversion due to submucous fibroid: a case report

An unusual case of non-puerperal uterine inversion is presented. The patient, a 37 year old multipara who had been earlier diagnosed with uterine fibroids, subsequently developed a protrusion from the vagina having declined surgery. The mass had become necrotic and infected at the time of presentation. Uterine inversion was diagnosed clinically and further confirmed at surgery where a vaginal hysterectomy was carried out. Uterine inversion is a rare condition not encountered by most gynaecologists. Diagnosis and treatment could thus be challenging. The literature on non-puerperal uterine inversion regarding the evaluation and management is reviewed.

Management of nonpuerperal uterine inversion using a combined laparoscopic and vaginal approach

Although described as a postpartum complication, uterine inversion may also occur in nonpregnant women. We report a case of nonpuerperal uterine inversion, because of a large exteriorized submucous myoma in a 40-year-old woman, which was surgically managed by hysterectomy using a combined laparoscopic and vaginal approach.

Technique of abdominal hysterectomy for non-puerperal uterine inversion

A 52-year-old postmenopausal woman presented with lower abdominal pain, bleeding per-vaginum and a mass protruding per-vaginum of 1-week duration. A clinical diagnosis of non-puerperal uterine inversion due to fundal leiomyoma was made. Non-puerperal uterine inversion is a rare clinical condition and usually follows a benign or malignant mass attached to the fundus of uterus. Surgical procedures described in the literature use different techniques to first reposition the uterus followed by hysterectomy. However, repositioning the uterus is not always successful. Surgery for inverted uterus is technically difficult due to close proximity of the ureters to the ovarian and uterine vessels due to traction on the vascular pedicles, difficulty in repositioning the uterus and constraints of mobilising the bladder down due to the inverted uterus. This paper illustrates the salient steps of surgery to safely accomplish abdominal hysterectomy without repositioning the uterus to treat this rare condition.

Ultrasound diagnosis and comprehensive surgical treatment of complete non-puerperal uterine inversion

INTRODUCTION

Ultrasonographic diagnosis of very rare case of complete non-puerperal uterine inversion secondary to a large sub-mucous fibroid.

CASE REPORT

A 50-year-old woman was admitted with heavy vaginal bleeding. Detailed vaginal and abdominal ultrasound, using color Doppler flow, raised the suspicion of complete uterine inversion. The distal ends of the fallopian tubes and part of the ovaries were demonstrated adherent to the uterine fundus. Laparoscopy showed there was no uterus inside the abdomen because of complete uterine inversion. Only a dimple with a constriction ring was found at the site of the uterus. A sub-mucous 6 cm fibroid was attached to the fundus, and vaginal myomectomy was performed to reduce uterine size in order to restore the uterus to its abdominal position. However, the uterus was impacted and only cutting longitudinally the anterior and posterior fornices helped to restore the uterus and facilitate an abdominal hysterectomy. Histological examination of the uterus and fibroid following hysterectomy confirmed their benign nature.

CONCLUSION

Ultrasonographic diagnosis of complete uterine inversion is feasible. However, high index of suspicion is necessary.

Chronic uterine inversion secondary to submucous fibroid: a case report

A rare case of non-puerperal chronic uterine inversion secondary to sub mucous fibroid in a 38-year-old woman is presented. There was complete uterine inversion with the incarcerated inverted uterus protruding through the vvgina beyond the vulva. The sub mucous fibroid was attached to the fundus. At laparotomy, a dimple with a constriction ring was found in the position of the uterus. The distal ends of the fallopian tubes and part of the ovary were visible through the constriction ring. Histological examination of the uterus and fibroid following hysterectomy confirmed their benign nature.

[Total inversion of the uterus]

Non puerperal inversion of the uterus is very uncommon. Patients may present with pelvic pain, vaginal bleeding or hemodynamic shock. We report a fifty five old woman with uterus inversion second stage.

Septic postpartum uterine inversion

Puerperal uterine inversion is an uncommon but life threatening obstetrical emergency. A 26-year-old woman, para six, was referred from a peripheral hospital seven days after delivery, with a mass protruding per vaginum. Complete uterine inversion had occurred after delivery of baby and placenta. She was resuscitated and her genital infection was treated. She had a vaginal hysterectomy upon request. Her postoperative recovery was uneventful. Poor management of the third stage of labour is a common cause of uterine inversion. Early replacement of the inverted uterus is important to prevent further complications.

Nonpuerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent

BACKGROUND

We report a case of nonpuerperal uterine inversion associated with an immature teratoma of the uterus.

CASE

An adolescent nullipara with prolonged vaginal bleeding, severe abdominal pain, symptomatic anemia, and a presumed diagnosis of retained products of conception was found to have a large mass in the vagina. Uterine inversion was diagnosed and corrected using the Haultain procedure. The inversion catalyst was found to be an immature teratoma of the uterus.

CONCLUSION

Reproductive age women with the rare finding of nonpuerperal uterine inversion are likely to have a malignancy. However, uterine-sparing surgery to correct the inversion should be attempted in young women until final pathology is known.

Non-puerperal inversion of the uterus caused by leiomyosarcoma: a case report and clinical management

Uterine inversion is a rare complication of the postpartum period, but it is an even rarer complication of the non-puerperal period. A 49-year-old nulliparous woman was admitted to the hospital with the following complaints: abnormal vaginal bleeding, pain, anuria and a mass protruding from the vulva. The mass was removed by twisting and a laparotomy was required for massive bleeding due to the inversion. The diagnosis of complete inversion was made during the laparotomy. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed and the pathological examination revealed a leiomyosarcoma. Uterine inversion in the non-puerperal period is an extremely rare event and it should be kept in mind that the cause of the inversion may be a malignant disease, like leiomyosarcoma.

Chronic uterine inversion at 14 weeks postpartum

BACKGROUND

Uterine inversion is a rare complication of vaginal delivery. When chronic inversion is encountered it is often associated with benign or malignant tumors of the uterus. Management of chronic uterine inversion may require several standard techniques before reversion is accomplished.

CASE

A woman presented with chronic vaginal bleeding 14 weeks after vaginal delivery complicated by a fourth-degree laceration. Chronic uterine inversion was diagnosed. This diagnosis was unique due to the length of time from delivery to diagnosis and therapeutic modalities implemented.

CONCLUSION

Uterine inversion can occur in the acute (less than 24 hours) or chronic (greater than 1 month) phases. The clinician's clue to chronic uterine inversion, as in this case, may be persistent vaginal bleeding.

Submucous myoma induces uterine inversion

OBJECTIVE

Inversion of the uterus is indeed a rarity for a gynecologist. The puerperal variety is associated with pregnancy, including term pregnancy and abortion. The nonpuerperal condition may be tumor-induced or idiopathic. We present a nonpuerperal uterine inversion and discuss a reasonable plan for its management.

CASE REPORT

A 42-year-old, unmarried woman without sexual experience and any systemic diseases noted a mass outside of the vaginal introitus combined with massive vaginal bleeding and abdominal pain of sudden onset after taking laxative agents for colonoscopic preparation. Then she had voiding difficulty with distended bladder. A suprapubic urinary catheter was inserted and 800 mL urine was drained out. The patient received emergency tumor resection and subtotal hysterectomy. The diagnosis of uterine inversion was confirmed during operation. The postoperative course was uneventful and she was discharged without complication.

CONCLUSION

Nonpuerperal inversion of the uterus is rarely encountered by gynecologists. Diagnosis of uterine inversion is often not easy and imaging studies might be helpful. Surgical treatment is the method of choice in nonpuerperal uterine inversion.

Prolapsed uterine sarcoma causing non-puerperal uterine inversion in a post menopausal woman

A rare case of non-puerperal uterine inversion caused by a large fundal sarcoma in a 57 year old menopausal woman who presented with profuse vaginal bleeding is reported. After vaginal excision of the fundal myoma, reduction of the uterine inversion combined approach both abdominal as well as vaginal successfully was then followed by total abdominal hysterectomy and bilateral salphingoopherectomy.

Embryonal rhabdomyosarcoma with uterine inversion: case report

Presented here is a 16-year-old nulliparous girl who had embryonal rhabdomyosarcoma causing uterine inversion. She had been referred with a one year history of continuous vaginal bleeding and vaginal swelling. Histology had shown sarcoma botyroides and had received five courses of chemotherapy at the referring hospital. At surgery she was found to have uterine inversion and extended hysterectomy was carried out to be followed by radiotherapy.

Nonpuerperal inversion of the uterus associated with endometrial cancer: a case report

Few nonpuerperal uterine inversions have been reported, with only 101 cases during the period from 1940 to date. Moreover, uterine inversion resulting from endometrial cancer is an extremely rare condition, with only 7 reported cases. In this article, we present a case of a patient with uterine inversion caused by endometrial cancer that could be diagnosed and treated with surgery. We also discuss the mechanism of onset and present a review of the literature.

Non-Puerperal Uterine Inversion due to Uterine Sarcoma

BACKGROUND

Uterine inversion is a very rare pathological condition that usually occurs in puerperium. Non- puerperal uterine inversion is exceptional and to our knowledge only a few cases of uterine inversion due to a uterine sarcoma have been reported.

CASE REPORT

A 79-year-old woman, gravida 0, para 0, presented with vaginal bleeding. Pelvic examination under anesthesia revealed a huge mass coming from the cervix filling the vagina to the introitus, and rectal examination could not identify the uterus. Diagnosis of uterine inversion was made and the patient was submitted to total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph node sampling. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day. She underwent postoperative pelvic radiation, and no recurrence was found during the 19-month follow-up period.

CONCLUSION

Chronic non-puerperal uterine inversion can be considered a rare complication of malignant mixed mullerian tumor of the uterus.

[Uterine inversion]

The uterine inversion is a rare but serious pathology of the delivery. We describe two cases of uterine inversion of secondary and quaternary degree; the first had a delay diagnosis and the second having a return after the manual replacement, finishing both on surgical resolution. The authors describe the causal factors, the diagnosis and the therapeutic of uterine inversion.

[Non-puerperal uterine inversion. Report of a case]

Non-puerperal uterine inversion is extremely rare. We report a case associated with leiomyoma. It is presented the case of a multiparous of 46 year-old for presenting severe vaginal bleeding, pelvic pain and strange body vaginal sensation. The diagnosis was uterine myoma in abortive phase. An abdominal hysterectomy was performed to find a complete uterine inversion. This report represents an anecdotal case of non-puerperal uterine inversion successfully treated surgically.

[Laparoscopic-assisted replacement of inverted puerperal uterus: a case report and brief review of the literature]

Chronic inversion of the uterus is a serious obstetric complication often requiring laparotomy as manual replacement alone usually fails. We report on the successful laparoscopic-assisted replacement of a chronically inverted puerperal uterus on the 11th day post partum. The scientific literature back to the 19th century is briefly discussed.

Delayed uterine re-inversion: a unique symptom complex

A case of late recurrence of uterine inversion is presented. Symptoms included constipation and urinary retention without uterine bleeding. Symptoms resolved 3 months after the replacement of the uterus. It is hypothesized that the symptoms were related to stretch injury to the pelvic parasympathetic nerves. Timely intervention may prevent long-term sequelae.

[Puerperal uterine inversion: about two cases]

Two cases of third- and second-degree acute puerperal uterine inversions that required surgical management after manual attempts failed are reported. The diagnosis was obvious in the first case but the second inversion was misdiagnosed as a myoma, which led to severe morbidity, linked with the hemorrhage.

Inversion of the uterus at caesarean section

INTRODUCTION

Inversion of the uterus through the uterine incision during caesarean section is a rare event. Therapy is usually simple and maternal morbidity is low when re-inversion of the uterus can be accomplished immediately. In cases of prolonged uterine inversion thereof, haemodynamic instability and shock, often out of proportion to the degree of blood loss, have been reported as serious sequelae.

CASE REPORT

We describe such a case with a prolonged inversion to re-inversion interval where the patient suffered an intraoperative cardiovascular arrest during unrepositioned uterine inversion. Reposition of the uterus led to an immediate return of the patient's vital signs and improvement of her haemodynamic status.

DISCUSSION

The mechanisms of haemodynamic instability and the technical aspects of manual reduction of the inverted, heavily contracted uterus during caesarean section are discussed.