Non-Pueperal Uterine Prolapse

- MANAGEMENT OF UTERINE INVERSION

(Emphasis on Non-Puerperal Uterine Inversion)

By: DR. KATTEY K. A MBBS (Port Harcourt), MPH (Johns Hopkins)

• Recap of terminology• Clinical Presentation• Investigations• Treatment• Complications• Differential diagnosis

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RecapUterine inversion refers to the descent of the uterine fundus to or through the cervix, so that the uterus is literally turned inside out.Classification

KATTEY K.A (MBBS, MPH)

Recap

• Non-puerperal uterine inversion accounts for 16% of cases of uterine inversion1.

• Causes of non-peurperal uterine inversion: Uterine leiomyoma (80-85%) Endometrial polyps Other uterine neoplasm e.g endometrial CA, leiomyosarcoma, rhabdomyosarcoma. Ovarian tumour (very rare)2

1Takano K, Ichikawa Y, Tsunoda H, Nishida M. Uterine inversion caused by uterine sarcoma: a case report. Jpn J Clin Oncol. 2001

2Gomathy E, Agarwal Y, Sreeramulu PN,Sheela SR. Non-puerperal uterine inversion with an ovarian tumor- a rare case. IJPBR, 2011

Clinical presentation of non-puerperal uterine inversion

• Acute or chronic based on the onset and evolution

• Acute (8.6%).3

o More dramatico Severe paino Severe haemorrhage

• Chronic• Insidious• Pelvic discomfort• Vaginal discharge• Irregular vaginal bleeding• Anemia

3Das, P., J Obstet Gynaecol Br Emp 1940,

Symptoms

Acute:• Severe abdominal pain• Sudden cardiovascular collapseChronic• Chronic vaginal discharge• Irregular uterine bleeding• Lower abdominal pain and pelvic discomfort• Urinary disturbance• Irregular cycle• Vaginal mass

Examination

• Palor• May present in shock (hypotension, tachycardia, bradycardia)

• Neurogenic• Hypovolaemic

• Abdominal tenderness• Absence of uterine fundus on bimanual palpation (rectoabdominal)• Lump in the vagina• Usually bleeds readily on palpation

****A high index of suspicion is required to make a prompt diagnosis

Investigations

• FBC, E/U/Cr• Urinalysis + m/c/s• USS• MRI• CT

*Diagnosis is usually based on clinical symptoms, but if not obvious, then USS, MRI

Ultrasound findings

• Transverse image• A hyperechoic fundus surrounded by hypoechoic rim.

• Longitudinal image• U-shaped depressed longitudinal groove from the uterine fundus to the

center of the inverted part

Investigations

MRI

• Sagittal section• U shaped uterine cavity• Thickened and inverted uterine fundus

• Transversial (axial)• ‘bulls-eye’ configuration

Treatment of uterine inversion• Immediate treatment of shock

• Replacement/ repositioning of the uterus• Non- Surgical (usually for puerperal inversion) **Use of tocolytics for acute cases

• Magnesium sulphate, terbutaline, nitroglycerin, halothane

• Surgical

• Hysterectomy (if indicated)• Abdominal• Vaginal

TREATMENT OF SHOCK

• Call for help• IV line with two large bore cannulae• Aggressive fluids replacement• Start resuscitation with normal saline or Hartmann’s solution• Administer oxygen • Blood transfusion • Analgesics• Use warm saline to apply compress• Insert a urinary catheter

Uterine replacement for puerperal/acute uterine inversionNon-surgical methods• Johnson’s procedure: repositioning the fundus by vaginal

manipulation.• O’Sullivan: hydrostatic reduction• Ogueh and AyidaSurgical Methods (if non-surgical does not correct it)

- Abdominal approach (Huntington & Haultian)- Vaginal approach (Kustner & Spinelli)

KATTEY K.A (MBBS, MPH)

REPOSITIONING OF INVERTED UTERUS

• MANUAL REDUCTION.

• Sterile procedure.

• Form a fist or grab the uterus and push it through the cervix of a lax uterus towards the umbilicus to its normal position.

• Use the other hand to support the uterus. (Johnson maneuver)4

4 Johnson AB. A new concept in the replacement of the inverted uterus and a report of nine cases. Am J Obstet Gynecol. 1949 Mar;57(3):557-62. 

• Use of tocolytics to allow uterine relaxation.

• Nitroglycerin (0.25-0.5 mg) intravenously over 2 minutes.

• Terbutaline 0.1-0.25mg slowly intravenously.

• Magnesium sulphate 4-6 g intravenously over 20 minutes.

• Use of general anaesthesia: halothane.

O’SULLIVAN HYDROSTATIC METHOD.5

• Done if initial replacement is unsuccessful• Patient in lithotomy or Tredenleburg position.• Run copious amounts of warmed irrigation fluid into the

vagina (by gravity or pressure) through a wide bore giving set.

• Fluid escape is prevented by blocking the introitus by using the labia and operator’s hand.

• The fluid distend the vagina, relieves the mild cervical constriction and result in correction or replacement of the inverted uterus.

• If unsuccessful, repeat or consider surgical management.5O’Sullivan J. Acute inversion of the uterus. Br J Obstet Gynecol 1945; 2: 282-283

NEW TECHNIQUE (Ogueh and Ayida)6

• A modified form of the O’Sullivan technique• Attach the IV tubing to silicone cup used in vacuum

extraction.• place the cup in the vagina, an excellent seal is created

(as against the assistant’s hand in O’Sullivan’s).

6 Ogueh O, Ayida G. Acute uterine inversion: a new technique of hydrostatic replacement. Br J Obstet Gynecol 1997; 104 (8): 951-951

Newer techniques

Majd et al 7 and Azubuike et al 8 have separately described successes with the use of SOS Bakri balloon catheter, and Rusch balloon catheter respectively to create hydrostatic pressure.• Used when the placenta is already separated• An additional advantage is that after repositioning the uterus, the balloon will helo to

prevent re-inversion and reduce postpartum haemorrhage.

7Majd HS, Pilsniak A, Reginald PW. Recurrent uterine inversion: a novel treatment approach using SOS Baki balloon. Br J Obstet Gynaecol 2009;116 (7) :999-1001

8Azubuike U Bolarinde O Complete uterine inversion managed with a Rusch balloon catheter J Med Cases 2010 1 (1): 8-9

Rusch balloon catheter

AFTER REPOSITIONING

• Remove the placenta manually if necessary

*** The placenta should only be removed after repositioning of the uterus and complete correction of the inversion to avoid shock and torrential bleeding

• Discontinue uterine relaxant/general anaesthesia.

• Start infusion of oxytocin or ergot alkaloids

• Continue fluid and blood replacement

• Bimanual uterine compression and massage are maintained until the uterus is well contracted and hemorrhage is ceased.

After repositioning

• Antibiotics

• Adequate analgesics.

• Oxytocics\ergot are continued for at least 24 hrs.

• Monitor closely after replacement to avoid re-inversion

MANAGEMENT OF CHRONIC UTERINE INVERSION

Surgical intervention.

Abdominal routeHuntington’s procedureHaultain's procedure

Vaginal routeSpinelliKaustner

• Chronic uterine inversion usually results in formation of dense constriction ring, progressive edema and tissue necrosis, thus the uterus cannot be reverted by vaginal manipulation.

• Surgery is usually required

Abdominal route• Huntington’s procedure• Haultain's procedure

Vaginal route• Spinelli• Kaustner

Surgical Management • Depends on the

• preoperative diagnosis,• stage of the inversion (e.g. stage 1 can afford easy repositioning

of the fundus)• Extent of uterine necrosis• the age of the patient• .reproductive desire of the patient• Skill of the attendant

• Abdo or vag hysterectomy with BSO is recommended for benign cases if childbearing is not an issue.

• For associated malignancy, abdo hysterectomy and staging biopsies is indicated.

HUNTINGTON PROCEDURE 9

• Make an abdominal incision• Locate the cup of the uterus

formed by the inversion• Dilate the constricting cervical

ring digitally• Stepwise traction on the funnel

of the inverted uterus or the round ligament is given with Allis forceps

• Reapplied progressively as fundus emerges

9 Huntington JL: Abdominal reposition in acute inversion of the puerperal uterus. Am J Obstet Gynecol. 1928, 15:34-40.

Haultain’s Procedure 10

• Incision of the constricting cervical ring posteriorly • traction on the round ligament for the replacement of uterus• repair of incision per abdomen; incision closed in 2 layers.

10 Haultain FWN: The treatment of chronic uterine inversion by abdominal hysterectomy, with a successful case. Br Med J. 1901, 2:974.

Vaginal RouteThe Spinelli’s operation

• involves dissection of the bladder from the inverted uterus. • A midline split is made in the cervix and it is carefully

separated from the bladder. • The anterior wall of the everted uterus is split. • By pressure with the operator’s index fingers and thumbs

the uterus is turned outside in. • The myometrium is reapproximated by two layers of running

suture, and the serosal surface by a single layer. • The vaginal skin is reapproximated with interrupted sutures,

as is the full thickness of the cervix.

Vaginal Route

The Kustner’s operation

• Involves opening the posterior cul-de-sac • Incision of the cervix and posterior wall of the uterus• thumb pressure along the sides of the uterus produce reversion• Interrupted sutures are used to close the incisions and the uterus

replaced in the pelvic cavity. • Closure of the colpotomy.

Hysterectomy

Indicated for:

• Failure of conservative surgery

• Family is completed

• sepsis

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The morbidity and mortality associated with uterine inversion correlate with • the degree of hemorrhage, • the rapidity of diagnosis, • and the effectiveness of treatment.

Summary of Surgical modalities for non-puerperal uterine inversion

• Vaginal removal of the tumor

• Reduction of the inversion

• + Hysterectomy (if indicated)

Post operatively• Antibiotics• Analgesics• IV fluids• Histopathology of the tumor is imperative

• 20% of tumors associated with non-puerperal uterine inversion are malignant.11

11J. Mwinyoglee, N. Simelela, and Marivate M. Nonpuerperal uterine inversions. A two case report and review of literature. Central African J Med. 1997; 43: 268-271.

COMPLICATIONS OF INVERSION OF UTERUS.

Hypovolaemic shock and all its consequence.

Vasovagal shock (due to severe pain).

Endometritis (sepsis).

Infection of adnexa.

Necrosis of adnexa (ovaries) due to compression of ovaries as they drawn inside.

Damage to intestine / septic paralytic ileus.

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Recurrence of inversion.

Increased risk of ruptured uterus in next pregnancy (when surgical procedure done for inversion).

Increased risk of c-section in subsequent delivery.

Chronic pelvic pain -> if chronic inversion is not treated.

DIFFERENTIAL DIAGNOSIS OF UTERINE INVERSION Prolapse of uterine tumor (submucous fibroid). Large endometrial polyp Endocervical polyp Uterovaginal prolapse Cervical cancer Genital tears Passage of succenturiate lobe of placenta

Conclusion

Though non-puerperal uterine inversion is uncommon, the few cases will still have to be managed without prior experience. High index of suspicion for the diagnosis and clear knowledge about gynaecological surgery will permit a successful outcome.