- 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.