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Chronic postpartum uterine inversion treated by abdominal replacement and cerclage.

Background

Uterine inversion is a rare and potentially life-threatening obstetric complication, occurring in up to 1 in 3,737 vaginal births. (1) Maternal mortality has been reported up to 15% of cases. (2) When recognized immediately after delivery, the preferred treatment is uterine replacement from the vaginal approach. Bleeding is the most common symptom of uterine inversion. A small number of cases of chronic, delayed or recurrent cases of uterine inversion have been described. (3,4,5)

Such cases pose significant management problems since vaginal reduction is often not possible and recurrent inversion can occur. (4,5)

We present a case in which future recurrence of uterine inversion is prevented with the placement of an abdominal cerclage at the time of reduction of the uterine inversion.

Case

A young primagravida delivered by spontaneous vaginal delivery at term. The third stage of labor was complicated by a retained placenta which was treated by manual extraction. At the time of the manual extraction of the placenta, uterine inversion was noted. The uterus was replaced from the vaginal approach. The delivering obstetrician had a clinical suspicion for focal placenta accreta so curettage was performed. The patient received a transfusion of four units of packed red blood cells to treat postpartum hemorrhage. She was discharged home on postpartum day two.

Beginning on postpartum day five, she reported experiencing complete and persistent unprovoked incontinence of urine. She did not recall any other symptoms and did not seek medical attention at that time. On postpartum day 39 she presented to her local emergency department with heavy vaginal bleeding. Pelvic examination at this time revealed a tender mass within the vagina that was suspicious for uterine inversion. She was then transferred to our facility for management.

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Pelvic examination confirmed the suspicion of uterine inversion. There was a moderate amount of vaginal bleeding. Transabdominal and transvaginal ultrasound imaging were performed (Figures 1 and 2). The ultrasound imaging showed only the cervical ring present within the abdomen with the body of the inverted uterus within the vagina. Preoperative hemoglobin was 12.4 g/dL and hematocrit 37.4 percent. Surgical consent was obtained and included exam under anesthesia, vaginal replacement of the uterus, cerclage placement or uterine balloon placement, exploratory laparotomy and total abdominal hysterectomy.

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Examination under general anesthesia showed that the inverted uterine fundus was protruding into the vagina through the cervical ring (Figure 3). Attempts were made to reduce the inverted uterus vaginally without success due to the constriction of the cervical ring tightly around the inverted uterine body. Nitroglycerin was administered intravenously as a tocolytic agent but attempts to replace the uterus from the vaginal approach were again unsuccessful. At laparotomy the round ligaments and fallopian tubes were noted to be pulled down within the cervical ring (Figure 4). Attempts to replace the uterus with sequential lateral traction to the round ligaments while pushing up the uterus from below were unsuccessful. The uterus was then incised vertically through the cervix and myometrium posteriorly. The inversion was then reduced (Figure 5) and the uterine and cervical incision was closed using multiple layers of absorbable suture. The patient received cefazolin 2 grams intravenously at the time of laparotomy for antibiotic prophylaxis.

Insertion of a Bakri balloon to prevent recurrent inversion was attempted but inflation of the balloon placed undue tension on the uterine closure so the balloon was removed. An abdominal cerclage using 5 mm woven polyester tape (Mersilene[R] Ethicon, Somerville, NJ) was then placed in order to prevent future recurrence of uterine inversion and to prevent possible future cervical incompetence since the posterior cervix was surgically divided to reduce the uterine inversion.

Her postoperative course was complicated by postoperative anemia with a hemoglobin of 6.6 g/dL and hematocrit of 18.7 percent. She was treated with transfusion of 4 units packed red blood cells. She was discharged home on postoperative day three. Pelvic examination six weeks after surgery showed a normal uterus and cervix in the proper anatomic location.

Conclusion

Reduction of chronic or recurrent uterine inversion requires addressing several clinical management issues. In cases that are treated weeks after delivery, vaginal reduction is often unsuccessful due to the contraction of the cervical ring around the edematous and inflamed uterus. Upward traction on the round ligaments from the abdominal approach can cause trauma and bleeding to these structures and may be unsuccessful for the same reasons that vaginal reduction often fails. Tocolytic medications have been shown to be helpful in cases that occur immediately postpartum (6) but have shown less promise in cases of delayed uterine inversion.

An incision through the posterior cervical ring extending into the posterior myometrium has been described to reduce postpartum uterine inversion. (7) Although an effective method, this poses risks to future pregnancy including potential uterine rupture or cervical incompetence and requires cesarean delivery for all future pregnancies.

Recurrence of uterine inversion can also occur. One method of preventing recurrence is the placement of a Bakri balloon. (3) We chose to place an abdominal cervical cerclage at the time of uterine replacement since we were unable to successfully place a Bakri balloon due to the strain placed on the uterine closure suture line.

In addition to preventing recurrent uterine inversion, one potential benefit to the placement of the abdominal cervical cerclage is possible prevention of future cervical incompetence related to the surgical division of the posterior cervical ring.

The placement of abdominal cervical cerclage can be considered in cases of delayed, chronic or recurrent uterine inversion when treated with abdominal reduction. The cerclage may potentially prevent the immediate recurrence of uterine inversion and may possibly prevent uterine inversion or cervical incompetence in a future pregnancy.

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References

(1.) Hostetler DR, Bosworth MF. Uterine inversion: a life-threatening obstetric emergency. J Am Board Fam Pract. 2000 Mar-Apr;13(2):120-3.

(2.) Baskett, TF. Acute uterine inversion: a review of 40 cases. J Obstet Gynaecol Can. 2002 Dec;24(12):953-6.

(3.) Majd HS, Pilsniak A, Reginald PW. Recurrent uterine inversion: a novel treatment approach using SOS Bakri balloon. BJOG. 2009 Jun;116(7):999-1001.

(4.) Livingston SL, Booker C, Kramer P, Dodson WC. Chronic uterine inversion at 14 weeks postpartum. Obstet Gynecol. 2007 Feb;109(2 Pt2):555-7.

(5.) Silver DF, Heyl PS, Linfert JB. Delayed uterine re-inversion: a unique symptom complex. Am J Obstet Gynecol. 2004 Jul;191(1):378-9.

(6.) Wendel PJ, Cox SM. Emergent obstetric management of uterine inversion. Obstet Gynecol Clin North Am. 1995 Jun;22(2):261-74.

(7.) Tank Parikshit D, Mayadeo Niranjan M, Nandanwar YS. Pregnancy outcome after operative correction of puerperal uterine inversion. Arch Gynecol Obstet. 2004 Mar;269(3):214-6.

Sheli Garrett-Albaugh, DO

Resident, Department of Obstetrics and Gynecology, WVU School of Medicine, Morgantown

Michael L. Stitely, MD

Associate Professor, Department of Obstetrics and Gynecology. WVU School of Medicine, Morgantown

Lina Millan, MD

Resident, Department of Obstetrics and Gynecology. WVU School of Medicine, Morgantown

Charles Hochberg, MD

Associate Professor, Department of Obstetrics and Gynecology. WVU School of Medicine, Morgantown
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Article Details
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Title Annotation:Scientific Article
Author:Garrett-Albaugh, Sheli; Stitely, Michael L.; Millan, Lina; Hochberg, Charles
Publication:West Virginia Medical Journal
Article Type:Case study
Geographic Code:1U5WV
Date:Sep 1, 2011
Words:1183
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