Fatal postpartum air embolism due to uterine inversion and atonic hemorrhage.

We report a case of a 19-year-old woman who developed a persistent uterine hemorrhage after spontaneous delivery of a healthy child. Emergency laparotomy was indicated and then begun under stable circulatory conditions. Cardiac arrest occurred during the course of massive manual compression and packing of the uterus. After successful resuscitation, a supracervical hysterectomy was performed. During the suturing of the remaining cervix, a second cardiac arrest followed. The procedure was completed under constant external heart massage. Resuscitation was terminated due to the persistence of widened pupils. An autopsy was ordered by the public prosecutor as the manner of death was declared to be unascertained. An X-ray and a CT scan prior to the autopsy showed extensive gas embolism in both arterial and venous vessels extending from the pelvic region to the head. During the autopsy, gas was collected by aspirometer from the right ventricle of the heart. The autopsy showed no additional relevant findings, and gas analysis confirmed the suspicion of air embolism. The histological examination of the excised uterus especially in the corpus/fundus revealed an edema of the local smooth muscle cells and dilated vessels showing no sign of thrombogenesis. Upon evaluation of the clinical records, it became evident that, in addition to uterine atony, there had been a complete uterine inversion. This inversion was manually repositioned. After this maneuver, manual compression was performed. The air embolism, thus, was a complication of the manual repositioning of the uterine inversion. There is no evidence for other possible entries of the detected gas. In order to perform an effective exploration, the availability of all clinical records should be mandatory for medico-legal investigations of unexpected postpartum deaths.

Uterine inversion in association with uterine sarcoma: a case report with MRI findings and review of the literature.

Non-puerperal uterine inversion due to uterine sarcomas represents a very rare event with no reliable estimate of frequency in the literature. Clinically, the diagnosis of inversion may be difficult, as far as imaging procedures are concerned, although ultrasonography may prove to be useful. However, some characteristics such as the indentation of the fundic area and a depressed longitudinal groove extending from the uterus to the center of the inverted portion are difficult to recognize. Moreover, there is no specific computed tomography feature accurate enough to aid in the differential diagnosis. Here, we report a case of uterine inversion due to Müllerian uterine adenosarcoma whose preoperative workup and diagnosis took advantage of the application of magnetic resonance imaging.

U-turn of uterine arteries: a novel sign pathognomonic of uterine inversion.

A uterine inversion occurs when the uterine fundus collapses into the endometrial cavity. It is a rare complication in obstetrics following delivery, and it is even more infrequently encountered in gynecology with the non-puerperal uterus. A submucous fibroid is the most common reported cause of the non-puerperal uterine inversion. If not promptly recognized and treated, uterine inversion may lead to a severe hemorrhagic shock and death. We describe a novel three-dimensional power Doppler feature for the diagnosis of uterine inversion.

Change in morphology and oxytocin receptor expression in the uterine blood vessels during the involution process.

BACKGROUND: The histological changes in uterine blood vessels during pregnancy have been well investigated, but there have been few reports focusing on the changes in blood vessels during the involution process, especially within the first 24 h. We observed the process of uterine involution, focusing on the vessels of the resected uterus. METHODS: Paraffin-embedded uterine samples from 15 patients who underwent hysterectomy because of severe cervical laceration and uterine rupture were examined. The time between delivery and hysterectomy ranged from 15 min to 456 h. The specimens were stained with hematoxylin-eosin, elastica-van Gieson and an antioxytocin receptor antibody. RESULTS: Changes in the uterine vessels varied substantially based on their location. The intima in arteries of the endometrial side thickened within 5 h after delivery. On the serosal side, phlebosclerosis was demonstrated 6 weeks postpartum. Immunoreactivity for the oxytocin receptor (OTR) appeared in the muscular medias of arteries 5 h after delivery although it was not expressed before this period. CONCLUSION: Remodeling of uterine vessels involved thickening of the arterial intima and OTR expression in vessel walls during the first 5 h postpartum; the parameters normalized within 6 weeks. However, phlebosclerosis persisted for a long time on the serosal side.

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.

Clinical profile of patients presenting with uterus inversion.

Inversion uterus is an unusual complication of vaginal delivery. Mismanaged third stage of labor is the most commonly identified predisposing risk factor. The condition requires immediate intervention. This retrospective study was conducted in Lady Hardinge Medical College and Associated Hospitals, New Delhi, India with the aim to study the clinical profile and outcome of patients admitted with inversion uterus. A total of six cases of inversion uterus were managed during the five year period reviewed. All patients had acute inversion and were managed successfully by manual reposition except one with chronic inversion which required laparotomy. In this case Huntington's technique was used to reposit back uterus. The patients were discharged in satisfactory condition with a mean hospital stay of nine days. Early diagnosis, resuscitation and replacement of inverted uterus are essential components of management of this rare but life threatening situation. Proper management of third stage is recommended.

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.

Acute uterine inversion due to a growing submucous myoma in an elderly woman: case report.

A case of acute non-puerperal uterine inversion due to a growing submucous myoma in elderly woman is presented. This is rare and the diagnosis is often difficult.

Complete non-puerperial uterine inversion as a result of a uterine sarcoma.

Complete non-puerperial uterine inversion is rare and when present is usually associated with a prolapsed submucous fibroid. The inversion in this case was associated with a uterine sarcoma in an 88 year old diabetic patient, gravida 13, who presented with a four month history of intermittent vaginal bleeding. She was successfully managed with a total abdominal hysterectomy and some of the difficulties with diagnosis and management are highlighted.

Neglected puerperal inversion of the uterus: ignorance makes acute a chronic form.

Inversion of uterus is a rare complication of vaginal delivery. The reported incidence of puerperal inversion varies from approximately 1 in 550 to 1 in several thousand normal deliveries. Maternal mortality has been reported to be as high as 15%, mainly because of associated life threatening blood loss and shock. Early diagnosis, prompt and aggressive management decrease the morbidity and mortality to minimal. We report a case of 21 year old primi, who presented to us with uterine inversion after delivery at a rural set up by untrained birth attendant ("Dai"). She was managed surgically with Haultain's operation and discharged after 5 days. She didn't turn up for follow up and was readmitted after 4 weeks with uterine reinversion associated with endometritis. A recent case is described, followed by a short review of literature.

Histological, hormonal and biomolecular analysis of the pathogenesis of ovine Prolapsus vaginae ante partum.

The objectives of the present study were to evaluate the hormonal profiles, histology of the vagina and biomolecular analysis of connective tissue of ewes with and without vaginal prolapse. Blood samples from the jugular vein and biopsies of the vaginal tissue were taken from five late term pregnant, unaffected animals, four sheep during parturition and six ewes suffering from vaginal prolapse ante partum. The blood samples were submitted for determining the concentration of the steroid hormones progesterone by automatic luminescence immunoassay and estradiol-17ß by the sequence test. Investigations in the mRNA-expression including the estimation of the transcript levels of the α(2)-chain of collagen I, the collagenolytic metalloproteinase 1 (MMP 1), the tissue inhibitor of MMP 1 (TIMP 1) and the estrogen receptor α were carried out by using semiquantitative reverse transcription-PCR. Additionally, the histology of the vaginal wall of ewes with and without vaginal prolapse and animals intra partum was assessed. Because of a right-skewed distribution, data were logarithmised and described using the geometric mean (xg) and the dispersion factor (DF). The average progesterone concentration of affected ewes (xg = 19.35 ng/ml, DF 1.33) was above those of control animals ante (xg = 10.44 ng/ml, DF 1.58) and intra partum (xg = 9.24 ng/ml, DF 1.92). Compared to the pregnant control group (xg = 20.13 pg/ml, DF 1.49) the plasma levels of 17ß-estradiol in animals suffering from ante partum vaginal prolapse (xg = 27.81 pg/ml, DF 1.56) appeared to be slightly increased, but the difference was without statistical significance. The analysis of mRNA expression revealed a difference in the ante partum collagen metabolism in affected sheep. In prolapsed tissue the α2-chain of collagen I showed a decreased expression level in relation to the control animals in late-term pregnancy (P < 0.01). The average mRNA synthesis of MMP 1 or TIMP 1 in affected ewes was higher or lower, respectively, than the synthesis in healthy, late-term pregnant sheep. Significant differences were not observed. The production of transcripts of the estrogen receptor α was significantly decreased within the group of affected sheep compared to the unaffected pregnant ewes. Histological assessment showed that oedema was only detected in the subepithelial zone of the vaginal wall of intra partum sheep. There was no evidence for an inflammation of the prolapsed vaginal tissue since infiltration of leucocytes was present in all samples equally. The thickest vaginal epithelium due to hyperplasia of the epithelial cells was observed in sheep suffering from ante partum vaginal prolapse (xg = 83.95 µm, DF 1.21). This difference was statistically significant between the ante (xg = 31.12 µm, DF 1.22) and intra partum groups (xg = 33.27 µm, DF 1.24). Peripheral concentrations of progesterone and estradiol-17ß seem to have no influence on the occurrence of vaginal prolapse in ewes. Regarding histology of the vaginal wall in combination with the expression of local estrogen receptors, it was determined that there is neither a pronounced oedema nor an overexpression of the estrogen receptor α in affected animals, which means that no local estrogenic effect provokes the prolapse of vaginal tissue. The biomolecular analysis led to the new result, that ewes suffering from vaginal prolapse show alterations in the antepartal metabolism of vaginal connective tissue.

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.

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.

Puerperal uterine inversion: a report of four cases.

Acute puerperal uterine inversion is a life-threatening and unpredictable obstetric emergency. If overlooked, it could lead to a maternal death. Although the precise cause is unknown, it is postulated to be caused by the mismanagement of the third stage of labor with premature traction of the umbilical cord and fundal pressure before placental separation. At the Ipoh General Hospital in Malaysia there were 31 394 deliveries and four acute uterine inversions occurring from 1 January 2002 to 30 June 2005. The four patients were between 25 and 36 years of age and their parities were between two and three. When manual repositioning of the uterus failed, successful correction was accomplished by the O'Sullivan's hydrostatic method. One case had to undergo subtotal hysterectomy after repositioning because of massive hemorrhage secondary to placenta accreta. Early diagnosis, immediate treatment of shock, and replacement are essential.

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.