Robotic-assisted Laparoscopic Supracervical Repair of a Chronic Puerperal Uterine Inversion.

Surgical correction of a chronic puerperal uterine inversion traditionally requires an anterior or posterior cervical incision to relieve the constricting band. This case is only the second reported case of robotic-assisted correction of a chronic puerperal uterine inversion and the first to avoid a cervical incision. The patient was 5 months postpartum and desired future pregnancy. After a laparoscopic Huntington technique was unsuccessful, a vertical hysterotomy was created in the anterior lower uterine segment and extended toward the fundus until the inversion could be relieved. The incision was repaired in 3 layers and a round ligament plication was performed to provide additional support within the pelvis. The patient's symptoms gradually improved during her postoperative course, and ultrasound 2 weeks after the procedure revealed the uterus in anatomic position in the pelvis. With a paucity of reported cases of laparoscopic correction of chronic puerperal uterine inversion, the present case offers a novel surgical approach that maintains cervical integrity and thereby minimizes long-term effects of the procedure on future pregnancies.

Acute uterine inversion following an induced abortion.

Acute uterine inversion is a rare and potentially life-threatening obstetric emergency. Its occurrence as a result of a mid-trimester abortion is an even rarer consequence. We report a case of a 32-year-old woman who presented with complete acute uterine inversion and hemorrhagic shock following an incomplete medical abortion at 14 weeks of gestation. Our attempts at non-operative reversal of the inversion failed. Therefore, we resorted to the manual replacement of the uterus via laparotomy without using surgical instruments or an incision in the cervical ring. The laparotomic manual replacement served as a successful alternative with minimal immediate or long-term morbidity that may have resulted from trauma and scarring of the uterus.

Sonographic confirmation of placental detachment during placental delivery for uterine inversion prevention.

AIM: To evaluate the usefulness of transabdominal sonographic confirmation of placental detachment in preventing uterine inversion. METHODS: This was 14-year retrospective cohort study that included women who had transvaginal deliveries in our hospital. We introduced routine transabdominal ultrasonography during placental delivery to prevent uterine inversion. Followed by the confirmation of placental detachment by ultrasonography, we started placental delivery procedure. The frequency of uterine inversion during placental delivery was compared before and after the ultrasonography was introduced. Moreover, the duration of the third stage of labor and bleeding volume during labor were compared between the ultrasonography performing group (USG group) and the non-performing group (non-USG groups). RESULTS: Five thousand and eighty-one women, including 1724 and 3357 women who delivered before and after the ultrasonography was introduced, respectively. The frequency of uterine inversion after the introduction of the ultrasonography system was significantly reduced compared to that before the introduction (0.03% vs. 0.23%, p = 0.03). Even after the introduction of ultrasonography, the actual rate of performing ultrasonography remained 54.1% due to various restrictions. The mean duration of the third stage of labor in the USG group was slightly longer than that in the non-USG group (8.4 ± 5.0 vs. 6.8 ± 3.6, p < 0.01). The mean bleeding volume during labor in the USG group was higher compared with the non-USG group (457 ± 329 vs. 418 ± 285, p < 0.01). CONCLUSIONS: Transabdominal sonographic confirmation of placental detachment may be useful in preventing uterine inversion.

Surgical technique for fertility preservation for placenta accreta spectrum without previa: Tourniquet, uterus inversion and placental dissection procedure.

The placenta accreta spectrum without previa is difficult to diagnose before delivery and sometimes requires hysterectomy. A fertility preservation procedure is useful when placenta accreta spectrum is unexpectedly encountered. A 38-year-old woman, conceived by in vitro fertilization (IVF), was not diagnosed of placenta accreta spectrum until delivery. A cesarean section was performed for fetal breech presentation. The placenta could not be detached from the uterine fundus and marked bleeding started. We conducted the "TURIP" procedure: ensured hemostasis with tourniquet of uterine isthmus, uterus inversion to expose the adhesion site with intra-venous nitroglycerin administration, placental detachment by sharp dissection under direct visualization. The detached areas were sutured for hemostasis. The patient recovered uneventfully and achieved the second pregnancy by IVF 1 year later. The TURIP procedure is useful to preserve fertility in unpredicted placenta accreta spectrum without previa, even in undiagnosed cases before delivery.

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.

A Rare Case Report of Successful Laparoscopy-Guided Reduction of Non-Puerperal Uterine Inversion.

Non-puerperal uterine inversion is an extremely rare and potentially dangerous condition. Cases are poorly described in the literature, and their actual incidence is unknown. A 34-year-old nulliparous female patient visited the emergency department following a loss of consciousness. She had experienced continuous vaginal bleeding over the preceding two months, with a two-day history of worsening symptoms. The patient showed signs of hypovolemic shock secondary to unceasing vaginal bleeding. Ultrasound and computed tomography revealed an inverted uterus and a large hematoma inside the patient's vaginal cavity. An emergency explorative laparoscopy was performed, which confirmed uterine inversion. Initially, Johnson's maneuver was attempted under laparoscopic visualization, but this failed to achieve uterine reduction. Following the unsuccessful performance of Huntington's maneuver, a re-trial of the manual reduction allowed the uterus to recover to its normal anatomy. The patient's vaginal bleeding was dramatically reduced after successful uterine reduction. The pathologic report conducted confirmed endometrioid adenocarcinoma. Laparoscopic visualization is a feasible and safe procedure for achieving uterine reduction in cases of non-puerperal uterine inversion with an unconfirmed pathology. Uterine malignancies should be considered in patients with non-puerperal uterine inversion.

Modified vaginal hysterectomy for chronic non-puerperal complete uterine inversion: video presentation.

INTRODUCTION AND HYPOTHESIS: Chronic non-puerperal complete uterine inversion is a relatively rare condition. Abdominal Haultain's operation is the usual management. We present such a case with fundal fibroids managed by modified vaginal hysterectomy. METHODS: Preoperative computerized tomography enhanced intravenous urogram depicted normal ureters and bladder. Diluted vasopressin (10   U in 100   ml normal saline) was infiltrated at the base of the myoma and a myomectomy was performed. The fundal raw area was pierced to reach the formed space between the anterior and posterior uterine serosa. The bilateral round ligaments were clamped, cut, and ligated. Diluted vasopressin was injected into the fundal anterior uterine wall and about 1   cm was excised. Then, the bilateral utero-ovarian ligaments were clamped, cut, and ligated. In the same way another 1   cm of anterior uterine wall was excised and the bilateral uterine vessels were clamped, cut, and ligated. The rest of the uterine wall area was infiltrated with diluted vasopressin circumferentially. An incision at the vesico-cervical junction was made and the bladder pushed up. The posterior fornix area was incised and the Pouch of Douglas (POD) opened. Vesico-uterine pouch opened under finger guidance placed through POD. The rest of the anterior uterine wall was excised. Exposed bilateral cardinal-uterosacral ligament complexes (CULCs) were clamped, cut, and ligated. The remaining vaginal attachments ligated hemostatically and the vault was closed. For vault prolapse prevention, vault closure suture ends were tied with ipsilateral CULC suture end, brought outside the vagina at vault angle. RESULTS: A follow-up visit up to 1   year found no complications. CONCLUSION: This novel reverse vaginal hysterectomy combining the principles of both abdominal and vaginal hysterectomy can successfully manage chronic non-puerperal complete uterine inversion.

Acute non-puerperal uterine inversion ascribed to malignant mixed Mullerian tumor of uterus: a rare presentation.

Non-puerperal uterine inversion is an extremely uncommon condition, and its occurrence due to malignant mixed Mullerian tumor (MMMT) of the uterus is quite exceptional. We report one such case of acute non-puerperal uterine inversion ascribed to MMMT in a 77-year-old postmenopausal woman. Such a case poses a diagnostic and management dilemma, and prior knowledge may result in a successful outcome.

Akutt uterusinversjon.

BACKGROUND: Acute uterine inversion is a rare, but serious, obstetric complication in the third stage of labour, commonly resulting in significant morbidity and mortality. A total or partial invagination of the uterine fundus occurs, followed by profuse bleeding and circulatory instability. The case presented here illustrates a typical clinical course of the condition. CASE PRESENTATION: After giving birth to a large, healthy boy, a woman developed acute uterine inversion. The uterus was successfully repositioned using Johnson's manoeuvre under general anaesthesia, and significant transfusion was needed to combat the resulting haemorrhage. INTERPRETATION: Acute inversion of the uterus should be suspected based on purely clinical signs. Treatment should commence without delay by a multidisciplinary team of obstetricians, anaesthesiologists and surgeons.

Uterine rhabdomyosarcoma complicated by cerebral venous thrombosis and uterine inversion in a young woman: case report and literature review.

BACKGROUND: Uterine rhabdomyosarcoma is an extremely rare malignant tumor that usually affects young women and has a poor prognosis. CASE PRESENTATION: A 19-year-old nulliparous woman presented to the emergency department under sedation due to seizures. Imaging examination revealed cerebral venous thrombosis. During thrombolytic therapy, she developed vaginal bleeding followed by uterine inversion secondary to uterine rhabdomyosarcoma. The inverted uterus was mistaken for a cervical tumour and was removed vaginally. The patient's disease progressed despite chemotherapy with vincristine, actinomycin D and cyclophosphamide and she died within 6 months. To our knowledge, this is the first case of uterine rhabdomyosarcoma complicated with cerebral venous thrombosis. CONCLUSIONS: Malignancy is an important diagnostic in patients with cerebral venous thrombosis with no obvious cause. This case demonstrates the importance of considering uterine neoplasms in the differential diagnosis of adolescent girls with abnormal uterine bleeding. Further, careful anatomical evaluation of vaginal masses should be performed prior to surgical intervention.

[Acute Puerperal Uterine Inversion: A Case Report]. / Akute Inversio uteri puerperalis: Eine Falldarstellung.

Puerperal inversion of the uterus is a rare but life-threatening obstetric complication. Unrecognized, it can lead to severe bleeding and shock and even maternal death. Manual replacement under general anesthesia is usually successful. If the manual replacement fails, surgical replacement by laparotomy needs to be performed. In any case, mortality and morbidity can be reduced by rapid recognition and immediate replacement. Therefore, regular practical exercises for the detection and treatment of acute uterine inversion as well as other obstetric emergencies should be performed as part of medical training. We would like to report of a 31-year-old Gravida 2 Para 0 at 39 weeks+4 days of gestation who, after an uncomplicated spontaneous vaginal delivery, had an acute third-degree uterine inversion, which was replaced by laparotomy after an unsuccessful vaginal replacement attempt.

Subacute uterine inversion following an induced abortion in a teenage girl: a case report.

BACKGROUND: Subacute uterine inversion is a very rare complication of mid-trimester termination of pregnancy that should be considered in a situation where unsafe abortion occurs. CASE PRESENTATION: We present a case of subacute uterine inversion complicated by hypovolemic shock following an unsafe abortion in a 17-year-old nulliparous unmarried girl. She presented with a history of collapse, mass protruding per vagina that followed Valsalva, and persistent lower abdominal pain but not vaginal bleeding. This followed her second attempt to secretly induce an abortion at 18 weeks amenorrhea. On examination, she was agitated, severely pale, cold on palpation, with an axillary temperature of 35.8 °C, a tachycardia of 143 beats per minute and unrecordable low blood pressure. The abdomen was soft and non-tender with no palpable masses; the uterine fundus was absent at its expected periumbilical position and cupping was felt instead. A fleshy mass with gangrenous patches protruding in the introitus was palpated with no cervical lip felt around it. We made a clinical diagnosis of subacute uterine inversion complicated with hypovolemic shock and initiated urgent resuscitation with crystalloid and blood transfusion. Non-operative reversal of the inversion failed. Surgery was done to correct the inversion followed by total abdominal hysterectomy due to uterine gangrene. CONCLUSION: Our case highlights an unusual presentation of subacute uterine inversion following unsafe abortion. This case was managed successfully but resulted in significant and permanent morbidity.

[Case report of 39-Year-Old Gravida III, Para III with Inverted Uterus after Breech Birth]. / Fallbericht 39-jährige III. Gravida, III. Para mit Inversio uteri nach Steißgeburt.

An inverted uterus is defined as the eversion of the uterus into the vagina. It is a very rare event but has to be treated as an emergency. A woman with an inverted uterus is in serious danger of developing atony with high blood loss in a short time. This can lead to hypovolemic shock and circulatory failure. Therapy includes urgent uterine repositioning under narcosis and curettage after manual abruption of the placenta. Afterwards, uterotonics such as prostaglandins should be administered. A disorder of the coagulation system is very common due to blood loss. Therefore, substitution of plasma components and antifibrinolytic drugs are recommended. If vaginal repositioning of the uterus cannot be achieved, laparotomy or hysterectomy are possible alternatives. We report the case of a 39 year-old gravida III, para III in the 36+3 gestational week who, after a spontaneous breech delivery with placenta accreta, experienced an inverted uterus, which was then repositioned.

Laparoscopic Management of Nonpuerperal Uterine Inversion.

Uterine inversions are a rare entity, and most occur in the postpartum period. Nonpuerperal inversion accounts for only 16% of cases and are mostly associated with a submucous myoma. A 38-year-old woman with a submucous myoma presented with severe lower abdominal pain, acute retention of urine, and hypotension. Because the clinical examination was inconclusive due to severe pain and the ultrasound was dubious, diagnosis was made with magnetic resonance imaging. Successful laparoscopic hysterectomy was contemplated after correcting uterine inversion. This case highlights the diagnostic dilemmas and the key points during laparoscopic management of uterine inversion.

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.

An exceptional uterine inversion in a virgo patient affected by submucosal leiomyoma: Case report and review of the literature.

Inversion of the uterus is quite a rare obstetric (puerperal) or gynecological (non-puerperal) condition. Non-puerperal type may be benign or malign mass induced or idiopathic. To the best of our knowledge, this is the first case with a large review of literature of uterine inversion in a patient without sexual experience. We report the case of a 52-year-old, unmarried virgo woman, affected by schizophrenia, was referred to our emergency room for evidence of a mass outside of the vaginal introitus, combined with vaginal bleeding and abdominal pain. The patient underwent vaginal myoma resection and abdominal hysterectomy with bilateral adnexectomy. The diagnosis of uterine inversion was confirmed during operation. Diagnosis of uterine inversion is often not easy and imaging studies might be helpful. Despite the rarity, uterine non-puerperal inversion is possible: for this reason, it is necessary to perform appropriate, conservative treatment, especially in women affected by benign myomas and with a desire for pregnancy.