It is a rare clinical condition that may occur to two possible types: puerperal uterine inversion (IUP) and no puerperal uterine inversion (IUNP). Obstetrician will observe often only once in his professional practice. The risk of maternal mortality by hemorrhage is high. We report two cases of uterine inversion requiring a hysterectomy, including a postpartum mode and the other gynecological mode with young women. Hysterectomy remained a last resort treatment in the two types, to reduce morbidity. In the case of uterine inversion, the treatments without hysterectomy could be facilitated if the management is early and adequate. Furthermore , the support should be multidisciplinary and fast in the two types.
The uterine inversion is a complication which is defined as an invagination of the uterine substance to “glove finger”, which can go up to its externalization to the vulva [
Madam T.S, 31 years old, African, primiparous primigravida, having no medical history, was admitted to the obstetrical emergencies of university hospital of Cocody (Abidjan) for massive bleeding of the immediate postpartum and pelvic pain. History found a vaginal delivery in a maternity, level I, dating back to three (3) hours, and the newborn weighing 3100 g with Apgar score to 9 at 5 minutes of live. Gestational age was 38 weeks of amenorrhea and 2 days. We found in the labor history the notion of excessive uterine expression at the time of the expulsion fetal. The labor occurred after seven (7) hours. At the time of admission, the patient was rough, in state of shock, blood pressure to 80/60 mmHg, pulse racing 120 beats per minute. Suprapubic palpation objectified the absence of uterus in the hypogastric region. Physical examination using vaginal valve showed a large soft mass at big bottom and corresponding to the uterine substance. The diagnosis of postpartum uterine inversion of 2nd degree is referred to. After several manual reduction failed three times, it was immediately decided a reduction during an emergency laparotomy (see Picture 1). The technique of progressive reduction by blunt clips according to the technique of Huntington has not been effective. A hysterectomy for hemostasis has so decided and conducted as a last recourse for maternal rescue. The patient received a blood transfusion of three (3) units globular to stabilize hemodynamic. The histological examination objectified several areas of infarction (see
It was a woman second gravida, primiparous, 28 years old, african. In its history, include chronic pelvic pain, pelvic heaviness and intermittent vaginal bleeding during 6 months for which she had received medical treatment without success. Admission to gynecological emergencies, she felt a vaginal mass accompanied by an intense urge to push. A thrust, a large fleshy mass is enacted at the vulva. Pelvic examination revealed a bilobed firm mass depending of the uterus (see
The frequency of uterine inversion reported in the literature is highly variable. It would be 1/100,000 in Europa and 1/2000 in United States [
III, the uterus is exteriorized out of the vagina. At the stage IV; the vaginal walls are involved in the turnaround. Classically, IUP occurs mainly in the primiparous and young women [
In contrast, no puerperal uterine inversion (IUNP) affects older women, at least 45 years. This type of uterine inversion is most often associated with benign tumors of the uterus [
The pathophysiology of the IUNP is not yet understood. In the literature, several theories have been mentioned: a thin uterine wall, a location of the tumor to the uterine substance, a pediculated tumor, a dilation of the cervix by distension of the uterine cavity and abrupt expulsion from the tumor of the vagina [
Puerperal uterine inversion (IUP) diagnosis is clinical, during delivery or immediately after, in front of three main signs that are hemorrhage, shock, and pelvic pain [
In the incomplete forms of the IUNP, the contribution of imagery is essential for an accurate diagnosis, for example the pelvic ultrasound and Imaging by Magnetic Resonance (MRI) [
Support of IUP needs multidisciplinary actions, involving obstetrician and anesthetist. It is an emergency. Multidisciplinary treatment allows improving significantly the mother’s prognosis. It combines a medical resuscitation aimed at correcting the shock, a quick manual reduction and antibiotic injection [
Hysterectomy can be done vaginally or through high according to the habits of the operator, but also according to the conditions surgical [
Several assumptions have been described in the literature in the IUNP: a conservative treatment in early forms. When there is no desire of pregnancy, or when the uterine inversion is the 3rd or 4th degree, hysterectomy remains the treatment of choice [
Laparoscopy and vaginal association seems to be a good alternative, to confirm the diagnosis, to assess the degree of ischemia of the annexes and the vagina, and hemostasis surgical of the uterus by laparoscopy by controlling the uterine pedicle from her origin [
The particularity of the study is a rare clinical situation or exceptional. In its postpartum mode, we must take care of the difficulties of the expulsive phase. Some acts should not be made because they are considered as risk of factor. Preventive treatment is based on the respect of the physiology of labor. In the case of uterine inversion, the treatments without hysterectomy could be facilitated if the management is early and adequate. The limits of this study were a lack in the management of puerperal uterine inversion. For the gynecological mode, awareness of the population in order to consult earlier hospital could these situations for a better living. Furthermore, hysterectomy remains a last resort treatment in the two types, to reduce morbidity.
Adjoby, R., Kakou, C., Kouame, A., Kouame, N., Abouna, D., Konan, J., Effoh, D., Alla, C. and Balde, I. (2018) Hysterectomy for Uterine Inversion: About Two Cases at University Hospital of Cocody (Abidjan―Ivory Coast). Open Journal of Obstetrics and Gynecology, 8, 368-375. https://doi.org/10.4236/ojog.2018.84041