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Subacute Uterine Inversion Following an Induced Abortion in a Teenage Girl: a Case Report Asiphas Owaraganise* , Leevan Tibaijuka and Joseph Ngonzi

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Subacute Uterine Inversion Following an Induced Abortion in a Teenage Girl: a Case Report Asiphas Owaraganise* , Leevan Tibaijuka and Joseph Ngonzi Owaraganise et al. BMC Women's Health (2020) 20:220 https://doi.org/10.1186/s12905-020-01089-0 CASE REPORT Open Access Subacute uterine inversion following an induced abortion in a teenage girl: a case report Asiphas Owaraganise* , Leevan Tibaijuka and Joseph Ngonzi Abstract 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. Keywords: Case report, Subacute, Uterine inversion, Unsafe abortion, Johnson’s manoeuvre, Hysterectomy Background management involves anatomical repositioning of the Subacute puerperal uterine inversion occurs when the uterus while preventing re-inversion, and treating haem- uterine fundus collapses into the endometrial cavity orrhage while restoring the patient’s haemodynamic sta- between 24 h to 1 month postpartum [1]. It is a rare gy- bility. Urgent resuscitation with crystalloids and blood naecological emergency in practice and literature [2] but transfusion improves patient outcomes [3, 4]. Reversing potentially fatal when not diagnosed and treated fast. uterine inversion is achieved using non-operative or sur- Uterine inversion is an unpredictable obstetric emer- gical means. Non-surgical options include manual re- gency that should be considered when a woman in puer- placement and hydrostatic reduction while surgical perium presents with postpartum bleeding, low blood correction includes laparotomy plus Huntington’s pro- pressure, abdominal pain and a mass in the vagina. Its cedure alone or combined with incision of the cervical constriction ring. The time interval between its recogni- tion and correction alongside resuscitation measures in- * Correspondence: [email protected] Department of Obstetrics and Gynecology, Mbarara University of Science stituted are the major drivers of the prognosis [5]. We and Technology, Mbarara, Uganda describe below a maternal near-miss case we managed © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Owaraganise et al. BMC Women's Health (2020) 20:220 Page 2 of 5 successfully in our department followed by a brief dis- of Douglas was markedly oedematous and friable. Anter- cussion of the same. ior incision (Ocejo incision) was made at the anterior surface of the uterus after reflecting bladder peritoneum, Case presentation transected the constriction ring. The inverted uterus was A 17-year-old nulliparous unmarried girl was carried then manually reduced. The fundus was necrotic and a into the admission room at Mbarara regional referral total abdominal hysterectomy performed. The postoper- hospital’s gynaecology ward. The chief complaints were: ative period was uneventful, Table 1. collapse, mass protruding per vagina that followed Valsalva (defecation), and persistent lower abdominal Discussion and conclusions pain but without vaginal bleeding. She had secretly Uterine inversion occurs when the uterine fundus col- induced abortion at 18 weeks amenorrhea with miso- lapses into the endometrial cavity, turning the uterus prostol at a rural clinic. Products of conception were not partially or completely inside out. The incidence of puer- expelled within 4 days prompting her to seek surgical peral uterine inversion ranges from 1 in 3500 to 20,000 uterine evacuation at a different clinic located ~ 40 km deliveries [5, 6]. It is a rare complication of abortion, but away. The third day after surgical evacuation, she when it occurs, it is a life-threatening gynaecological collapsed at home and was brought to our facility. The emergency [7]. If the uterine inversion is not timely rec- pregnancy was unplanned. Contraception had been de- ognized and reduced, the resulting severe haemorrhage sired but was not readily available. and shock can lead to maternal death [8]. Our case pre- On examination, she was agitated, severely pale, and sented with a life-threatening haemorrhagic shock and cold (temperature 35.8 °C), in a state of shock with a fee- suffered serious morbidity—removal of the uterus. ble radial pulse at 143 beats/minute, and nonrecordable Uterine inversion is classified according to the extent low blood pressure. The abdomen was soft and non- of inversion and timing of occurrence. Four categories tender with no palpable masses. On vaginal inspection, a are recognised by the extent of inversion. They include: fleshy mass with gangrenous patches measuring about 8 first-degree also called incomplete (fundus remains cm by 5 cm was protruding in the introitus. The raw within the endometrial cavity); second-degree also called surface was not actively bleeding but foul-smelling pus complete (fundus protrudes through cervical os); third- oozed out of the necrotic patches of the inverted uterine degree also called prolapsed (fundus protrudes to or be- fundus. On digital vaginal examination, the cervical lip yond the introitus); and then fourth-degree also called was not felt around the mass, on bimanual palpation, total (both the uterus and vagina are inverted. Majority the uterine fundus was absent at its expected periumbili- of cases present as complete inversion [5, 9]. Our patient cal position and cupping was felt. A clinical diagnosis of presented with the fundus protruding beyond introitus subacute uterine inversion with hemorrhagic shock was but the vagina was not inverted. Categorisation accord- made. ing to the time of occurrence can either be puerperal We called for immediate assistance, informed anaes- (more common) or nonpuerperal (commonly associated thesiology staff, and blood bank personnel. Simultan- with tumours). Puerperal inversion is further sub- eously, two large-bore intravenous lines plus crystalloid grouped into acute—within 24 h postpartum, subacute— infusion and blood transfusion were initiated. Three 24 h up to 1 month, and chronic—above 1 month units of whole blood were transfused. The antibiotics postpartum [10]. Our patient presented with subacute given were intravenous ceftriaxone and metronidazole inversion on the 3rd day post-abortion. while the analgesic was an injection of diclofenac. The The pathogenesis of uterine inversion has been attrib- pre-transfusion complete blood count showed severe an- uted to the use of excessive cord traction and fundal aemia with a haemoglobin concentration of 4.5 g/dl, and pressure (Credé manoeuvre) or use of uterine relaxants 12,600 leucocytes per microliter with 89% neutrophilia; [9]. Also, at 18 weeks gestation, the placenta is firmly other parameters were within normal ranges. attached to the uterus [11]. We think our patient meets She was then transferred urgently to the operation the- both conditions. She presented at 18 gestation weeks atre for examination under anaesthesia, and the reposi- with a history of two attempts to evacuate the uterus at tioning of the uterus. Nonsurgical correction using different rural clinics. Johnson’s and O Sullivan’s methods were attempted with The extent and time of occurrence of the inversion no success. We proceeded and performed a laparotomy. determine the clinical picture of the patient at presenta- Intraabdominal, the classic flowerpot appearance
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