Image
Author Information
Mehta V*, Prasad M**,
Gupta AS***.
(*Second Year Resident, **Assistant
Professor,
***Professor, Department of Obstetrics and Gynecology, Seth G S Medical College and KEM
Hospital , Mumbai , India
Abstract
A
prolapsed vaginal mass in the immediate postpartum period is most commonly
considered
to be
uterine inversion. However, other differential diagnoses are also to be
considered. A case of prolapsed cervical fibroid which mimicked uterine inversion
is presented here.
Introduction
Inversion
of uterus is a rare condition that usually occurs in early postpartum period.
Here we are presenting an image
of a large
prolapsed cervical leiomyoma that was referred as a case of sub acute uterine inversion.
Sub mucosal pedunculated cervical myoma may protrude from the vagina but sessile myoma that prolapses out of the introitus can pose a
diagnostic and management challenge.
Case
Report
A 32 year married,
tribal, G5P5L4NND1 was referred
with the presumptive diagnosis of uterine inversion on
day 6 of
preterm vaginal delivery. She had a prolapsed huge mass, lying outside the vagina and acute renal failure. She delivered a preterm, singleton, female, neonate who
died immediately after birth. Delivery was conducted by Traditional Birth Attendant (TBA). The childbirth was preceded by the expulsion of this large mass. Soon after childbirth she developed anuria.
She was transferred to the District hospital from where she was sent to our
tertiary care center with a serum creatinine of 5.7 mg% and suspected uterine inversion. Urine output was only 50cc in the preceding 24
hours. On arrival,
patient was stable, general and
systemic examinations were in the normal
range. Uterus was not palpable on abdominal examination. A solid, inflamed, ulcerated, fleshy, non repositable mass
with blackish discoloration of around 13x7 cm was seen outside the introitus. Ultrasonography
showed bilateral hydroureter and hydronephrosis. Serological, and biochemical
investigations were as
follows: Hb 8.2 gm/dl, serum creatinine 7.4
mg/dl, BUN 49.2 mg/dl and serum K+ 5.3 meq/l. Nephrologist performed hemodialysis. Two units of blood were transfused. Parenteral antibiotics
were started. After hemodialysis serum creatinine and potassium were 5.5 mg% and
3.9 meq/ liter respectively. Under general anesthesia, with careful and minute
observation, the anterior lip of the cervix that was fully effaced,
discolored,
stretched obliquely, was found. The entire mass was seen to be arising from the
posterior lip of the cervix. It was sessile. A vaginal myomectomy was done by
taking a transverse incision on the posterior part of the myoma. The myoma of
size about 12x10 cm was enucleated from its
pseudocapsule. It weighed around 900 gm.
Figure 1. Inflamed,
ulcerated Solid Mass posterior cervical fibroid. Yellow arrows mark the
stretched, thinned rim of the anterior cervical lip.
Figure 2. Vaginal myomectomy
Figure 3. Elongated posterior cervix (myoma
bed)
Figure 4. Enucleated myoma.
Myomectomy was followed by immediate drainage
of 100 ml of urine.
Myoma bed was trimmed but the dimension of the posterior lip of the
cervix was around 11 x 6 x 3 cm and as it was not possible to amputate the
cervix, reconstruct it and keep it reposited in its anatomical position. Presence of the necrotic tissue and
risk of septicemia resulting from leaving behind the raw, long cervix was also real. An abdominal
hysterectomy to which the patient
had consented previously was done. Two units blood and four units
fresh frozen plasma were transfused. End surgery urine output was 500 ml. Her serum
creatinine serially dropped from 5.5 mg % to 3.9 mg% on day 1 to 1.2 mg% on day
2 to 1 mg% on day 3 and serum potassium serially dropped from 5.3 meq/l to 4.3 meq/l to 3.1meq/l on day four. Her renal
function returned to normal by postoperative day 4 with creatinine value of 0.9 mg%. On
histopatholgy report uterus measured 16x10x8 cm, corpus was 11 cm, cervix
measured 5 cm, fibroid
measured
9.5 cm. Posterior lip of the cervix 11x6x3 cm showed necrotic
tissue, inflammatory infiltrates predominantly polymorphs. Endometrial cavity
was lined by necrotic material.
Discussion
Puerperal
uterine inversion, an obstetric catastrophe is most commonly acute in nature.[1] Cervical fibroid is a differential diagnosis
of a non-puerperal inversion in a gynecological patient, and usually leads to
confusion in diagnosis.[2] Our patient had no
history of neurogenic shock which is usually present in inversion but not with
prolapsed fibroids. Renal failure due to
obstructive nature of fibroids, occurs
but is usually not acute in nature. It does not occur with uterine inversion as
the ureters do not get compressed in the tight cervical ring. She developed acute
retention because the fibroid weighing 900 gm gave traction to the uterus and
dragged it down to compress the ureters by the uterine vessels resulting in
back pressure changes and hyroureter and hydronephrosis. Prompt surgery
relieved this back pressure on the ureters and prevented permanent renal
parenchymal damage. The dramatic nature in which urine drained immediately after removal
of the fibroid, suggests the acute nature of the obstruction.[3] Peripartum
obstetric hysterectomy is commonly done for uterine atony and adherent placenta.[4] The occurrence of a peripartum hysterectomy for a prolapsed huge
cervical fibroid post delivery is a rarity.
Even the best of clinical presentations may not be as they appear. It is
advisable that the clinician is alert to other differentials and use various imaging methods to confirm the
diagnosis. A thorough examination under anesthesia also aids diagnosis, treatment
planning and patient counseling.
References
- Cunningham FG, Leveno KJ, Bloom SL, Sponge CY, Dashe JP, Hoffman BL. Obstetrical Hemorrhage. Eds. Williams obstetrics. 24th edition. 2014; 787
- Turhan N, Simavli S, Kaygusuz I, Kasap B. Totally inverted cervix due to a huge prolapsed cervical myoma simulating chronic non-puerperal uterine inversion. Int J Surg Case Rep.2014 Jan;5(8):513–5
- Breech LL, Rock JA.
Leiomyomata Uteri and Myomectomy. In: Rock JA, Jones III HW, eds. Telinde’s
Operative Gynecology. 10th edn.
- Sahin S, Guzin K, Eroğlu M, Kayabasoglu F, Yaşartekin MS. Emergency peripartum hysterectomy: our 12-year experience. Arch Gynecol Obstet. 2014 May;289(5):953–8.
Mehta V, Prasad M, Gupta AS. Cervical Fibroid
Mimicking Uterine Inversion. JPGO 2016. Volume 3 No. 3. Available from: http://www.jpgo.org/2016/02/cervical-fibroid-mimicking-uterine.html