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An unusual case of chronic inversion of the uterus
AN UNUSUAL HARRY
CASE OF CHRONIC THE UTERUS” ARANOW,
M.D.,
INVERSION
OF
NEW TORE;, N. T.
c
HRONIC inversion of the uterus per se is sufficiently rare to make it worth whrle reporting every case and what makes my case still more unusual is the fact that the inversion involved not only the body of the uterus but also t,he cervix including the portio vaginalis (Fig. 1). In a rather superficial examination of the literature I have been unable to find a report of a similar case.
CASE REPORT M. S., white, housewife, aged 2-l years, married 5 years, was born in New York. No operations. Menstruation began at 12, every thirty-five days, periods lasting two days, scant in amount and without pain. Sexual life apparently normal. Took contraceptive precautions for four years. Her last period was on June 30, 1935. Expected date of confinement April 7, 1936. She had a normal pregnancy. Patient began to have irregular pains on April 8, 1936. On April 9 she was admitted to a private hospital. After twelve hours the patient was sent home. She continued to have irregular pains for ten days. At about 11 P.H. on April 19 the bag of waters ruptured, and the patient was apparently about to deliver. She ‘was rushed to the hospital, and the baby was born spontaneously. The placenta was delivered with difficulty, i.e. there was considerable pressure necessary to deliver it. This took place about twenty minutes after the birth of the baby. The delivery was followed by a severe post-partum hemorrhage which the family physician was unable to control. The patient repeatedly bled through the packing in the vagina. One of my associates who was called in consultation told me that he thou:ght the patient had a cervical tear but that she bled so furiously and was in such bad shape that he could not attempt a repair. She was packed and repacked. She received a transfusion at 1:50 *\.lhl. and another at 3:30. The bleeding was tinally controlled the following day. The anemia and shock were treated by transfusions, infusions, liver, iron, etc. During her post-partum period the patient complained of severe backache and inabdity to move her legs. She had a peroneal paralysis of both legs with foot drop. She remained at the hospital for a fortnight and was taken home in an ambulance. At home she was bedridden because of the paralysis and there was continuous vaginal spotting. On June 5, 1936, she had a sudden severe vaginal hemorrhage and was brought to the Morrisania Hospital much exsanguinated. The condition was readily diagnosed. There was a firm bleeding mass the size and shape of an inverted pear filling the vagina, and a bimdnual examination revealed the absence of a uterus above the vaginal vault. The vagina was packed and the patient was given a transfusion. The packing had to be replaced several times because of saturation. On June 8 an attempt at a careful examination for the purpose of deciding the best method of treatment was accompanied by such severe hemorrhage that it had to be abandoned. However, we obtained sufficient information to make us feel that a vaginal operation was indicated as soon as the patient’s condition permitted. In the meantime the patient ‘P condition continued to be rather serious. Her pulse was rapid and weak and she On the night of June 9 she began to bleed continued to bleed through the packing. However, we felt that profusely and her general condition grew rapidly worse. ~*l?resented at a meeting of the New York Obstetrical Society, November 8. 1938. 1041
*ervix.
Fig.
Z.-Showinl
5 transverse
incision above edge of cervix, peritoneal cavity opened.
bladder
pushed
UP,
ARANOW
:
CHRONIC
INVERSION
01”
I:TERIiS
1043
under the circumstances a hysterectomy would be fatal and suggested an exposure of the inverted uterus, controlling the bleeding points with the coagulation cautery to be followed by another transfusion. The patient reacted so favorably to the above treatment that on June 13 she was prepared for a vaginal replacement according to the Spinelli method. At the operation, when the vagina was retracted and the inverted uterus exposed, I was greatly surprised to find that there was no cervical cuff. Apparently the inversion had proceeded and involved the entire cervix, including the portio vaginalis. At the base of the inversion the mucous membrane of the uterus was continuous with the mucous membrane of the vagina without a ridge or sear. This necessitated a slight change in the technique of the operation. The tip of the inverted cervix was identified by palpation and a transverse incision was made in the mucous membrane of the vagina just above it. With a sound in the bladder, the bladder wall was exposed and separated from the anterior wall of the cervix and vagina. The vesicouterine fold of peritoneum was opened, exposing the edge of the cervix and the inversion funnel1 (Fig. 3). An incision was made from the cervix to a little beyond the apex of the fundus and the uterus turned “inside-in ” without difficulty. Here another unexpected situation awaited us. In our efforts to control the bleeding we had coagulated the greater portion of the anterior wall of the uterus. The tissues were gray and bloodless. We were extremely reluctant to sacrifice the uterus in such a young woman and so we excised the dead parts of the anterior wall of the uterus Tubes and brought the healthy raw edges together by layers of chromic catgut. and ovaries were found normal. A rubber tube drain was placed in the cul-de-sac through a stab wound and another into the vesicouterine space. Peritoneum, fascia, and mucous membrane were sutured with chromic catgut. The perineum which had been lacerated during the delivery and subsequent manipulations was repaired. The patient made an uneventful recovery. During her convalescence the neurologic and orthopedic departments of our and on July 5 exactly a month hospital helped us take care of the paralysis, after her admission the patient walked out of the hospital a well woman. For about a year the patient did not menstruate but had no signs of menopause. Just as we were about to make a hormonal study of the blood and urine, the patient had a normal menstruation. She has menstruated regularly since. A follow-up note by my resident on Dec. 17, 193i, reads as follows: “Menses regular, no leucorrhea, excellent anatomic result.” DISCCSSION DR. ONSLOW A. GORDON.--In 1931 I reported a series of 7 cases of inversion of tlhe uterus, all operated upon without mortality. One patient in the series, who had a Spinelli operation, died two years later following rupture of the uterus, orcurring before the onset of labor. One must bear in mind that when the Spinelli operation is done, subsequent pregnancies are a dangerous complication. I believe that the abdominal operation devised by James Huntington, of Roston, would have been particularly apropos in Dr. Aranow ‘s case, for there was no apparent cervical constriction. It is the cervical constriction in rhronic inversion which is the difficult factor in reduction of the inversion. Masson, however, reported a series of patients with chronic inversion operated upon abdominally in which there was marked cervical constriction. He incised the cervix in the midline, posteriorly, and, thus, easily reduced the inverted corpus abdominally. The advantages of the abdominal operation are: The exposure is much better. There is usually much less bleeding. There is less trauma to the body of the uterus. The woman is left in a much safer condition for subsequent pregnancy. Should hysterectomy be necessary it may be more readily done either before or after reduction of the inversion. DR. DAVID NYE BARROWS.-About six years ago I reported before this Society a similar case of complete inversion operated upon abdominally. The procedure was extremely simple as the cervix had risen nearly to the pelvic brim and an incision through the posterior lip into the vaginal vault made it, easy to split the
1044 posterior become cesarean
AMERICAN
uterine pregnant section
JOIJRNAI,
OF
OBSTETRICS
AND
GPNECOLOGS
wall, and reinvert the uterus. That, patient was advised for five years, but after four years she conceived. An was done, and the 0111 scar fouml to have healed perfectly.
not to elective
I)R. EDWIN I\‘. HOLI,dI)hT.-H:rrirly uoticetl tlm trcl\ni(~al rlifficulties in two Spinelli operations and the simplicity of! the uhdominal operation, I wish to corroborate what Dr. Barrows has said as to the superiority of the abdominal approach. 1 believe Dr. Aranow would have found this so in his case. The technique is very simple. With the operator workin g through the abdominal wound, he can dilate the constricting ring or cut it posteriorly. A third assistant. with a hand in the vagina, pushes up the inverted ut.erur to the vault of the vagina. The operator can now seize in the hollow of his hand the still inverted uterus. H> kneading with the tips of his fingers and with gentle traction, he will be amazed to see the uterus piactieally correct its position itself. DR. F. A. WUBZBACH, JR.-To stop thr bleeding in this case I had to cauterize the anterior surface of the uterus. In cases that do not have the rough treatment to which T had to subject this uterus 1 do not doubt that the abThis patient, however, was in pretty bad condidominal operation would he better. tion and undoubtedly the peritoneal rzavity would have become infected. DR. EDWARD CT. \VATERR.--1 think it may be worth while to comment on the advisability of doing a vaginal examination on bleeding patients post partum and There are three things that cause a woman before discharge from the hospital. to bleed immediately post partum: cervical lacerations, rupture of the uterus, and inversion of the uterus. There is no way of telling which of the latter two may be present except by an adequate vaginal examination in the presence of bleeding that is demonstrated as not. coming from the cervix. We have seen five cases at Margaret Hague Maternity, and one fatality ncThe other four were immediately curred where the inversion was not recognized. replaced and then shock t,reatment was instituted. The response of the patients was so good that one or two days later you would not know that anything serious had happened. DR. ELItlT BISHOP.--Cases of inversion of the uterus must. be placed in two categories: One as to time-is it acute or chronic? the other as to the physical state-is the patient infected or in shock? If the case is in the first category, and inversion has just occurred, immediate laparotomy, with presumably a transfusion? and traetion from above according to the method published by Huntington, Irving and Kellogg some years ago, ought to bring cures with a low mortality and morbidity. If the case is in the first category, but not infect,ed or shocked, an elective Rpinelli operation should be the choice, fort thus, the inversion can he reduced with no loss of organs. If the case is in the second category and is infected, but. not in shock or with hemorrhage, she must be treated for infection, in any way that seems best suited. If shock and hemorrhage exist, t.reatment, should be directed toward them; transfusion should be given, and it would seem to me that the suggestion of the reader of the paper, local cauterization, deep suturing and firm packing, are t.he first methods of attack. DR. ARANOW (closing).-We are allowed to do vaginal work only on our service at the Morrisania Hospital. As a result I have learned to prefer vaginal work. I find the vaginal route just as easy and a little safer. In this particular case the abdominal route was considered but because of the marked edema of the endometrium, a simple reduction of the inversion without extensive incision of the corpus uteri seemed impossible.
CASE OF CHRONIC THE UTERUS” ARANOW,
M.D.,
INVERSION
OF
NEW TORE;, N. T.
c
HRONIC inversion of the uterus per se is sufficiently rare to make it worth whrle reporting every case and what makes my case still more unusual is the fact that the inversion involved not only the body of the uterus but also t,he cervix including the portio vaginalis (Fig. 1). In a rather superficial examination of the literature I have been unable to find a report of a similar case.
CASE REPORT M. S., white, housewife, aged 2-l years, married 5 years, was born in New York. No operations. Menstruation began at 12, every thirty-five days, periods lasting two days, scant in amount and without pain. Sexual life apparently normal. Took contraceptive precautions for four years. Her last period was on June 30, 1935. Expected date of confinement April 7, 1936. She had a normal pregnancy. Patient began to have irregular pains on April 8, 1936. On April 9 she was admitted to a private hospital. After twelve hours the patient was sent home. She continued to have irregular pains for ten days. At about 11 P.H. on April 19 the bag of waters ruptured, and the patient was apparently about to deliver. She ‘was rushed to the hospital, and the baby was born spontaneously. The placenta was delivered with difficulty, i.e. there was considerable pressure necessary to deliver it. This took place about twenty minutes after the birth of the baby. The delivery was followed by a severe post-partum hemorrhage which the family physician was unable to control. The patient repeatedly bled through the packing in the vagina. One of my associates who was called in consultation told me that he thou:ght the patient had a cervical tear but that she bled so furiously and was in such bad shape that he could not attempt a repair. She was packed and repacked. She received a transfusion at 1:50 *\.lhl. and another at 3:30. The bleeding was tinally controlled the following day. The anemia and shock were treated by transfusions, infusions, liver, iron, etc. During her post-partum period the patient complained of severe backache and inabdity to move her legs. She had a peroneal paralysis of both legs with foot drop. She remained at the hospital for a fortnight and was taken home in an ambulance. At home she was bedridden because of the paralysis and there was continuous vaginal spotting. On June 5, 1936, she had a sudden severe vaginal hemorrhage and was brought to the Morrisania Hospital much exsanguinated. The condition was readily diagnosed. There was a firm bleeding mass the size and shape of an inverted pear filling the vagina, and a bimdnual examination revealed the absence of a uterus above the vaginal vault. The vagina was packed and the patient was given a transfusion. The packing had to be replaced several times because of saturation. On June 8 an attempt at a careful examination for the purpose of deciding the best method of treatment was accompanied by such severe hemorrhage that it had to be abandoned. However, we obtained sufficient information to make us feel that a vaginal operation was indicated as soon as the patient’s condition permitted. In the meantime the patient ‘P condition continued to be rather serious. Her pulse was rapid and weak and she On the night of June 9 she began to bleed continued to bleed through the packing. However, we felt that profusely and her general condition grew rapidly worse. ~*l?resented at a meeting of the New York Obstetrical Society, November 8. 1938. 1041
*ervix.
Fig.
Z.-Showinl
5 transverse
incision above edge of cervix, peritoneal cavity opened.
bladder
pushed
UP,
ARANOW
:
CHRONIC
INVERSION
01”
I:TERIiS
1043
under the circumstances a hysterectomy would be fatal and suggested an exposure of the inverted uterus, controlling the bleeding points with the coagulation cautery to be followed by another transfusion. The patient reacted so favorably to the above treatment that on June 13 she was prepared for a vaginal replacement according to the Spinelli method. At the operation, when the vagina was retracted and the inverted uterus exposed, I was greatly surprised to find that there was no cervical cuff. Apparently the inversion had proceeded and involved the entire cervix, including the portio vaginalis. At the base of the inversion the mucous membrane of the uterus was continuous with the mucous membrane of the vagina without a ridge or sear. This necessitated a slight change in the technique of the operation. The tip of the inverted cervix was identified by palpation and a transverse incision was made in the mucous membrane of the vagina just above it. With a sound in the bladder, the bladder wall was exposed and separated from the anterior wall of the cervix and vagina. The vesicouterine fold of peritoneum was opened, exposing the edge of the cervix and the inversion funnel1 (Fig. 3). An incision was made from the cervix to a little beyond the apex of the fundus and the uterus turned “inside-in ” without difficulty. Here another unexpected situation awaited us. In our efforts to control the bleeding we had coagulated the greater portion of the anterior wall of the uterus. The tissues were gray and bloodless. We were extremely reluctant to sacrifice the uterus in such a young woman and so we excised the dead parts of the anterior wall of the uterus Tubes and brought the healthy raw edges together by layers of chromic catgut. and ovaries were found normal. A rubber tube drain was placed in the cul-de-sac through a stab wound and another into the vesicouterine space. Peritoneum, fascia, and mucous membrane were sutured with chromic catgut. The perineum which had been lacerated during the delivery and subsequent manipulations was repaired. The patient made an uneventful recovery. During her convalescence the neurologic and orthopedic departments of our and on July 5 exactly a month hospital helped us take care of the paralysis, after her admission the patient walked out of the hospital a well woman. For about a year the patient did not menstruate but had no signs of menopause. Just as we were about to make a hormonal study of the blood and urine, the patient had a normal menstruation. She has menstruated regularly since. A follow-up note by my resident on Dec. 17, 193i, reads as follows: “Menses regular, no leucorrhea, excellent anatomic result.” DISCCSSION DR. ONSLOW A. GORDON.--In 1931 I reported a series of 7 cases of inversion of tlhe uterus, all operated upon without mortality. One patient in the series, who had a Spinelli operation, died two years later following rupture of the uterus, orcurring before the onset of labor. One must bear in mind that when the Spinelli operation is done, subsequent pregnancies are a dangerous complication. I believe that the abdominal operation devised by James Huntington, of Roston, would have been particularly apropos in Dr. Aranow ‘s case, for there was no apparent cervical constriction. It is the cervical constriction in rhronic inversion which is the difficult factor in reduction of the inversion. Masson, however, reported a series of patients with chronic inversion operated upon abdominally in which there was marked cervical constriction. He incised the cervix in the midline, posteriorly, and, thus, easily reduced the inverted corpus abdominally. The advantages of the abdominal operation are: The exposure is much better. There is usually much less bleeding. There is less trauma to the body of the uterus. The woman is left in a much safer condition for subsequent pregnancy. Should hysterectomy be necessary it may be more readily done either before or after reduction of the inversion. DR. DAVID NYE BARROWS.-About six years ago I reported before this Society a similar case of complete inversion operated upon abdominally. The procedure was extremely simple as the cervix had risen nearly to the pelvic brim and an incision through the posterior lip into the vaginal vault made it, easy to split the
1044 posterior become cesarean
AMERICAN
uterine pregnant section
JOIJRNAI,
OF
OBSTETRICS
AND
GPNECOLOGS
wall, and reinvert the uterus. That, patient was advised for five years, but after four years she conceived. An was done, and the 0111 scar fouml to have healed perfectly.
not to elective
I)R. EDWIN I\‘. HOLI,dI)hT.-H:rrirly uoticetl tlm trcl\ni(~al rlifficulties in two Spinelli operations and the simplicity of! the uhdominal operation, I wish to corroborate what Dr. Barrows has said as to the superiority of the abdominal approach. 1 believe Dr. Aranow would have found this so in his case. The technique is very simple. With the operator workin g through the abdominal wound, he can dilate the constricting ring or cut it posteriorly. A third assistant. with a hand in the vagina, pushes up the inverted ut.erur to the vault of the vagina. The operator can now seize in the hollow of his hand the still inverted uterus. H> kneading with the tips of his fingers and with gentle traction, he will be amazed to see the uterus piactieally correct its position itself. DR. F. A. WUBZBACH, JR.-To stop thr bleeding in this case I had to cauterize the anterior surface of the uterus. In cases that do not have the rough treatment to which T had to subject this uterus 1 do not doubt that the abThis patient, however, was in pretty bad condidominal operation would he better. tion and undoubtedly the peritoneal rzavity would have become infected. DR. EDWARD CT. \VATERR.--1 think it may be worth while to comment on the advisability of doing a vaginal examination on bleeding patients post partum and There are three things that cause a woman before discharge from the hospital. to bleed immediately post partum: cervical lacerations, rupture of the uterus, and inversion of the uterus. There is no way of telling which of the latter two may be present except by an adequate vaginal examination in the presence of bleeding that is demonstrated as not. coming from the cervix. We have seen five cases at Margaret Hague Maternity, and one fatality ncThe other four were immediately curred where the inversion was not recognized. replaced and then shock t,reatment was instituted. The response of the patients was so good that one or two days later you would not know that anything serious had happened. DR. ELItlT BISHOP.--Cases of inversion of the uterus must. be placed in two categories: One as to time-is it acute or chronic? the other as to the physical state-is the patient infected or in shock? If the case is in the first category, and inversion has just occurred, immediate laparotomy, with presumably a transfusion? and traetion from above according to the method published by Huntington, Irving and Kellogg some years ago, ought to bring cures with a low mortality and morbidity. If the case is in the first category, but not infect,ed or shocked, an elective Rpinelli operation should be the choice, fort thus, the inversion can he reduced with no loss of organs. If the case is in the second category and is infected, but. not in shock or with hemorrhage, she must be treated for infection, in any way that seems best suited. If shock and hemorrhage exist, t.reatment, should be directed toward them; transfusion should be given, and it would seem to me that the suggestion of the reader of the paper, local cauterization, deep suturing and firm packing, are t.he first methods of attack. DR. ARANOW (closing).-We are allowed to do vaginal work only on our service at the Morrisania Hospital. As a result I have learned to prefer vaginal work. I find the vaginal route just as easy and a little safer. In this particular case the abdominal route was considered but because of the marked edema of the endometrium, a simple reduction of the inversion without extensive incision of the corpus uteri seemed impossible.