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IMAGING FOR RESIDENTS ANSWER Table of Contents  
Ahead of print publication
A 29-year-old female with nonpuerperal vaginal bleeding – Complete uterine inversion


1 Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Radiodiagnosis, Doon Government Medical College, Dehradun, Uttarakhand, India

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Date of Submission20-Jan-2021
Date of Decision05-Apr-2021
Date of Acceptance21-May-2021
Date of Web Publication24-Aug-2021
 


How to cite this URL:
Saran S, Kaushik R. A 29-year-old female with nonpuerperal vaginal bleeding – Complete uterine inversion. J Med Ultrasound [Epub ahead of print] [cited 2021 Oct 26]. Available from: http://www.jmuonline.org/preprintarticle.asp?id=324264





  Section 2 – Answer Top


Case

A 29-year-old female patient presented with painless vaginal bleeding for 12 days. She was G2P2A0 with the youngest child, 6 years old. There was no history of difficult vaginal delivery during any of her pregnancies. A brown and white voluminous vaginal mass was felt with a small amount of vaginal bleeding on per-vaginal examination. Transabdominal ultrasound of the patient was performed, which is shown in [Figure 1] and Video 1. What is your interpretation?
Figure 1: Transabdominal ultrasound image with full urinary bladder (UB) and Foley's bulb (fb) in situ in longitudinal (a) and transverse (b) planes showing upside-down uterine fundus (fallen fundus sign) in longitudinal plane and a bull's eye or target-like appearance in the transverse plane. Line diagram of the fallen fundus sign and bull's eye/target appearance are shown in (c and d)

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Interpretation

A transabdominal ultrasound in the longitudinal plane showed an upside-down uterine fundus (fallen fundus sign) and a “bull's eye or target-like” appearance in the transverse plane, suggesting the diagnosis of complete uterine inversion [Figure 1]. Normally, the uterus should appear as a pear-shaped structure in the longitudinal section and oval-shaped in the transverse section. The fundus should be convex cranially in the normal uterus. As the patient was claustrophobic, magnetic resonance imaging (MRI) could not be performed. A hysterectomy was performed. There was no evidence of any leiomyoma or any other mass lesion in the uterus, which could have led to uterine inversion.


  Discussion Top


Uterine inversion is the collapse of the uterine fundus into the uterine cavity, which can be classified as incomplete (the uterine fundus descends inferiorly but not through the cervix), complete (the fundus and uterine body extend through the cervix), and total (the vagina is also inverted). It is a rare condition and can be further classified based on the etiology – puerperal and nonpuerperal. Puerperal uterine inversion is reported to occur in 1/2000 to 30,000 deliveries and is considered a serious postpartum complication that can be fatal.[1],[2] Nonpuerperal uterine inversion is even rarer. Gomez-Lobo et al. reported 150 cases of nonpuerperal uterine inversions from 1887 to 2006.[3] Our case was a nonpuerperal complete uterine inversion with no apparent cause identified, i.e., idiopathic. However, 70%–80% of cases of nonpuerperal inversions are associated with benign or malignant uterine tumors.[2],[3],[4],[5],[6] Raised intra-abdominal pressure due to coughing, sneezing, and straining can further aggravate the inversion.

The diagnosis of nonpuerperal inversion is complicated based on physical findings alone, with chronic ones presenting with vague abdominal discomfort and bleeding per-vaginam. Other clinical findings described in the literature are vaginal mass, urinary dysfunction, and anemia. A vaginal mass can be palpated on per-vaginal examination, with a nonpalpable uterine fundus on bimanual pelvic examination.[1]

Transvaginal ultrasound examination is difficult to perform because of the presence of vaginal mass. Transabdominal ultrasound is generally the first imaging modality for the evaluation of such patients. It is readily available, less expensive, and noninvasive radiological investigation, and it is also fast and accurate in experienced hands. On transabdominal ultrasound, two signs are described: “fallen fundus sign” in longitudinal plane indicating upside-down uterine fundus and “a bull's eye or target-” like appearance in transverse plane.[7] Both the signs were present on the ultrasound examination of our patient, so the diagnosis of complete uterine inversion was quickly made.

MRI is the gold standard imaging modality of choice for confirmation of the diagnosis of uterine inversion. On sagittal and coronal MRI images, a “U-shaped” uterine cavity can be observed with round ligaments and  Fallopian tube More Detailss bulging centrally out of the top of the uterus; on axial images, a bull's eye or target sign can be seen similar to ultrasound. MRI can also characterize the mass responsible for inversion in some cases. The majority of cases require hysterectomy.[8],[9]

As ultrasound is the first imaging modality, knowledge of typical ultrasound appearance is very important for early diagnosis and preventing any fatal complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krenning RA. Nonpuerperal uterine inversion. Review of literature. Clin Exp Obstet Gynecol 1982;9:12-5.  Back to cited text no. 1
    
2.
Ueda K, Okamoto A, Yamada K, Saito M, Takakura S, Tanaka T, et al. Nonpuerperal inversion of the uterus associated with endometrial cancer: A case report. Int J Clin Oncol 2006;11:153-5.  Back to cited text no. 2
    
3.
Gomez-Lobo V, Burch W. Nonpuerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent. Obstet Gynecol 2008;112:708-9.  Back to cited text no. 3
    
4.
Shabbir S, Ghayasuddin M, Younus SM, Baloch K. Chronic non puerperal uterine inversion secondary to sub-mucosal fibroid. J Pak Med Assoc 2014;64:586-8.  Back to cited text no. 4
    
5.
Mehra R, Siwatch S, Arora S, Kundu R. Non-puerperal uterine inversion caused by malignant mixed mullerian sarcoma. Case Reports. 2013 Dec 12;2013:bcr2013200578.  Back to cited text no. 5
    
6.
Occhionero M, Restaino G, Ciuffreda M, Carbone A, Sallustio G, Ferrandina G. Uterine inversion in association with uterine sarcoma: A case report with MRI findings and review of the literature. Gynecol Obstet Invest 2012;73:260-4.  Back to cited text no. 6
    
7.
Hsieh TT, Lee JD. Sonographic findings in acute puerperal uterine inversion. J Clin Ultrasound 1991;19:306-9.  Back to cited text no. 7
    
8.
Mihmanli V, Kilic F, Pul S, Kilinc A, Kilickaya A. Magnetic resonance imaging of non-puerperal complete uterine inversion. Iran J Radiol 2015;12:e9878.  Back to cited text no. 8
    
9.
Moulding F, Hawnaur JM. MRI of non-puerperal uterine inversion due to endometrial carcinoma. Clin Radiol 2004;59:534-7.  Back to cited text no. 9
    

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Correspondence Address:
Sonal Saran,
Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None



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