Edwin Armawan

Urogynecology Divison
Obstetrics & Gynaecology Dept
Hasan Sadikin Hospital
Universitas Padjadjaran Bandung

INTRODUCTION
PROLAPSE OF THE FUNDUS TO OR THROUGH

THE CERVIX SO THAT THE UTERUS IS IN EFFECT

TURNED INSIDE OUT .
IS POTENTIALLY LIFE THREATING
COMPLICATION OF CHILDBIRTH.
ALMOST ALL CASES OCCUR AFTER DELIVERY.
BUT CAN OCCUR EVEN IN THE NON PREGNANT
UTERUS IN RELATION TO THE EXPULSION OF AN
INTRAUTERINE TUMOUR.

EPIDEMIOLOGY
INCIDENCE VARIES WIDELY
VARIED FROM 1:4.000 TO 1:100.000 DELIVERIES

DEFINITION OF SOME TERMS

INCOMPLETE INVERSION : AN INVERTED FUNDUS THAT LIES

WITHIN THE ENDOMETRIAL CAVITY WITHOUT EXTENDING

BEYOND THE EXTERNAL OS.
COMPLETE INVERSION : AN INTERVED FUNDUS THAT EXTENDS
BEYOND THE EXTERNAL OS.
A PROLAPSED INVERSION : THE INVERTED UTERINE
FUNDUS EXTENDS BEYOND THE VAGINAL INTROITUS.
A TOTAL INVERSION : INVERSION OF
THE UTERUS AND VAGINAL WALL
AS WELL.

CLASSIFICATION
BASED ON THE DEGREE OF INVERSION :
1ST : THE INVERTED FUNDUS EXTEND TO, BUT NOT
THROUGH THE CERVIX
2ND : THE INVERTED FUNDUS EXTEND THROUGH
THE CERVIX BUT REMAINS WITHIN THE VAGINA
3RD : THE INVERTED FUNDUS EXTEND OUTSIDE
THE VAGINA

INCOMPLETE-1ST
COMPLETE-2ND & 3RD DEGREE

CLASSIFICATION
BASED ON THE TIME OF ONSET :
o ACUTE : IMMEDIATELY AFTER DELIVERY

BEFORE THE CERVIX CONSTRICTS

o SUB ACUTE : ONCE CERVIX CONSTRICTS
o CHRONIC : NOTED>4/52 AFTER DELIVERY, OR
NON PUERPERAL

EXAMINATION
o ABDOMINAL

CUPPING OF THE FUNDUS-1ST & 2ND DEGREE

ABSENCE OF THE UTERUS-3RD DEGREE

o VAGINAL

SOFT PURPLE (DARK BLUISH RED) MAAS IN THE VAGINA

OR VULVA

NOTE :
DIAGNOTIC IS MUCH MORE DIFFICULT IN A FIRST DEGREE INVERSION AND OBESITY
CHRONIC CASES MAY PRESENT WITH SPOTTING, DISCHARGE AND LOW BACK PAIN.
ULTRASOUND MAY BE REQUIRED TO CONFIRM THE DIAGNOSIS

INVESTIGATIONS
DIAGNOSIS IS USUALLY BASED ON CLINICAL

SYMPTOMS AND SIGNS

IF NOT CLINICALLY VERY OBVIOUS, IMAGING IS
USEFUL IF PATIENT IS CLINICALLY STABLE TO
UNDERGO SUCH EVALUATION
oUSS:
TRANSVERSE IMAGE : A HYPOECHOIC MASS IN THE VAGINA
WITH A CENTRAL HYPOECHOIC H-SHAPED CAVITY
LONGITUDINAL : U SHAPED DEPRESSED LONGITUDINAL
GROOVE FROM THE UTERINE FUNDUS TO THE CENTRE OF
THE INVERTED PART
oMRI:FINDINGS ARE MORE CONSPICIUOUS

Transabdominal transverse
sonogram
A, showing the target sign with the hyperechoic inverted fundus

centrally surrounded by hypoechoic fluid between the fundus and

vaginal wall. The image plane is in the lower pelvis. B, Illustration of
the target sign

Transabdominal sagittal sonogram

A, showing a mirror image of the uterus with the endometrial

pseudostripe represented by the two opposing serosal surfaces. B,

Illustration of the pseudostripe.
Cervix

Serosal surface

Vaginal wall

Endometrial surface

Reposition procedures
Like that of Johnson are more likely to be successful in acute inversion

but in chronic cases, surgery is imperative.

Depending on the clients reproductive desire and associated
conditions, surgical reposition or hysterectomy could be considered.
2 APPROACH SURGICAL INTERVENTION
o ABDOMINAL (HUNTINGTONS and HAULTAINS PROCEDURE)
o VAGINAL (SPINELLIS and KUSTNERS METHOD)

the basic differences being that Spinells approach is anterior and requires
dissection of the bladder and has uterine incision on anterior wall while
Kustners is posterior approach with incision on the posterior uterine wall,
which makes it a bit easier and safer.

HYSTERECTOMY : IF PRESENT LATE WITH ISCHAEMIC CHANGES OF

THE UTERUS OR NON VIABLE UTERINE TISSUES

HUNTINGTON PROCEDURE
o LOCATE THE CUP OF THE
UTERUS
o DILATE THE CONSTRICTING
CERVICAL RING DIGITALLY
o PLACE TWO ALLIS FORCEPS /
CLAMPS IN THE CUP OF THE
INVERSION BELLOW THE
CERVICAL RING AND GENTLE
UPWARD TRACTION IS
APPLIED
o REPEATED CLAMPING AND
TRACTION CONTINUE UNTIL
THE INVERSION IS
CORRECTED

HUNTINGTON PROCEDURE
Instead of allies forceps

alternative velt vacuum

can be used

HAULTAIN PROCEDURE
o INCISION IS MADE IN THE POSTERIOR PORTION OF THE

CERVICAL RING TO INCREASE THE SIZE OF THE RING AND

ALLOW REPOSITIONING OF THE UTERUS
o FURTHER STEPS SIMILAR TO HUNGTINGTON PROCEDURE
o ALL INCISION CLOSED W INTERRUPTED SUTURE

Spinellis method
Under spinal anaesthesia, patient was cleaned and draped in lithotomy position. A
transverse incision was made at the cervico-uterine junction, dissecting anteriorly till
bladder was separated and the anterior peritoneum was opened.

Spinellis method
A full thickness longitudinal incision was made from the level of the cervix to the fundus
of the uterus, exposing this way both fallopian tubes, ovaries and round ligaments.

Spinellis method
The uterus is turn side in
The myometrium is reapproximated by two layer

interrupted/continued PGA suture

Serosa reapproximated by a single layer
Vaginal skin is reapproximated with interrupted sutured, as
is the cervix

Kustner Method
The cul-de-sac of Douglas is opened by posterior colpotomy
The index finger of the operators is inserted into the peritoneal

invagination of the uterus

The posterior uterine wall is incised and then the corpus is flipped
through the post colpotomy

Vaginal Hysterectomy
A full thickness longitudinal incision was made from the level of the cervix to the fundus of the

uterus, exposing this way both fallopian tubes, ovaries and round ligaments.

These structures were clamped transected and ligated bilaterally. The cardinal ligament,

uterosacral ligament and uterine arteries were separately clamped, transected and ligated;
permiting uterus to be extirpated.

Laparoscopy

COMPLICATION
ENDOMYOMETRITIS
DAMAGE TO INTESTINES AND UTERINE

APPENDAGES

PROGNOSIS
GOOD IF MANAGED CORRECTLY

Thank you