Case For Nov 6

CASE FOR NOV 6
SM, 35yo, female presented to ER with the complaint of bleeding per vagina and the feeling of
something inside the vagina.
Pre-op:
For 15 months, she used to have vaginal bleeding with clots in one- to two-week interval which lasts
for 2-5 days (no separate recognizable menstrual cycle). In between intermenstrual bleeding, she had
a watery discharge from the vagina without any foul smell of per vaginal itch.
Regarding her vaginal mass, she used to feel the mass occasionally which stays inside the vaginal
canal, but it never came our of the introitus. There were postcoital bleeding and generalized
weakness with no shortness of breath, palpitation, gum bleed, or rashes.
She underwent minilaparotomy for permanent sterilization 11 years ago and had recanalization of the
tubes 5 years ago.
She delivered 3 children vaginally which were all home deliveries assisted by traditional birth
attendant; last childbirth was 12 years back. All 3 children were full term and without complications.
During these 15 months, she visited different local barangay health institutes where she was
investigated for resons of bleeding including coagulation profile, ultrasonography of the pelvis (were
all normal as claimed), and prescribed tranexamic acid, mefenamic acid, and treatment for vaginal
discharge syndrome which could not help much to improve her problems.
Persistence of vaginal bleeding associated now with passage of blood clots and the feeling of
something inside the vagina made the patient to seek consultation in a Provincial Hospital.
ON ADMISSION:
On examination, shw was well built, pale with vital signs within normal limits. The abdomen was soft
and nontender. On bimanual examination, approximately 6x4cm firm, globular mass was felt within
the vaginal canal, the separate cervical os could not be appreciated, the uterus could not be palpated,
and there was active vaginal bleeding.
On investigation, Hgb was 5.3gm%. Platelets and Prothrombin time/INR were within normal range.
Ultrasonography done by a radiologis in 2 separate centers was reported to be normal.
MRI could not be done since patient cannot afford the cost. Patient was then scheduled for surgery.
On admission, she was resuscitated with IV fluid, and 2 units of whole blood since PRBC were not
available during that time. Ultrasonography was repeated in the preoperative room which was again
unable to differentiate whether it was a pedunculated fibroid or uterine inversion.
She was planned for Stat OR with Haultain’s procedure to be done. Foley’s catheterization was done.
Provisional diagnosis was Chronic Inversion of uterus secondary to submucosal fibroid uterus (arising
from the fundus).
INTRA-OP:
With all standard precautions, the abdomen was opened in layers. A cup-like depression was noted in
the mispelvic cavity, and bilateral round ligaments, fallopian tubes, and ovarian ligaments were
coming out of the cup-like depression.
A cyst of 5x6cm in the right ovary was noted which got iatrogenically ruptured during the procedure,
releasing serous fluid. Attempt to reduce uterine inversion abdominally was not successful. So, with
the index finger of the assistant surgeon in the cup-like depression from the abdomen, the patient
was repositioned in the lithotomy position; the mass was pulled out vaginally. With an index finger
still in depression placed up to the fundus of the uterus from the abdominal cavity, myomectomy was
done vaginally.
The excised mass showed a whorled pattern consistent with uterine fibroid. Myometrium and
endometrium were repaired. Again in the supine position of the patient, anterior and posterior edges
of depression were held with Allis forceps.
With sustained traction on the bilateral round ligament, a vertical incision was made in the posterior
portion of the depression (posterior uteirne wall), fundus was then pushed vaginally, and the uterine
inversion was corrected.
The posterior opening of the uterus was repaired.
The ruptured ovarian cyst was removed but 30% of the ovary was preserved on the right side, and the
left ovary was normal in appearance. The abdomen was closed in layers. The vaginal pack was kept for
24 hours. Histopath examination of tissue was consistent with fibroid tissue.
The postoperative period was uneventful. 1 unit whole blood was transfused in the postoperative
ward. Her hemoglobin level on the 3rd post-op day was 90%. She was counseled regarding decreased
chance of conception. She was advised not to conceive for at least 2-3 years, and if she got pregnant,
she will undergo an elective CS. She was discharged on the 7 th post-op day with Iron tablets.

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CASE FOR NOV 6

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