PUERPERAL INVERSION OF THE RIGHT HORN OF A UTERUS BICORNIS UNICOLLIS, WITH A REVIEW OF THE LITERATURE

BY

JOSEPH WARD, M.R.C.O.G. Senior Registrar in Obstetrics and Gynaecology

DAVID R. HUGHES, M.B., B.Ch., M.R.C.O.G. Consultant Obstetrician and Gynaecologist

Woolwich Group of Hospitals

AND

THERE are 6 cases of inversion of one horn of a uterus bicornis unicollis associated with preg- nancy reported in the literature. The first case was described by Henkel (1905) and the others by Zenela (1935), Bates (1940), Wallau (1941), §ieberts (1950) and Watson (1953).

Details of a seventh case are now presented.

CASE REPORT Mrs. J.G., age 27 years, was examined on 8th

December, 1954, and found to be 10 weeks advanced in her first pregnancy. In the lower third of her vagina, lying in the sagittal plane, was a septum about 4 inch thick, running between the lower half of the anterior and posterior vaginal walls. The only uterine abnormality found at this examination was some deviation of the fundus towards the left iliac fossa.

The pregnancy proceeded normally to term. Labour commenced spontaneously on 21st June, 1955, and pro- ceeded rapidly to the second stage, when the vaginal septum was divided to allow a normal delivery. The third stage was quite normal. The puerperium appeared to be proceeding satisfactorily with the fundus uteri involuting normally, in spite of its deviation into the left iliac fossa. The lochia continued to be fairly heavy and bright red, and, as this persisted on her 14th puerperal day, a vaginal examination was performed to determine its cause. A tumour which bled freely on touch was found to be filling the vagina. It was polypoid, 4 inches in diameter and 5 inches long. It was a soft tumour with a haemorrhagic degenerating surface (see Fig. 1). It was emerging from the external cervical 0s and its base was attached to the right side of the cervical canal at the level of the internal 0s directly opposite the internal 0s of the apparently normally involuting left parturient horn of a bicornuate uterus. The left horn was approximately 5 inches in diameter and the internal 0s 13 inches diameter.

In view of these findings and the previous division of a vaginal septum, the diagnosis of inversion of the non- parturient right horn of a uterus bicornus unicollis appeared irrefutable. An examination under anaesthesia followed forthwith to confirm this, to exclude the presence of any retained products of conception in the left horn as the cause of the continued heavy lochia, and to attempt to reduce the inversion.

The previous findings were confirmed by a bimanual examination. A uterine sound entered the single patulous cervix and passed with ease into the left horn to a distance of 44 inches. The base of the inverted right horn was at the same level as the left internal cervical 0s and separated from it by the medial part of a small circular muscular ridge I inch in diameter, which was surrounding the base of the inversion. Palpable in the right side of the pelvis above the base of this horn was a small tumour which was 14 inches in diameter and thought to be the right ovary attached to the base of the funnel formed by the inverted right uterine horn.

Manual compression and attempts at digital reposition of the inverted horn caused profuse bleeding, and, as the fundus of the horn felt extremely thin near a minute depression, which was thought to be the intra-uterine orifice of the Fallopian tube, the gentle and unsuccessful attempts at reposition were abandoned. Some retained degenerating membrane was removed from the left horn. As the amount of blood lost during the examination was about 30 ounces, she was given a blood transfusion and a course of Ergometrine was started orally.

On her 23rd puerperal day a bimanual examination showed the left horn was well involuted and the right horn was now only 14 inches in diameter and 3 inches long. There was only a slight serosanguineous vaginal discharge. She was allowed home to continue breast- feeding of her child and to be observed in the postnatal clinic.

The inverted horn continued to diminish in size and on 20th August, 1955 a salpingogram was attempted

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PUERPERAL INVERSION OF THE RIGHT HORN OF A UTERUS BICORNIS UNICOLLIS 921 without anaesthesia. The cervical canal was too patulous however and in spite of an attempt to pack the vagina, satisfactory filling of the left horn was not obtained. An intravenous pyelogram showed no renal tract abnor- malities.

She was seen on 13th September and involution of the left horn was complete. On 10th October she reported that she was 2 weeks late with her menstrual period when suddenly she had started to lose blood clots per vaginam. She was admitted for observation and 2 days later as the bleeding was still very heavy an examination under anaesthesia was performed. The uterine sound entered the left horn to a distance of 3 inches and the internal 0s was patulous. Curettage produced thick endometrium showing no decidual change. The inverted right horn was 11 inches in diameter and 2+ inches long. Its endometrium was bleeding heavily. Manual reduction was impossible. The bleeding subsided in the next 5 days and she was allowed home.

On 29th December she was readmitted with another severe menstrual haemorrhage for which she had to be given a transfusion of 3 pints of blood as her haemo- globin estimation was only 50 per cent of normal. Again, after 5 days, the bleeding had completely ceased.

On 11th January, 1956, under general anaesthesia, salpingography was again attempted. The right horn was still inverted and the cervix was patulous. It was found to be impossible to prevent leakage back into the endo- cervix and vagina when the acorn nozzle of the syringe was inserted into the similarly patulous internal 0s of the left horn. Finally, a piece of polythene tubing was inserted into the cavity of the left horn, the internal 0s of this horn was closed by direct pressure with a finger inserted through the common external 0s and endocervix, the Neo-Hydriol was injected under direct observation by X-ray screening and the clinical diagnosis confirmed, as shown in Fig. 2.

She had now discontinued her breast feeding and it was decided that on account of her severe menorrhagia and of the irreducibility of the inverted horn spontaneously o r artificially, and in order that she might proceed with a normal married life, an excision of the inverted horn should be performed. On 18th January, 1956 at laparo- tomy the left horn was well involuted and displaced to the left side of the pelvis. Running from the urachus over &he bladder and cervix between the two horns to the anti- mesenteric surface of the upper part of the sigmoid colon was a sagittal plane fold of peritoneum. The right horn was represented by a funnel-shaped depression into which disappeared the right Fallopian tube and the right round ligament. The right ovary was at the mouth of the funnel. Traction was applied to the right round ligament but correction of the inversion was not possible. The con- stricting ring of the endocervix was plainly visible with the elongated ovarian ligament disappearing into the neck of the funnel. This ring was divided posteriorly as in Haultain’s operation and the inversion was now corrected with ease with the aid of a little traction on the right round ligament. The right tube, round ligament and the ovarian ligament were then clamped, divided and tied.

The right uterine vessels were similarly ligated. The right horn was then excised from the endo-cervix and this was oversewn in two layers with the stump of the right round ligament sutured to the edges. The two leaves of peri- toneum of the right broad ligament were resutured over this bare area enclosing retroperitoneally the ovarian ligament. Haemostasis was complete and the abdomen was closed.

The patient’s convalescence proceeded uneventfully and she was discharged from hospital on the 2nd February, 1956. Follow-up since shows she is well and symptom-free.

Inversion of one horn of a uterus bicornis unicollis is an extremely rare cause of vaginal haemorrhage following childbirth. It has been the presenting symptom in all the cases so far described. In 2 of the recorded cases a uterine sound was passed into the normal horn beyond the polypoid vaginal tumour, in the mistaken idea that it was in a normal uterine cavity, and inversion of the uterus was thought to have been excluded by this manceuvre.

In the first 6 cases the inverted horn pro- truding through the cervix was diagnosed initially as a fibromyomatous polypus and the true diagnosis was only arrived at after excision of the tumour had been attempted or performed. The seventh case is the first to be diagnosed pre- operatively and fully investigated before excision. More than half of the cases in which the informa- tion is available had an incomplete vaginal septum. No urinary tract investigations were carried out to exclude the possible presence of associated congenital abnormalities except in the present case. Intensive pre-operative investi- gation of the genito-urinary tract is important so that the operation of choice may be performed for excision of the redundant inverted horn without injury to nearby structures.

All the cases except one were primiparae and only one breech presentation is recorded.

There were no symptoms suggestive of an acute uterine inversion in any of the series and the earliest case discovered was on the second puerperal day (Watson, 1953), whilst the latest was 18 months after delivery (Henkel, 1905). The 5 most recent cases have all been discovered within 24 days of delivery.

The gravid horn was on the left in 3 instances, on the right in 2, and no information was available in the other 2 cases. It is of great

6 2 ~

922 interest to see that in 4 cases, and probably also in Bates’s case, the inversion occurred in the non- gravid horn. It is in these 5 cases only that the information is available.

Two patients were treated with ecbolics for primary uterine inertia and both of these cases and one other had CredC expression of the placenta.

The lack of complications and haemorrhage found after simple vaginal excision of the inverted horn in 2 cases is impressive. Three other undiagnosed causes where this method was being used required a laparotomy in 2 and a colpotomy in the third.

The left internal cervical 0s in the present case was dilated sufficiently to admit the tips of three fingers with ease on her fourteenth puerperal day. The large dilated endocervix and patulous external cervical 0s easily admitted three fingers and the cervical canal was three inches long. Presuming the circular ridge around the base of the inverted horn marked the boundaries of the right internal cervical os, this was similar in diameter to that of the opposite side, and possibly sufficiently dilated to allow complete inversion of the smaller horn to occur with an increased intra-abdominal pressure such as straining with defaecation or coughing.

JOURNAL OF OBSTETRICS AND GYNAECOLOGY

SUMMARY A seventh case of puerperal inversion of one

horn of a uterus bicornis unicollis has been described. It was diagnosed and investigated pre-operatively.

Manual reposition failed but an opportunity for spontaneous correction to occur was allowed without success. Severe menorrhagia demanded treatment which consisted of excision of the inverted uterine horn by the abdominal route.

The relevant available details of the other 6 cases are summarized. It is suggested that the inversion is due to an incompetent internal cervical 0s and a patulous cervical canal in which the relatively small non-parturient horn is finally inverted when there is a sudden increase of intra-abdominal pressure as in straining or coughing.

We wish to thank Mr. John W. Mitchell for the photographs.

REFERENCES Bates, L. E. (1940): Amev. J . Obstet. Gynec., 39, 1067. Henkel, H. (1905): Zbl. Gynuk., 29, 751. Sieberts, H. (1950): Zbf. Gyizak., 72, 186. Wallau, F. (1941): Zbl. Gynuk., 65, 1264. Watson, R. (1953): Bol. SOC. chil. Obstet. Giiiec., 18, 229- Zenela, S. (1935): Zbl. Gynuk., 59, 1879.

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