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Chronic Uterine Inversio due to Myoma Geburt

Background: Uterine inversion is a rare obstetric emergency but potentially serious complication of labour. This disease characterized by severe pain and can cause life threatening condition. If these not immediately identified, the massive and underestimated blood loss can lead to hypovolemic shock. There for, early diagnosis and management of this condition is desirable. Objective: Report on the management of chronic uterine inversion due to myoma geburt Methods: Case report Case: A 46 years old patient was admitted to the gynaecology ward of Dr. M. Djamil Central General hospital with slight bleeding from vagina since 1 month ago with 2-3 pieces of underware dark-red colored, with pain. Bleeding from the vagina often recurs. There was a mass revealed from vagina with size as big as baby’s head. The mass had pus and necrotic tissue. Conclusion: Uterine inversion is an serious obstetric complication due to life threaten of the patient. Its low incidence leads to scarce experience in solving this kind of situation. There are some risk factors or mechanism as an underlying etiology of uterine inversion. The authors concluded that the presence of myoma geburt can be assosiated with the chronic uterine inversion. Surgical approach by eksterpation of myoma geburt with total hysterectomy can be the right procedure. Therefore, it is essential to keep in mind this diagnosis in all cases of vaginal bleeding.


INTRODUCTION
Uterine inversion is a rare obstetric emergency but potentially serious complication of labour. This disease characterized by severe pain and can cause life threatening condition. If these not immediately identified, the massive and underestimated blood loss can lead to hypovolemic shock. This condition include of maternal death and reach 15% in some series. Puerperal uterine inversion is a rare complication of mismanaged third stage of labour in which the uterus turns inside out through the cervix. Puerperal uterine inversion is more common than non-puerperal uterine inversion and its incidence varies from 1 in 2000 to 1 in 50,000 births. The most common etiology of uterine inversion is excessive umbilical cord traction with a fundal attachment of placenta and fundal pressure in the setting of a relaxed uterus. Another risk factors are rapid labor, uterine over distension, invasive placentation, manual removal of placenta, short umbilical cord, use of uterine-relaxing agents, fetal macrosomia, nulliparity, placenta previa, connective tissue disorders, and history of uterine inversion in the previous pregnancy. However, this condition can be unpredictable due to no risk factors are identified. The diagnosis is based on clinical examination and must be identified quickly to avoid the formation of a constriction ring. Early diagnosed and treated will decrease the mortality rate. Reinversion should be quick followed by shock resuscitation management. There are several therapeutic management including drugs and manual maneuvers described in the literature. The aim of this article is to describe a case of chronic uterine inversion due to myoma geburt. 1,2

CASE REPORT
A 46 years old patient was admitted to the gynaecology ward of Dr. M. Djamil Central General hospital on April 14th 2019 at 12:00 Am, sent from polyclinic. Slight bleeding from vagina since 1 month ago with 2-3 pieces of underware dark-red colored, with pain. Bleeding from the vagina often recurs. There was a mass revealed from vagina with size as big as baby's head. The mass had pus and necrotic tissue. One month ago, the patient had PA curettage, and the results of leomyoma were known ( Figure 1). History Enlargement of abdomen had been felt since 1 years ago. There was no history of extreme decreasing body weight, trauma, and flour albus. Patient had menarche at 12 years old, with irregular cycle every month which last for about 4-5 days each cycle with the amount of 2-3 times pad changes/day without pain. Patient has 2 child, the youngest one was 24 years old. There was no contraceptive history.
There was no previous history of heart disease, liver disease, kidney disease, diabetic, hypertension and allergy. From family illness history, there was no history of contagious disease, hereditary and physiological illness in the family.

DISCUSSION
Uterine inversion is defined as the uterine fundus turning to inside out through the endometrial cavity and cervix. The causes of uterine inversion still unexplained. Some risk factors associated with this situation are tension on the umbilical cord, fetal macrosomia, excessive fundal pressure, placenta accreta, short umbilical cord, ligaments laxity, and congenital abnormalities. 4 It is classified as 1st degree if the fundus is inside the cavity. Then, a 2nd degree inversion when it reaches but does not exceed the cervical external os. A 3rd degree inversion due to fundus extends out of the external os, and 4th degree called as complete inversion beyond the vagina; introitus. 5 The uterine inversion can be diagnosed by clinical examination. A 4th degree or complete inversion can be easily identified as the uterine fundus beyond the vaginal introitus. But, the diagnosis often be identified by the presence of massive blood loss after childbirth. Uterine fundus was absence in the abdominal palpation. These condition associated with serious condition marked by hypotension and tachycardia. The patient could be evolve into hypovolemic shock. Although the certain etiology is still unknown, some mechanisms, such as thin uterine wall, co-existent and rapidly growing tumor, fundal tumoral location, tumor with a thin pedicle, and cervical dilatation are condition associated to uterine inversion. 6 The most common tumor in benign group was myoma. In our case, the presence of the myoma geburt excised during the operation. These indicated the rapidly growing myomas as the etiological factor.
The management of these patients should be based on the underlying etiology. Our case might provide evidence to chronic uterine inversion due to myoma geburt. An chronic uterine inversion which might threaten the patients' life needs either manual reduction. In   (Figure 2).

CONCLUSION
Uterine inversion is an serious obstetric complication due to life threaten of the patient. Rapid diagnosis and immediate clinical action is desirable. Its low incidence leads to scarce experience in solving this kind of situation. There are some risk factors or mechanism as an underlying etiology of uterine inversion. The authors concluded that the presence of myoma geburt can be associated with the chronic uterine inversion. Surgical approach by eksterpation of myoma geburt with total hysterectomy can be the right procedure. Therefore, it is essential to keep in mind this diagnosis in all cases of vaginal bleeding. Late diagnose and treatment of myoma causing serious complication.