Chronic Postpartum Uterine Inversion Managed with the Haultain Procedure: A Case Report

Abstract

Uterine inversion is a rare condition in which the uterine fundus collapses into the endometrial cavity and passes through the cervical canal. Chronic postpartum uterine inversion, defined as inversion persisting for four weeks or longer after delivery, is exceptionally uncommon and may present with abnormal uterine bleeding, anemia, and pelvic pain, while a persistent cervical constriction ring frequently precludes manual reduction. This report describes the diagnosis and uterus-preserving management of chronic uterine inversion using the Haultain procedure. A 28-year-old woman (P2A0) was admitted on 10 June 2024 with bright-red vaginal bleeding of approximately three months’ duration and intermittent abdominal pain. Her second delivery, a term vaginal home birth attended by a midwife in 2023, was complicated by a placenta retained for more than one hour that was delivered by traction; she also received abdominal massage about 40 days postpartum. The uterine fundus was not palpable abdominally, and speculum and vaginal examination revealed a mass with an endometrial mucosal surface filling the vaginal introitus, a non-visualized portio, and a palpable constriction ring. Ultrasonography showed the inverted fundus in the vagina with the cervix superior to it. Laboratory studies demonstrated severe hypochromic microcytic anemia (hemoglobin 2.4 g/dL; MCV 53 fL) with low serum iron (9 µg/dL) and hypoalbuminemia (3.3 g/dL). After transfusion of seven units of packed red cells (hemoglobin 10.3 g/dL), laparotomy was performed on 26 June 2024. The fundus was drawn into the cervix and vagina, with both fallopian tubes pulled into the cervical ring. Reduction was achieved by the Haultain procedure through a vertical incision on the posterior uterine corpus, followed by blunt repositioning and repair with a baseball suture; blood loss was 400 mL. Postoperatively, vaginal bleeding ceased, hemoglobin was 10.3 g/dL, and the patient was discharged on postoperative day 3. Chronic uterine inversion should be considered in postpartum women presenting with abnormal uterine bleeding, a vaginal mass, and a non-palpable uterine fundus. Ultrasonography is a useful adjunct for confirming the diagnosis. When a persistent constriction ring makes conservative reduction impossible, the Haultain procedure offers an effective uterus-preserving option after optimization of anemia. Counseling regarding risks in future pregnancies and delivery in a facility capable of managing obstetric complications are essential.