Uterine inversion


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Uterine inversion

  1. 1. Life-Threatening Obstetrical Emergency May 2010
  2. 3. Risk Factors & Incidence <ul><li>Cord traction &/or fundal pressure </li></ul><ul><li>Uterine anomalies </li></ul><ul><li>Short umbilical cord </li></ul><ul><li>Placenta Accreta </li></ul><ul><li>Grand Multiparity </li></ul><ul><li>Fetal macrosomia </li></ul><ul><li>Rapid labor and delivery </li></ul><ul><li>Incidence 1/2000 </li></ul>
  3. 4. DIAGNOSIS INTRA-UTERINE MANUAL EXPLORATION <ul><li>The diagnosis of uterine inversion is based upon clinical findings: </li></ul><ul><li>Bleeding , which may be severe and result in Hemorrhagic Shock </li></ul><ul><li>Palpation of the prolapsed uterine fundus : </li></ul><ul><li>Lower uterine segment = INCOMPLETE </li></ul><ul><li>Vagina = COMPLETE </li></ul><ul><li>Beyond the perineum = PROLAPSED </li></ul>
  4. 5. STAT SIMULTANEOUS TREATMENT <ul><li>The more time that elapses the more difficult it is to replace the fundus resulting in a greater risk for Hemorrhagic shock & Death </li></ul><ul><li>Stop Pitocin Immediately </li></ul><ul><li>Do Not Remove the Placenta </li></ul><ul><li>HELP ---Hem Cart , Anesthesia, 3 RN’s , Another Ob </li></ul><ul><li>Establish 2 IV’s and give 2 liters crystalloid as fast as possible or until the fundus is replaced </li></ul><ul><li>Call for: 2 units O neg/ H & H/T & X/Coags/OR set up </li></ul><ul><li>Manually replace the uterine fundus/SQ Brethine </li></ul>
  5. 6. TREATMENT <ul><li>If the initial attempt at manual uterine replacement is unsuccessful administer IV NITROGLYCERIN to relax the uterus and reattempt manual replacement of the fundus </li></ul><ul><li>Nitroglycerin is highly effective and has a short duration of action </li></ul><ul><li>Initial 100 micrograms IV Bolus </li></ul><ul><li>Followed by up to three additional doses keeping the total </= to 1000 mcg </li></ul>Obstet Gynecol Surv 1998 Sep;53(9):559
  6. 7. NITROGLYCERIN IV Dosing <ul><li>In general an initial 100 microgram Nitroglycerin IV bolus, with repeat doses of 100-2o0-400 micrograms IV every 3 minutes will produce rapid and adequate uterine relaxation in the majority of patients with acceptable maternal side effects. Total IV NTG </= to 1000 micrograms </li></ul><ul><li>IV NTG has rapid onset (<1 minute) and short duration of action (minutes) </li></ul><ul><li>Hypotension as a side effect from IV nitroglycerin is preventable with aggressive fluid resuscitation </li></ul><ul><li>If necessary nitroglycerin related hypotension can be reversed or preempted with </li></ul><ul><li>IV ephedrine 5-10 mg or </li></ul><ul><li>IV Phenylephrine 100 mcg </li></ul><ul><li>Headache and reflex tachycardia are also important side effects. </li></ul>
  7. 8. LESS EFFECTIVE Options for Uterine Relaxation. <ul><li>Magnesium sulfate ( 6 grams IV over 15 minutes) </li></ul><ul><li>Terbutaline (0.25 Mg IV or SQ) </li></ul><ul><li>Both have relatively mild effects on the myometrium and MgSo4 has a slow onset of action </li></ul>
  8. 9. FAILURE OF UTERINE RELAXATION <ul><li>A persistent contraction ring in the lower uterine segment may prevent manual replacement of the fundus. </li></ul><ul><li>Surgery may be required if manual replacement fails after administering Nitroglycerin /Brethine /or MgSo4 </li></ul><ul><li>If IV NTG fails to produce adequate uterine relaxation to replace the fundus, the Ob/Anesthesia team and patient should be prepared to proceed immediately to general anesthesia </li></ul><ul><li>Halogenated anesthetic agents , such as halothane and enflurane are excellent uterine relaxants. These drugs can be administered in the operating room as an initial step before proceeding to laparotomy </li></ul>
  9. 10. SURGICAL REPLACEMENT <ul><li>Huntington procedure </li></ul><ul><li>An Allis or Babcock clamp is placed on each round ligament about 2 cm deep into the inverted fundus. Clamping and traction are repeated until the inversion is corrected. This procedure is similar to the hand-over-hand movements used when pulling up an anchor line. </li></ul><ul><li>A second operator with a hand in the vagina can apply upward pressure on the fundus to facilitate the procedure </li></ul><ul><li>Haultain procedure involves making an incision in the lower uterine segment to bisect the inversion ring facilitating replacement of the fundus by the Huntington procedure. </li></ul><ul><li>The posterior lower uterine segment can be incised to avoid iatrogenic cystotomy. </li></ul>
  10. 11. MAINTAIN UTERINE POSITION <ul><li>UTERINE ATONY /REINVERSION </li></ul><ul><li>IS COMMON AFTER REPLACEMENT </li></ul><ul><li>Cytotec 600-800 micrograms PR </li></ul><ul><li>Methergine 0.2 IM and Pitocin 40 units/liter </li></ul><ul><li>Hemabate added if persistent atony </li></ul><ul><li>Continue Cytotec 200 po Q 6 for 24 hours </li></ul><ul><li>Or Continue Methergine 0.2 mg po Q 6 for 24 hours </li></ul><ul><li>IV ANTIBIOTIC PROPHYLAXIS </li></ul>
  11. 12. NTG References <ul><li>Am J Obstet Gynecol 1992;166:1237 Intravenous nitroglycerin for uterine relaxation of an inverted uterus. </li></ul><ul><li>Anesth Analg. 1996 May;82(5):1091 The use of small-dose intravenous nitroglycerin in a case of uterine inversion </li></ul><ul><li>Obstet Gynecol Surv 1998 Sep;53(9):559 Use of Nitroglycerin for uterine relaxation </li></ul><ul><li>Analg 1996;82:1091 The use of small-dose intravenous nitroglycerin in a case of uterine inversion. </li></ul><ul><li>Anesthesiology 1996;85:683 Nitroglycerin and uterine relaxation. </li></ul><ul><li>J Clin Anesth 1992;4:487 Intravenous nitroglycerin for uterine inversion. </li></ul>