INVERSION OF UTERUSDefinition of uterusThe uterus is a hollow pyriform muscular organ situated in the pelvis between the bladderinfront and rectum behind.PositionIts normal position is one of the anteversion and anteflexion. The uterus usually inclines tothe right so that the cervix is directed to the left and comes in close relation with the leftureter.The uterus measures about 8cm long, 5cm wide at the fundus and its walls are about 1.25 cmthick. Its weight varies from 50-80 gram. It has got the following parts.1 Body Or Corpus2 Isthmus3 CervixDefinition of Inversion of UterusIt is an extremely rare but a life threatening complication in third stage in which the uterus isturned inside out partially or completely. Incidence rate is about 1 in 20000 deliveries. Theobstetricinversion is almost always an acute one and usually complete.ClassificationPart of the uterus indents towards, and eventually prolapses through, the dilated cervix. Itrequires relaxation of the uterus to allow the initial indentation, followed by resumption ofcontractions in such a way that inversion ensues. Classification according to severity of uterine inversion First degree:The fundus reaches the internal os. Second degree:The body or corpus of the uterus is inverted to the internal os. Third degree:The uterus, cervix and vagina are inverted and are visible. Classification according to timing of the event Acute Occurs within 24 hours of birth. SubacuteOccurs after 24 hours, within 4 weeks. Chronic Occurs after 4 weeks, rare.PresentationUterine inversion may present: Acutely - within 24 hours of delivery.
Subacutely - over 24 hours and up to the 30th postpartum day. Chronic - more than 30 days after delivery.It presents most often with symptoms of a postpartum haemorrhage. The classic presentationis of: Postpartum haemorrhage. Sudden appearance of a vaginal mass. Cardiovascular collapse (varying degrees).The sudden appearance of a large dark red mass accompanying the placenta is alarming. Painis extreme. The diagnosis is usually then immediately obvious and confirmed by inability tofeel the fundus. Diagnosing a first-degree inversion is much more difficult. Obesity can makediagnosis more difficult. Chronic cases are unusual and difficult to diagnose. They maypresent with spotting, discharge and low back pain. Ultrasound may be required to confirmthe diagnosis. Complete inversion is accompanied by extreme cardiovascular collapse, morethan might be expected from the degree of blood loss alone.AetiologyVarious factors have been linked to uterine inversion, although there may be no obviouscause. Identified factors include: Spontaneous: 40%: this is brought about by localized atony on the placental site over the fundus associate with sharp rise of intra-abdominal pressure as in coughing, sneezing or bearing down effort. Fundal attachment of the placenta (75%), short cord and placenta acereta are often associated. Iatrogenic: this is due to the mismanagement of third stage of labour. - Pulling the cord when the uterus is atonic specially when combined with fundal pressure - Fundal pressure while the uterus is relaxed. - Faulty technique in manual removal. Common risk factors are uterine over enlargement, precipitate or prolonged labour, foetalmacrosomia, uterine malformations (Unicornuate uterus), morbid adherent placenta, Previous uterine inversion, nulliparity, tocolysis (such as magnesium sulphate), Chronic endometritis, Vaginal births after previous Caesarean section and manual removal of placenta. It is more common in women with the collagen disease like EhlerDanlos Syndrome.
Note:It is not usually considered to be a consequence of mismanagement of the third stage oflabour, despite the factors listed above. However, when the rate is high, it has been ascribedto poor management of the third stage of labour. Active management of the third stage oflabour may reduce the incidence.DiagnosisSymptoms: Acute lower abdominal pain with bearing down sensation.Sign: It presents most often with symptoms of a postpartum haemorrhage. The classicpresentation is of: Postpartum haemorrhage. Sudden appearance of a vaginal mass. Cardiovascular collapse (varying degrees).The sudden appearance of a large dark red mass accompanying the placenta is alarming. Thediagnosis is usually then immediately obvious and confirmed by inability to feel the fundus.Diagnosing a first-degree inversion is much more difficult. Obesity can make diagnosis moredifficult. Chronic cases are unusual and difficult to diagnose. They may present with spotting,discharge and low back pain. Ultrasound may be required to confirm the diagnosis. Completeinversion is accompanied by extreme cardiovascular collapse, more than might be expectedfrom the degree of blood loss alone.Differential diagnosis Prolapse of a uterine tumour. Gestational trophoblastic disease. Occult genital tract disease. Marked uterine atony. Undiagnosed second twin.ManagementNote: If the women is in severe pain, give pethedine 1mg per Kg body weight (but not more than 100mg) IM/IV slowly or give morphine 0.1mg/Kg IM. Maternal resuscitation while attempting uterine replacement should be initiated simultaneously. If the placenta is still in situ, leave in place until uterine replacement is complete. Attempt manual replacement of the uterus by re-inverting it and keeping the hand in theuterus until firm contraction of the uterus is felt.
1. If uterine replacement is unsuccessful or no medical attention is immediately available-call for extra help2. Insert two 16 gauge intravenous cannula. Group and cross-match 4 units of blood andorder a full blood picture. Consider performing coagulation studies.3. Commence intravenous fluids:- If the woman has blood loss more than 1000mls, continues to bleed, or show signs ofclinical shock, in consultation with the anaesthetist the volume and rate of fluids is adjustedaccording to the clinical situation. Warming of the solution may be required.4. If not already administered, withhold the oxytocic until uterine replacement is complete.5. Assess vital signs - blood pressure, pulse, respirations, and oxygen saturation levels 15minutely (more frequently if maternal conditions necessitates). Monitor vital signscontinuously as soon as practical with access to continuous monitoring equipment.6. Administer oxygen via a face mask.7. Insert an indwelling catheter. Monitor urine output.8. If the uterus is successfully replaced commence an oxytocic infusion (30unitsSyntocinon® in 500mL solution commencing at 240mL / hour) as per PPH therapeuticinfusion regimen.9. If the replacement of the uterus is not possible, resuscitate the woman and transfer her totheatre immediately. IN THEATRE 1. Stabilise the woman and obtain effective anaesthesia. 2. Relax the uterus with either: a. Glycereryltrinitrate 600micrograms – sublingual OR b. Terbutaline 250micrograms – subcutaneous 3. Replace the uterus 4. Administer prophylactic antibiotics: a. Cefazolin 2 gm intravenous – one dose only AND b. Metronidazole 500 milligrams intravenous – one dose only 5. Commence oxytocin therapy following uterine replacement. 6. Prophylactic and therapeutic oxytocin administration and infusion regimens. MANUAL REPLACEMENT (JOHNSON MANOEUVRE)The uterus may require relaxation prior to manual replacement.
1. Using the palm of the hand push the fundus of the uterus along the direction of the vaginatowards the posterior fornix.2. Then lift the uterus towards the umbilicus and return to its normal position.3. Maintain the hand in situ until a firm contraction is palpated.Oxytocin therapy should be administered to initiate and maintain contraction of the uterus. HYDROSTATIC REDUCTION (O’SULLIVAN’S TECHNIQUE)Hydrostatic reduction is a method of reinverting the uterus by infusing warm saline into thevagina.Note: uterine rupture should be exclude prior to this performing the procedure.The women may be placed in the reverse Tredelenburg position to assist gravity and reducetraction on the infundibulo-pelvic ligaments, round ligaments and the ovaries.Method one:1. Attach a 2 x 1 litre bags of warmed saline to a Y-Cystoscopy giving set. Additional fluidsmay be required.2. Insert the hand into the vagina with the open end of the tubing near the posterior fornix.Obtain a seal at the vaginal entrance by enclosing the labia around the wrist/hand to preventfluid leakage.3. Infuse warmed fluid under gravity. Several litres of fluid may be required.Method two:1. Attach a 2 x 1 litre bags of warmed saline to a Y-Cystosopy giving set.2. Gently push the inverted uterus into the vagina.83. Insert a 6cm (or appropriate sized) silasticventouse cup into the lower vagina. Avoidpushing the cup deep into the vagina. Attach tubing to a container with warmed saline tubingor the giving set, and then place it 1 metre above the patient.4. If leaking occurs at the introitus gently withdraw the cup until it fits against the inneraspect of the introitus.Following the procedure the uterus should be digitally explored. The hand should be kept inthe uterus until the oxytocic therapy produces a contracted uterus. SURGICAL MANAGEMENTLaparotomy with open reduction of the uterine inversion may be necessary if the previousmethods are unsuccessful.
Complications: 1. Shock: it is extremely profound mainly of neurogenic origin due to – a) tension on the nerves due to stretching of the infundibulo-pelvic ligament 2. Haemorrhage: specially after detachment of placenta 3. Pulmonary embolism 4. If left uncared for, it may lead to- a) infection, b) uterine sloughing and c) chronic onePrevention: 1. Don not employ any method to expel the placenta out when the uterus is relaxed. Pulling the cord simultaneous with fundal pressure should be avoided. Manual removal should be done in a manner as it should be.Prognosis: As it is met commonly in unfavourable surrounding, the prognosis is very gloomy with maternal survival rate of about 85%. Even if the patient survives, infection, sloughing of the uterus and chronic inversion with ill health may occur.