Acute uterine inversion

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Acute uterine inversion

  1. 1. Acute uterine inversion Kah Pin, Low O&G Trainee Dept O&G, Hospital Penang
  2. 2. Incidence <ul><li>depends on geographic location; India > 3x USA </li></ul><ul><li>data in a North American, 24 years 4fold decrease w active management of the third stage, from 1 in 2304 to 1 in 10 044 </li></ul><ul><li>British, traditionally, one in a decade 1:27 902 births </li></ul><ul><li>Baskett et al., 6 however, reported the incidence as 1:3737 (once in a year) </li></ul><ul><li>Mortality 80% </li></ul><ul><li>Abouleish et al .9 and Platt et al .,reported no associated maternal mortality in a study of 18 and 28 cases </li></ul>
  3. 3. Aetiology <ul><li>Commonest – </li></ul><ul><li>mismanagement of 3rd stage of labour (premature traction on umbilical cord and fundal pressure before separation of placenta) </li></ul><ul><li>Others </li></ul><ul><li>uterine atony, </li></ul><ul><li>fundal implantation of a morbidly adherent </li></ul><ul><li>placenta,manual removal of the placenta, </li></ul><ul><li>precipitate labour, a short umbilical cord, placenta </li></ul><ul><li>praevia and connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome) </li></ul>
  4. 4. <ul><li>50% of cases, </li></ul><ul><li>No risk factors are identified </li></ul><ul><li>No mismanagement of the third stage. </li></ul>
  5. 5. Pathophysiology <ul><li>a portion of uterine wall prolapses through the dilated cervix or indents forward </li></ul><ul><li>relaxation of part of the uterine wall </li></ul><ul><li>simultaneous downward traction on the fundus leading to inversion of the uterus. </li></ul>
  6. 6. Classification <ul><li>Degree Description </li></ul><ul><li>First (incomplete) The inverted fundus extends to, but not beyond, the cervical ring </li></ul><ul><li>Second (incomplete) The inverted fundus extends through the cervical ring but remains within the vagina </li></ul><ul><li>Third (complete) The inverted fundus extends down to the introitus </li></ul><ul><li>Fourth (total) The vagina is also inverted </li></ul>
  7. 7. Clinical presentation <ul><li>(94%) present with haemorrhage,with or without shock. </li></ul><ul><li>neurogenic with signs of bradycardia and hypotension but,with time, postpartum haemorrhage will ensue </li></ul><ul><li>Signs </li></ul><ul><li>Lump in the vagina </li></ul><ul><li>Abdominal tenderness </li></ul><ul><li>Absence of uterine fundus on abdominal palpation </li></ul><ul><li>Polypoidal red mass in the vagina with placenta attached </li></ul><ul><li>Symptoms </li></ul><ul><li>Severe abdominal pain </li></ul><ul><li>Sudden cardiovascular collapse </li></ul><ul><li>Postpartum haemorrhage </li></ul>
  8. 8. Management <ul><li>Teamwork = resuscitation + uterine repositioning simultaneously </li></ul><ul><li>postpartum haemorrhage drill. </li></ul><ul><li>The quickest way to treat neurogenic shock - to replace the uterus. </li></ul>
  9. 10. Manual replacement <ul><li>1949 AB Johnson </li></ul><ul><li>chances of immediate reduction are </li></ul><ul><li>quoted as 43–88%. </li></ul>
  10. 11. Hydrostatic method <ul><li>1949 JV O’ Sullivan </li></ul>
  11. 12. <ul><li>Ogueh & Ayida </li></ul>
  12. 13. Role of surgery <ul><li>Need for surgery is rare (<3%) (?3 times in 100 years) </li></ul><ul><li>no role for vaginal surgery. </li></ul>
  13. 14. <ul><li>Huntingdon’s operation </li></ul><ul><li>A crater will be noted in the region of the cervix,with indrawn tubes and round ligaments. </li></ul><ul><li>Two Allis forceps into the crater & gentle upward traction </li></ul><ul><li>further placement of forceps on the advancing fundus. </li></ul><ul><li>uterus is pulled out of the constriction ring and restored </li></ul>
  14. 15. <ul><li>Haultain’s operation </li></ul><ul><li>cervical ring is incised posteriorly with a longitudinal incision. The rest - similar to Huntingdon’s method. </li></ul><ul><li>all incisions closed with interrupted sutures. </li></ul><ul><li>Uterotonics </li></ul>
  15. 17. <ul><li>Antonelli et al . </li></ul><ul><li>Laparotomy + silastic cup used from above </li></ul><ul><li>advantages </li></ul><ul><ul><li>gentler on the tissues </li></ul></ul><ul><ul><li>afforded easy placement </li></ul></ul><ul><ul><li>manoeuvring through the constriction ring. </li></ul></ul>
  16. 18. Role of tocolysis <ul><li>Controversial </li></ul><ul><li>MgSO4 (4–6 g intravenously [IV] over 20 minutes), </li></ul><ul><li>Nitroglycerin (100 micrograms IV slowly, uterine relaxation in 90 seconds when given sublingually) </li></ul><ul><li>Terbutaline (0.25 mg IV slowly) </li></ul><ul><li>Recommended: terbutaline as first-line </li></ul><ul><ul><li>rapid onset of action, </li></ul></ul><ul><ul><li>Short half-life, </li></ul></ul><ul><ul><li>ease of use </li></ul></ul><ul><ul><li>availability on the labour ward </li></ul></ul><ul><ul><li>familiarity to the obstetrician. </li></ul></ul>
  17. 19. Role of GA <ul><li>maternal pain relief </li></ul><ul><li>promotes uterine relaxation </li></ul>
  18. 20. The only slide that matter <ul><li>Unpredictable – requires regular training </li></ul><ul><li>Identify risk factors & proper 3 rd stage management – prevent 50% of it </li></ul><ul><li>Address the maternal shock and uterine inversion at the same time </li></ul><ul><li>Theater </li></ul><ul><li>Johnson & O’ Sullivan (then Ogueh Ayida) </li></ul><ul><li>Operation </li></ul>
  19. 21. <ul><li>That’s all folks! </li></ul>

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