Ahmad mukhtar MD.,M.B.B.Ch., M.Sc Obstetrics and GynecologyConsultant and Lecturer of Obstetrics and Gynecology, Faculty of MEDICINE, Zagazig University.

1. Displacement of theDisplacement of the
uterusuterus
Dr ; Ahmad mukhtarDr ; Ahmad mukhtar
Consultant and Lecturer ofConsultant and Lecturer of
Obstetrics and Gynecology, FacultyObstetrics and Gynecology, Faculty
ofof
MEDICINE, Zagazig University.MEDICINE, Zagazig University.

2. The uterus has central position in the pelvicThe uterus has central position in the pelvic
The ternal os is at the level of the ischial spineThe ternal os is at the level of the ischial spine
It is ante verted & ante flexedIt is ante verted & ante flexed
Anteverted ;angle between axisAnteverted ;angle between axis of the cervic and vertical
axis of female .axis of female .
Ante flexed ;angle betweenAnte flexed ;angle between
Axis of the uterine body andAxis of the uterine body and
Axis of the cervixAxis of the cervix

3. Retroversion of the uterus ;
it mean that the axis of the cervix become
behind the vertical axis of femal body .
Retoflexion;
axis of the uterine body become behind the ais
of female body .

4. Uterine inversionUterine inversion
Uterine inversion may occur immediately postpartumUterine inversion may occur immediately postpartum
or, much less frequently, during the puerperiumor, much less frequently, during the puerperium..
Inversions are usually described as acuteInversions are usually described as acute ((<30 d after<30 d after
deliverydelivery)) or chronicor chronic ((>30 d after delivery>30 d after delivery).).

5. DegreeDegree
 In firstIn first--degree inversion, the inverted walldegree inversion, the inverted wall
extends to but not through the cervixextends to but not through the cervix..
 In secondIn second--degree inversion, the inverted walldegree inversion, the inverted wall
protrudes through the cervix but remainsprotrudes through the cervix but remains
within the vaginawithin the vagina..
 In thirdIn third--degree inversion, the inverted fundusdegree inversion, the inverted fundus
extends outside the vaginaextends outside the vagina.. In fourth degree orIn fourth degree or
total inversion, both the vagina and uterus aretotal inversion, both the vagina and uterus are
invertedinverted..

6.  Possible etiologyPossible etiology
 Reported associations for uterine inversion include theReported associations for uterine inversion include the
following:following:
 IdiopathicIdiopathic
 Excessive cord traction or a short umbilical cordExcessive cord traction or a short umbilical cord
 Credé (fundal) pressureCredé (fundal) pressure
 Placenta accreta or increta or percretaPlacenta accreta or increta or percreta
 Fundal implantation of the placentaFundal implantation of the placenta
 Chronic endometritisChronic endometritis
 Fetal macrosomiaFetal macrosomia
 Trials of vaginal birth following cesarean deliveryTrials of vaginal birth following cesarean delivery
 Myometrial weaknessMyometrial weakness
 Precipitate laborPrecipitate labor
 drugs, including magnesium sulfatedrugs, including magnesium sulfate


7. S&SS&S
 The classic observations includeThe classic observations include
 postpartum hemorrhage,postpartum hemorrhage,
 the sudden appearance of a vaginal mass, andthe sudden appearance of a vaginal mass, and
 varying degrees of cardiovascular collapse—all usuallyvarying degrees of cardiovascular collapse—all usually
occurring in the immediate puerperiumoccurring in the immediate puerperium..
 The postpartum hemorrhage is usually the most strikingThe postpartum hemorrhage is usually the most striking
of the symptoms and initially commands the attention ofof the symptoms and initially commands the attention of
the clinicianthe clinician..
 In other cases, the sudden and disconcerting protrusionIn other cases, the sudden and disconcerting protrusion
of a large, dark red, polypoid mass through the vaginaof a large, dark red, polypoid mass through the vagina
either accompanying or following the placenta is noted.either accompanying or following the placenta is noted.
The characteristic appearance of the inverted uterusThe characteristic appearance of the inverted uterus
either retained within the vagina or protruding externallyeither retained within the vagina or protruding externally
is both surprising and startling and usually immediatelyis both surprising and startling and usually immediately
establishes the correct diagnosisestablishes the correct diagnosis

8.  ManagementManagement
 Following uterine inversion, prompt treatmentFollowing uterine inversion, prompt treatment
of hemorrhage and shock is vital in limitingof hemorrhage and shock is vital in limiting
maternal morbidity and the risk of mortality.maternal morbidity and the risk of mortality.
 Hypotension and hypovolemia requireHypotension and hypovolemia require
aggressive fluid resuscitation. The generalaggressive fluid resuscitation. The general
principles of treatment follow the (STAR)principles of treatment follow the (STAR)
protocolprotocol

9.  ShockShock
1.1. Initiate fluid resuscitation with 2 large-bore intravenousInitiate fluid resuscitation with 2 large-bore intravenous
lines. Promptly administer 1 or more liters of an isotoniclines. Promptly administer 1 or more liters of an isotonic
salt solution such as lactated Ringer parenterally.salt solution such as lactated Ringer parenterally.
2.2. Submit specimens to the laboratory for possible transfusionSubmit specimens to the laboratory for possible transfusion
and for determination of baseline values of hemoglobinand for determination of baseline values of hemoglobin
(Hgb), hematocrit (Hct), and coagulation factors.(Hgb), hematocrit (Hct), and coagulation factors.
3.3. Insert a Foley catheter.Insert a Foley catheter.
4.4. Immediately summon an anesthesiologist.Immediately summon an anesthesiologist.
5.5. Treat aggressivelyTreat aggressively
6.6. Order appropriate surgical equipment and assistants to readyOrder appropriate surgical equipment and assistants to ready
the operating room for a possible laparotomy.the operating room for a possible laparotomy.
7.7. Administer tocolytics to promote uterine relaxation. TheseAdminister tocolytics to promote uterine relaxation. These
may include nitroglycerin , or magnesium sulfate at 4-6 gmay include nitroglycerin , or magnesium sulfate at 4-6 g
IV over 20 minutes.IV over 20 minutes.

10.  Attempt prompt uterine replacement.Attempt prompt uterine replacement.
First, proceed with a trial of simpleFirst, proceed with a trial of simple
manual replacement. If this ismanual replacement. If this is
unsuccessful, promptly perform aunsuccessful, promptly perform a
laparotomy for a surgicallaparotomy for a surgical
replacement At laparotomy, generalreplacement At laparotomy, general
anesthesia employing a uterineanesthesia employing a uterine
relaxing agent is best,relaxing agent is best,

11.  It is important that the part of the uterusIt is important that the part of the uterus
that came out lastthat came out last ((the part closest to thethe part closest to the
cervixcervix)) goes in firstgoes in first..
 Figure P-52Figure P-52
 Manual replacement of the invertedManual replacement of the inverted
uterusuterus


12.  RepairRepair
 Suture birth canal lacerations and any surgicalSuture birth canal lacerations and any surgical
incisions in cervix or vaginaincisions in cervix or vagina..
 Perform uterine massage (after replacement).Perform uterine massage (after replacement).
 Administer uterotonics. These may includeAdminister uterotonics. These may include
methyl ergonovine maleate (Methergine 0.2methyl ergonovine maleate (Methergine 0.2

13.  Surgical techniquesSurgical techniques
 If 2 or more attempts at manual replacementIf 2 or more attempts at manual replacement
are unsuccessful, surgery is indicated. Anare unsuccessful, surgery is indicated. An
abdominal approach for uterine replacement isabdominal approach for uterine replacement is
favored. A vaginal technique has also beenfavored. A vaginal technique has also been
described but has few adherents.described but has few adherents.
 In the vaginal procedure, the bladder isIn the vaginal procedure, the bladder is
dissected from the cervix, and the anterior lipdissected from the cervix, and the anterior lip
of the cervix and the anterior wall of the uterusof the cervix and the anterior wall of the uterus
are incised to the extent necessary to permitare incised to the extent necessary to permit
replacementreplacement..

14.  POSTPOST--PROCEDURE CAREPROCEDURE CARE
 Once the inversion is corrected, infuse oxytocin 20Once the inversion is corrected, infuse oxytocin 20
units in 500 mL IV fluids (normal saline orunits in 500 mL IV fluids (normal saline or
Ringer’s lactate) at 10 drops per minute:Ringer’s lactate) at 10 drops per minute:
 - If haemorrhage is suspected, increase the- If haemorrhage is suspected, increase the
infusion rate to 60 drops per minute;infusion rate to 60 drops per minute;
 - If the uterus does not contract after oxytocin,- If the uterus does not contract after oxytocin,
give ergometrine 0.2 mg or prostaglandins (give ergometrine 0.2 mg or prostaglandins (
Table S-8Table S-8).).
 Give a single dose of prophylactic antibiotics after correctGive a single dose of prophylactic antibiotics after correct
::
 - ampicillin 2 g IV PLUS metronidazole 500 mg- ampicillin 2 g IV PLUS metronidazole 500 mg
IV;IV;
 - OR cefazolin 1 g IV PLUS metronidazole 500 mg- OR cefazolin 1 g IV PLUS metronidazole 500 mg
IV.IV.