1) Uterine inversion occurs when the uterus turns inside out, and can be acute or chronic. It is usually caused by uterine fibroids or polyps. 2) Symptoms include abdominal pain, bleeding, and a vaginal mass. Diagnosis involves ultrasound or MRI. 3) Treatment options include manual repositioning, hydrostatic reduction using fluids, or surgery such as abdominal or vaginal approaches. 4) Complications include shock, infection, and recurrence if not properly treated. Prompt diagnosis and treatment are important for reducing risks.

1. - MANAGEMENT OF UTERINE INVERSION
(Emphasis on Non-
Puerperal Uterine Inversion)
By: DR. KATTEY K. A
MBBS (Port Harcourt), MPH (Johns Hopkins)

2. • Recap of terminology
• Clinical Presentation
• Investigations
• Treatment
• Complications
• Differential diagnosis

3. 3

4. Recap
Uterine inversion refers to the descent of the uterine
fundus to or through the cervix, so that the uterus is
literally turned inside out.
Classification
KATTEY K.A (MBBS, MPH)

5. Recap
• Non-puerperal uterine inversion accounts for 16% of cases of uterine inversion1.
• Causes of non-peurperal uterine inversion:
 Uterine leiomyoma (80-85%)
 Endometrial polyps
 Other uterine neoplasm e.g endometrial CA, leiomyosarcoma, rhabdomyosarcoma.
 Ovarian tumour (very rare)2
1Takano K, Ichikawa Y, Tsunoda H, Nishida M. Uterine inversion caused by uterine sarcoma: a case report. Jpn J Clin Oncol. 2001
2Gomathy E, Agarwal Y, Sreeramulu PN,Sheela SR. Non-puerperal uterine inversion with an ovarian tumor- a rare case. IJPBR, 2011

6. Clinical presentation of non-puerperal uterine
inversion
• Acute or chronic based on the onset and evolution
• Acute (8.6%).3
o More dramatic
o Severe pain
o Severe haemorrhage
• Chronic
• Insidious
• Pelvic discomfort
• Vaginal discharge
• Irregular vaginal bleeding
• Anemia
3Das, P., J Obstet Gynaecol Br Emp 1940,

7. Symptoms
Acute:
• Severe abdominal pain
• Sudden cardiovascular collapse
Chronic
• Chronic vaginal discharge
• Irregular uterine bleeding
• Lower abdominal pain and pelvic discomfort
• Urinary disturbance
• Irregular cycle
• Vaginal mass

8. Examination
• Palor
• May present in shock (hypotension, tachycardia, bradycardia)
• Neurogenic
• Hypovolaemic
• Abdominal tenderness
• Absence of uterine fundus on bimanual palpation (rectoabdominal)
• Lump in the vagina
• Usually bleeds readily on palpation
****A high index of suspicion is required to make a prompt diagnosis

9. Investigations
• FBC, E/U/Cr
• Urinalysis + m/c/s
• USS
• MRI
• CT
*Diagnosis is usually based on clinical symptoms, but if not obvious,
then USS, MRI

10. Ultrasound findings
• Transverse image
• A hyperechoic fundus surrounded by hypoechoic rim.
• Longitudinal image
• U-shaped depressed longitudinal groove from the uterine fundus to the
center of the inverted part

11. Investigations
MRI
• Sagittal section
• U shaped uterine cavity
• Thickened and inverted uterine fundus
• Transversial (axial)
• ‘bulls-eye’ configuration

12. Treatment of uterine inversion
• Immediate treatment of shock
• Replacement/ repositioning of the uterus
• Non- Surgical (usually for puerperal inversion)
**Use of tocolytics for acute cases
• Magnesium sulphate, terbutaline, nitroglycerin, halothane
• Surgical
• Hysterectomy (if indicated)
• Abdominal
• Vaginal

13. TREATMENT OF SHOCK
• Call for help
• IV line with two large bore cannulae
• Aggressive fluids replacement
• Start resuscitation with normal saline or Hartmann’s solution
• Administer oxygen
• Blood transfusion
• Analgesics
• Use warm saline to apply compress
• Insert a urinary catheter

14. Uterine replacement for puerperal/acute
uterine inversion
Non-surgical methods
• Johnson’s procedure: repositioning the fundus by vaginal
manipulation.
• O’Sullivan: hydrostatic reduction
• Ogueh and Ayida
Surgical Methods (if non-surgical does not correct it)
- Abdominal approach (Huntington & Haultian)
- Vaginal approach (Kustner & Spinelli)
KATTEY K.A (MBBS, MPH)

15. REPOSITIONING OF INVERTED UTERUS
• MANUAL REDUCTION.
• Sterile procedure.
• Form a fist or grab the uterus and push it
through the cervix of a lax uterus towards the
umbilicus to its normal position.
• Use the other hand to support the uterus.
(Johnson maneuver)4
4 Johnson AB. A new concept in the replacement of the inverted uterus
and a report of nine cases. Am J Obstet Gynecol. 1949
Mar;57(3):557-62.

16. • Use of tocolytics to allow
uterine relaxation.
• Nitroglycerin (0.25-0.5 mg)
intravenously over 2 minutes.
• Terbutaline 0.1-0.25mg slowly
intravenously.
• Magnesium sulphate 4-6 g
intravenously over 20
minutes.
• Use of general anaesthesia:
halothane.

17. O’SULLIVAN HYDROSTATIC METHOD.5
• Done if initial replacement is unsuccessful
• Patient in lithotomy or Tredenleburg position.
• Run copious amounts of warmed irrigation fluid into
the vagina (by gravity or pressure) through a wide
bore giving set.
• Fluid escape is prevented by blocking the introitus by
using the labia and operator’s hand.
• The fluid distend the vagina, relieves the mild
cervical constriction and result in correction or
replacement of the inverted uterus.
• If unsuccessful, repeat or consider surgical
management.
5O’Sullivan J. Acute inversion of the uterus. Br J Obstet Gynecol 1945; 2:
282-283

18. NEW TECHNIQUE (Ogueh and Ayida)6
• A modified form of the O’Sullivan technique
• Attach the IV tubing to silicone cup used in vacuum
extraction.
• place the cup in the vagina, an excellent seal is created (as
against the assistant’s hand in O’Sullivan’s).
6 Ogueh O, Ayida G. Acute uterine inversion: a new technique of hydrostatic
replacement. Br J Obstet Gynecol 1997; 104 (8): 951-951

19. Newer techniques
Majd et al 7 and Azubuike et al 8 have separately described successes with the use
of SOS Bakri balloon catheter, and Rusch balloon catheter respectively to create
hydrostatic pressure.
• Used when the placenta is already separated
• An additional advantage is that after repositioning the uterus, the balloon will
helo to prevent re-inversion and reduce postpartum haemorrhage.
7Majd HS, Pilsniak A, Reginald PW. Recurrent uterine inversion: a novel treatment approach using SOS Baki balloon. Br J
Obstet Gynaecol 2009;116 (7) :999-1001
8Azubuike U Bolarinde O Complete uterine inversion managed with a Rusch balloon catheter J Med Cases 2010 1 (1): 8-9

20. Rusch balloon catheter

21. AFTER REPOSITIONING
• Remove the placenta manually if necessary
*** The placenta should only be removed after
repositioning of the uterus and complete
correction of the inversion to avoid shock and
torrential bleeding
• Discontinue uterine relaxant/general anaesthesia.
• Start infusion of oxytocin or ergot alkaloids
• Continue fluid and blood replacement
• Bimanual uterine compression and massage are
maintained until the uterus is well contracted and
hemorrhage is ceased.

22. After repositioning
• Antibiotics
• Adequate analgesics.
• Oxytocicsergot are continued for at least 24 hrs.
• Monitor closely after replacement to avoid re-inversion

23. MANAGEMENT OF CHRONIC
UTERINE INVERSION
Surgical intervention.
Abdominal route
Huntington’s procedure
Haultain's procedure
Vaginal route
Spinelli
Kaustner

24. • Chronic uterine inversion usually results in formation of dense constriction ring,
progressive edema and tissue necrosis, thus the uterus cannot be reverted by vaginal
manipulation.
• Surgery is usually required
Abdominal route
• Huntington’s procedure
• Haultain's procedure
Vaginal route
• Spinelli
• Kaustner

25. Surgical Management
• Depends on the
• preoperative diagnosis,
• stage of the inversion (e.g. stage 1 can afford easy repositioning
of the fundus)
• Extent of uterine necrosis
• the age of the patient
• .reproductive desire of the patient
• Skill of the attendant
• Abdo or vag hysterectomy with BSO is recommended for
benign cases if childbearing is not an issue.
• For associated malignancy, abdo hysterectomy and staging
biopsies is indicated.

26. HUNTINGTON PROCEDURE 9
• Make an abdominal incision
• Locate the cup of the uterus
formed by the inversion
• Dilate the constricting
cervical ring digitally
• Stepwise traction on the
funnel of the inverted uterus
or the round ligament is
given with Allis forceps
• Reapplied progressively as
fundus emerges
9 Huntington JL: Abdominal reposition in acute inversion of
the puerperal uterus. Am J Obstet Gynecol. 1928, 15:34-40.

27. Haultain’s Procedure 10
• Incision of the constricting cervical ring posteriorly
• traction on the round ligament for the replacement of uterus
• repair of incision per abdomen; incision closed in 2 layers.
10 Haultain FWN: The treatment of chronic uterine inversion by abdominal hysterectomy, with a successful case. Br Med J. 1901, 2:974.

28. Vaginal Route
The Spinelli’s operation
• involves dissection of the bladder from the inverted
uterus.
• A midline split is made in the cervix and it is carefully
separated from the bladder.
• The anterior wall of the everted uterus is split.
• By pressure with the operator’s index fingers and thumbs
the uterus is turned outside in.
• The myometrium is reapproximated by two layers of
running suture, and the serosal surface by a single layer.
• The vaginal skin is reapproximated with interrupted
sutures, as is the full thickness of the cervix.

29. Vaginal Route
The Kustner’s operation
• Involves opening the posterior cul-de-sac
• Incision of the cervix and posterior wall of the uterus
• thumb pressure along the sides of the uterus produce reversion
• Interrupted sutures are used to close the incisions and the uterus
replaced in the pelvic cavity.
• Closure of the colpotomy.

30. Hysterectomy
Indicated for:
• Failure of conservative surgery
• Family is completed
• sepsis

31. 31

32. 32

33. The morbidity and mortality associated with uterine inversion correlate
with
• the degree of hemorrhage,
• the rapidity of diagnosis,
• and the effectiveness of treatment.

34. Summary of Surgical modalities for non-
puerperal uterine inversion
• Vaginal removal of the tumor
• Reduction of the inversion
• + Hysterectomy (if indicated)

35. Post operatively
• Antibiotics
• Analgesics
• IV fluids
• Histopathology of the tumor is imperative
• 20% of tumors associated with non-puerperal uterine inversion
are malignant.11
11J. Mwinyoglee, N. Simelela, and Marivate M. Nonpuerperal uterine inversions. A two case
report and review of literature. Central African J Med. 1997; 43: 268-271.

36. COMPLICATIONS OF
INVERSION OF UTERUS.
Hypovolaemic shock and all its
consequence.
Vasovagal shock (due to severe pain).
Endometritis (sepsis).

37.  Infection of adnexa.
Necrosis of adnexa (ovaries) due to
compression of ovaries as they drawn
inside.
Damage to intestine / septic paralytic
ileus.
37

38. Recurrence of inversion.
Increased risk of ruptured uterus in next
pregnancy (when surgical procedure done for
inversion).
Increased risk of c-section in subsequent delivery.
Chronic pelvic pain -> if chronic inversion is not
treated.

39. DIFFERENTIAL DIAGNOSIS OF UTERINE
INVERSION
 Prolapse of uterine tumor (submucous fibroid).
 Large endometrial polyp
 Endocervical polyp
 Uterovaginal prolapse
 Cervical cancer
 Genital tears
 Passage of succenturiate lobe of placenta

40. Conclusion
Though non-puerperal uterine inversion is uncommon, the
few cases will still have to be managed without prior
experience. High index of suspicion for the diagnosis and
clear knowledge about gynaecological surgery will permit a
successful outcome.