Uterine inversion is a life-threatening obstetric emergency that requires immediate treatment to prevent hemorrhagic shock and death. The diagnosis is based on clinical findings of bleeding and palpation of the inverted uterus. The first steps in treatment are to stop oxytocin, establish IVs, and manually replace the inverted uterus. If manual replacement fails, intravenous nitroglycerin can be used to relax the uterus and allow replacement, with doses up to 1000 micrograms. Surgery may be required if inversion persists after attempts at uterine relaxation and manual replacement.

1. Life-Threatening Obstetrical Emergency May 2010

3. Risk Factors & Incidence Cord traction &/or fundal pressure Uterine anomalies Short umbilical cord Placenta Accreta Grand Multiparity Fetal macrosomia Rapid labor and delivery Incidence 1/2000

4. DIAGNOSIS INTRA-UTERINE MANUAL EXPLORATION The diagnosis of uterine inversion is based upon clinical findings: Bleeding , which may be severe and result in Hemorrhagic Shock Palpation of the prolapsed uterine fundus : Lower uterine segment = INCOMPLETE Vagina = COMPLETE Beyond the perineum = PROLAPSED

5. STAT SIMULTANEOUS TREATMENT The more time that elapses the more difficult it is to replace the fundus resulting in a greater risk for Hemorrhagic shock & Death Stop Pitocin Immediately Do Not Remove the Placenta HELP ---Hem Cart , Anesthesia, 3 RN’s , Another Ob Establish 2 IV’s and give 2 liters crystalloid as fast as possible or until the fundus is replaced Call for: 2 units O neg/ H & H/T & X/Coags/OR set up Manually replace the uterine fundus/SQ Brethine

6. TREATMENT If the initial attempt at manual uterine replacement is unsuccessful administer IV NITROGLYCERIN to relax the uterus and reattempt manual replacement of the fundus Nitroglycerin is highly effective and has a short duration of action Initial 100 micrograms IV Bolus Followed by up to three additional doses keeping the total </= to 1000 mcg Obstet Gynecol Surv 1998 Sep;53(9):559

7. NITROGLYCERIN IV Dosing 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 IV NTG has rapid onset (<1 minute) and short duration of action (minutes) Hypotension as a side effect from IV nitroglycerin is preventable with aggressive fluid resuscitation If necessary nitroglycerin related hypotension can be reversed or preempted with IV ephedrine 5-10 mg or IV Phenylephrine 100 mcg Headache and reflex tachycardia are also important side effects.

8. LESS EFFECTIVE Options for Uterine Relaxation. Magnesium sulfate ( 6 grams IV over 15 minutes) Terbutaline (0.25 Mg IV or SQ) Both have relatively mild effects on the myometrium and MgSo4 has a slow onset of action

9. FAILURE OF UTERINE RELAXATION A persistent contraction ring in the lower uterine segment may prevent manual replacement of the fundus. Surgery may be required if manual replacement fails after administering Nitroglycerin /Brethine /or MgSo4 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 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

10. SURGICAL REPLACEMENT Huntington procedure 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. A second operator with a hand in the vagina can apply upward pressure on the fundus to facilitate the procedure 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. The posterior lower uterine segment can be incised to avoid iatrogenic cystotomy.

11. MAINTAIN UTERINE POSITION UTERINE ATONY /REINVERSION IS COMMON AFTER REPLACEMENT Cytotec 600-800 micrograms PR Methergine 0.2 IM and Pitocin 40 units/liter Hemabate added if persistent atony Continue Cytotec 200 po Q 6 for 24 hours Or Continue Methergine 0.2 mg po Q 6 for 24 hours IV ANTIBIOTIC PROPHYLAXIS

12. NTG References Am J Obstet Gynecol 1992;166:1237 Intravenous nitroglycerin for uterine relaxation of an inverted uterus. Anesth Analg. 1996 May;82(5):1091 The use of small-dose intravenous nitroglycerin in a case of uterine inversion Obstet Gynecol Surv 1998 Sep;53(9):559 Use of Nitroglycerin for uterine relaxation Analg 1996;82:1091 The use of small-dose intravenous nitroglycerin in a case of uterine inversion. Anesthesiology 1996;85:683 Nitroglycerin and uterine relaxation. J Clin Anesth 1992;4:487 Intravenous nitroglycerin for uterine inversion.