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Uterine inversion, either partial or complete, is a rare but serious obstetric complication. It usually occurs in the second stage of labour and is a life-threatening complication requiring prompt diagnosis and definitive management. It very rarely occurs in non-pregnant patients and is then usually associated with prolapsing uterine fibroids, although it can occur with other tumours.
Part of the uterus indents towards, and eventually prolapses through, the dilated cervix. It requires relaxation of the uterus to allow the initial indentation, followed by resumption of contractions in such a way that inversion ensues.
Description of the degree of inversion:
- First-degree - the inverted fundus extends to, but not through, the cervix.
- Second-degree - the inverted fundus extends through the cervix but remains within the vagina.
- Third-degree - the inverted fundus extends outside the vagina.
- Total inversion - the vagina and uterus are inverted.
Various factors have been linked to uterine inversion, although there may be no obvious cause. Identified factors include:
- Short umbilical cord.
- Excessive traction on the umbilical cord.
- Excessive fundal pressure.
- Fundal implantation of the placenta.
- Retained placenta and abnormal adherence of the placenta.
- Chronic endometritis.
- Vaginal births after previous Caesarean section.
- Rapid or long labours.
- Previous uterine inversion.
- Certain drugs such as magnesium sulphate (drugs promoting tocolysis).
- Unicornuate uterus.
It is not usually considered to be a consequence of mismanagement of the third stage of labour, despite the factors listed above. However, when the rate is high, it has been ascribed to poor management of the third stage of labour. Active management of the third stage of labour may reduce the incidence.
Uterine 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 presentation 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. Pain is extreme. The diagnosis 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 more difficult. 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. Complete inversion is accompanied by extreme cardiovascular collapse, more than might be expected from the degree of blood loss alone.
- Prolapse of a uterine tumour.
- Gestational trophoblastic disease.
- Occult genital tract disease.
- Marked uterine atony.
- Undiagnosed second twin.
The important principles are:
- Treatment should follow a logical progression.
- Hypotension and hypovolaemia require aggressive fluid and blood replacement. Steps may include:
- Calling help. This should include the most experienced anaesthetic help available.
- Securing further intravenous access with large-bore cannulae and commencing fluids. Resuscitation is usually started with crystalloid, such as normal saline or Hartmann's solution, although some people prefer colloids from the outset.
- Inserting a urinary catheter.
- Immediate uterine repositioning is essential for acute puerperal inversion. Measures may include:
- Preparing theatres for a possible laparotomy.
- Administering tocolytics to allow uterine relaxation. For example:
- Nitroglycerin (0.25-0.5 mg) intravenously over 2 minutes.
- Or terbutaline 0.1-0.25 mg slowly intravenously.
- Or magnesium sulphate 4-6 g intravenously over 20 minutes.
- Attempt prompt repositioning of the uterus. This is best done manually and quickly, as delay can render repositioning progressively more difficult. Reposition the uterus (with the placenta if still attached) by slowly and steadily pushing upwards.
- If this fails then a general anaesthetic is usually required. The uterus may then be returned by placing a fist on the fundus and gradually pushing it back manually into the pelvis through the dilated cervix.
- Maintain bimanual uterine compression and massage until the uterus is well contracted and bleeding has stopped.
- If this is unsuccessful, a surgical approach is required. Laparotomy for surgical repositioning is more usual (find and apply traction to the round ligaments) but a vaginal or even laparoscopic approach can be used.
- General anaesthetic or uterine relaxant is then stopped and replaced with oxytocin, ergometrine or prostaglandins.
- Start antibiotics and continue the stimulant for at least 24 hours. Monitor closely after repositioning, in order to avoid re-inversion.
Complications include endomyometritis, and damage to intestines or uterine appendages.
The condition carries a good prognosis if managed correctly.
Further reading & references
- Reisenauer C, Solomayer E; Images in clinical medicine. Pelvic-organ prolapse and uterine inversion. N Engl J Med. 2009 Mar 19;360(12):1238.
- Chen YL, Chen CA, Cheng WF, et al; Submucous myoma induces uterine inversion. Taiwan J Obstet Gynecol. 2006 Jun;45(2):159-61.
- Ojwang SB, Rana F, Sayed S, et al; Embryonal rhabdomyosarcoma with uterine inversion: case report. East Afr Med J. 2006 Mar;83(3):110-3.
- Cormio G, Loizzi V, Nardelli C, et al; Non-puerperal uterine inversion due to uterine sarcoma. Gynecol Obstet Invest. 2006;61(3):171-3. Epub 2006 Jan 26.
- Hussain M, Jabeen T, Liaquat N, et al; Acute puerperal uterine inversion. J Coll Physicians Surg Pak. 2004 Apr;14(4):215-7.
- Fofie CO, Baffoe P; Non-puerperal uterine inversion: a case report. Ghana Med J. 2010 Jun;44(2):79-81.
- Tsivos D, Malik F, Arambage K, et al; A life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case report. Cases J. 2009 Feb 12;2(1):138.
- Tank Parikshit D, Mayadeo Niranjan M, Nandanwar YS; Pregnancy outcome after operative correction of puerperal uterine inversion. Arch Gynecol Obstet. 2004 Mar;269(3):214-6. Epub 2002 Nov 14.
- Sangwan N, Nanda S, Singhal S, et al; Puerperal uterine inversion associated with unicornuate uterus. Arch Gynecol Obstet. 2009 Feb 6.
- Baskett TF; Acute uterine inversion: a review of 40 cases. J Obstet Gynaecol Can. 2002 Dec;24(12):953-6.
- Livingston SL, Booker C, Kramer P, et al; Chronic uterine inversion at 14 weeks postpartum. Obstet Gynecol. 2007 Feb;109(2 Pt2):555-7.
- Anderson JM, Etches D; Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82.
- Klufio CA, Amoa AB, Kariwiga G; Primary postpartum haemorrhage: causes, aetiological risk factors, prevention and management. P N G Med J. 1995 Jun;38(2):133-49.
- Pistorius LR, Hartman CR; Sonographic diagnosis of subacute puerperal uterine inversion. J Obstet Gynaecol. 1998 Sep;18(5):483.
- Momin AA, Saifi SG, Pethani NR, et al; Sonography of postpartum uterine inversion from acute to chronic stage. J Clin Ultrasound. 2009 Jan;37(1):53-6.
- Beringer RM, Patteril M; Puerperal uterine inversion and shock. Br J Anaesth. 2004 Mar;92(3):439-41.
- Abouleish E, Ali V, Joumaa B, et al; Anaesthetic management of acute puerperal uterine inversion. Br J Anaesth. 1995 Oct;75(4):486-7.
- Steigrad S; Re: A new surgical technique for dealing with uterine inversion. Aust N Z J Obstet Gynaecol. 2005 Dec;45(6):538; author reply 538.
- Shepherd LJ, Shenassa H, Singh SS; Laparoscopic management of uterine inversion. J Minim Invasive Gynecol. 2010 Mar-Apr;17(2):255-7.
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Dr Richard Draper
Dr Hayley Willacy
Dr John Cox