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Uterine Inversion

Uterine inversion is a rare but serious complication where the uterus turns inside out, occurring in approximately 1 in 20,000 deliveries. It can be partial or complete, and acute (within 24 hours), sub-acute (24 hours to 4 weeks), or chronic (beyond 4 weeks postpartum). Risk factors include uterine over-enlargement, prolonged labor, macrosomia, uterine malformations, morbidly adherent placenta, and iatrogenic causes during delivery. Diagnosis is based on clinical findings like hemorrhage, abdominal pain, and mass in the vagina. Treatment involves immediate resuscitation and manual repositioning of the inverted uterus, while complete inversions may require hydro

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53 views25 pages

Uterine Inversion

Uterine inversion is a rare but serious complication where the uterus turns inside out, occurring in approximately 1 in 20,000 deliveries. It can be partial or complete, and acute (within 24 hours), sub-acute (24 hours to 4 weeks), or chronic (beyond 4 weeks postpartum). Risk factors include uterine over-enlargement, prolonged labor, macrosomia, uterine malformations, morbidly adherent placenta, and iatrogenic causes during delivery. Diagnosis is based on clinical findings like hemorrhage, abdominal pain, and mass in the vagina. Treatment involves immediate resuscitation and manual repositioning of the inverted uterus, while complete inversions may require hydro

Uploaded by

Deek
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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UTERINE INVERSION

BY DR SAGARIKA
• DEFINITION
• ‘‘ When Uterus Turns Inside Out, It Is Called Uterine Inversion.”
• ‘‘Inversion of Uterus means Uterus is Turned Inside Out Partially OR Completely.
• Uterine inversion is the folding of the fundus into the uterine cavity in varying degrees
• It Occurs in Approximately 1 in 20,000 Deliveries
• This is Rare.But Potentially Life Threatening Complication of the Third Stage Of Lobour.
• CLASSIFICATION
• A. According Types
• B. According Degrees
• C. According the Timing of Event
A. Types
• 1)Incomplete Inversion : When fundus of
uterus has turned inside out, like toe of
socks, but inverted fundus has not
descended through Cx…
• 2)Complete Inversion : When the inverted
fundus has passed completely through Cx to
lie within the vagina or lie often outside the
Vaginal Wall.
B. Degrees
First degree: The uterus is partially turned out
• Second degree: The fundus has passed through
the cervix but not outside the vagina
• Third degree: The fundus is prolapsed outside
the vagina
• Fourthdegree: The uterus, cervix and vagina are
completely turned inside out and are visible
Universally….
First Degree : Incomplete Inversion
Second Degree : Complete inversion in the vagina
Third Degree : Complete inversion outside the Vagina
C. According to Timing of Event
•
Acute : It occurs within 24 hrs of
delivery.
• Sub-acute : It presents between 24 hrs
& 4 wks of delivery.
• Chronic : It presents beyond 4 wks of
delivery or in non pregnant stage.
COMMON RISK FACTORS
 UTERINE OVER ENLARGEMENT ,
 PROLONGED LABOR ,
 FETAL MACROSOMIA ,
 UTERINE MALFORMATIONS ,
 MORBID ADHERENT PLACENTA ,
 SHORT UMBLICAL CORD ,
 TOCOLYSIS ,
 AND MANUAL REMOVAL OF PLACENTA ,
 WOMEN WITH COLLAGEN DISEASE LIKE EHLER DANLOS SYNDROME TOO
CAUSES
IATROGENIC
SPONTANEOUS
Spontaneous (40%) :
• Abnormal short umbilical cord or functionally shortened by being
wrapped around the fetal body.
• Sudden rise in intra abdominal pressure due to maternal coughing or
vomiting.
• Morbid adherence of fundally implanted placenta
• Connective tissue disorder such as Marphan’s syndrome.
•Iatrogenic: Due to mismanagement of third stage of labor…

• Pulling the cord when the uterus is atonic while combined with fundal pressure
• Crede’s Expression while the uterus is relaxed
• Faulty technique in manual removal of placenta While separating retained placenta from the wall, a portion
may remain attached and as the placenta is withdrawn, the fundus is also withdrawn.
PATHOPHYSIOLOGY
• a portion of uterine wall prolapses through the dilated
cervix or indents forward

• relaxation of part of the uterine wall

• simultaneous downward traction on the fundus

• leading to inversion of the uterus.


• SIGNS AND SYMPTOMS
• Hemorrhage (94%)
• Severe abdominal pain in 3rd stage
• Hypotension with Bradycardia: shock out of proportion to the blood loss (neurogenic due to increased vagal tone)
• Uterine fundus not palpable abdominally
• Mass in the vagina on vaginal examination.
• Sudden cardiovascular collapse
• Lump in the vagina
• Abdominal tenderness
• Absence of uterine fundus on abdominal palpation
• Shock Shock is initially out of proportion with the amount of blood loss. Woman becomes sweaty with
bradycardia, profound hypotension and rarely cardiac arrest.
• In short time there is marked hemorrhage and Hypovolemic shock.
DIAGNOSIS
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
• By Intra Uterine Manual Examination
DIFFRENTIAL DIAGNOSIS
• Inversion of uterus
• Uterine rupture.
• Prolapse of uterine tumor (submucous fibroid).
• Large endometrial polyp.
• Passage of succenturiate lobe of placenta .
Resuscitate, IV access, fluids/ bolus
replacement

Immediate replacement

UTERUS
YES REPLACED NO

GA/STABILIZE
THE PATIENT
Remove placenta Oxytocic
infusion (40 units/500mls O’Sullivan hydrostatic method -
NS) Antibiotics observe Manual reduction -apply pressure to
dependent part of uterus - dependent part replace into vagina -5L
simultaneous pressing with other or more physiological solution
hand on other part which inverted deposited onto posterior fornix -
last assistant create water tight seal
Teamwork = resuscitation + uterine
repositioning simultaneously
postpartum hemorrhage drill.

The quickest way to treat neurogenic shock


- to replace the uterus.
• Management of acute inversion –
• 1. manual method called the JHONSONS METHOD- Delay in treatment increases the
mortality, simultaneously measures to treat shock including blood transfusion should be
arranged
• Before shock develops : When one is on the spot when the inversion happens TRY
IMMEDIATE MANUAL REPLACEMENT, even without anesthesia if not easily
available.

• Principle : “ The part of the uterus which has come


down last , should go back first.
• REPLACE THAT PART FIRST WHICH IS INVERTED LAST WITH PLACENTA
ATTACHED TO UTERUS BY STEADY FIRM PRESSURE EXERTED BY THE
FINGERS
• APPLY CONTINUE SUPPORT WITH THE OTHER HAND ON THE ABDOMEN
• AFTER REPLACEMENT HAND SHOULD REMAIN INSIDE TH EUTERUS UNTIL
THE UTERUS CONTRACTED BY PARENTRAL OXYTOCIN
• PLACENTA IS TOP BE REMOVED MANUALLY AFTER THE UTERUS BECOMES
CONTRACTED ( IN CASES TO REDUSCE THE BULK WGICH FACILITATES
REPLACEMENT OR TO REDUCE BLOOD LOSS IF PARTIALLY SEPERATED IT
CAN BE REMOVED BEFORE REPLACEMENT)
O’Sullivan’s hydrostatic method - IF SHOCK
DEVELOPS
Administered along with other measures such as –

urgent normal saline infusion and blood transfusion ,

Presuure exerted on fundus it gradually returns into vagina the vagin ais packed with antiseptic
roller gauze

footend elevation

If reposition fails – haultains operation is done


• Vaginal route-
• Spinellis’s method
• Kustner’s method
• Hysterectomy
Prevention
• Do not employ any method to expel the placenta when the uterus is relaxed
• Patient should not be instructed to change her position.
• Pulling the cord simultaneously with fundal pressure should be avoided
• Manual removal of placenta should be done in proper manner.
Thank you

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