Uterine inversion

  • Overview/procedure description

    The characteristic presentation is a partial delivery of the placenta followed by profound maternal hypotension (shock which is out of proportion to any apparent blood loss). Uterine inversion is usually associated with a fundally implanted placenta and is often misdiagnosed as an aborted myoma or a partially delivered placenta. The greatest risk group is multigravidae with a fundally implanted placenta. The risk is 1/2000 deliveries.

    Related Policy

    Nil

    Definition of Terms

    Procedure details

    Classification

    First degree           The fundus is inverted but is not below the cervix.

    Second degree      The inverted fundus is through the cervix and in the vagina.

    Third degree         The inverted fundus outside the vagina to the perineum.

    Total                      The inverted uterus and vagina appear outside the perineum.

    Management

    Immediate management

    1.       Attempt to replace the uterus by manually pushing the inverted fundus cephalad through the cervix and keeping the hand in the uterus while giving oxytocin until it contracts.

    2.       If the immediate replacement is not possible, relax the uterus with glycerol trinitrate (600mcg) or terbutaline (250mcg) and then, again attempt to replace the uterus.

    3.       An alternative method of dealing with uterine inversion is hydrostatic replacement. Set up four drip sets with warm saline, place the open ends of the tubing into the vagina in the palm of an examining hand, and pack a towel(s) around the examining wrist to "seal" the vaginal introitus. The hydrostatic pressure of the fluid distends the vagina and cervix.

    Surgical management

    1.       Combined procedure of manual or hydrostatic replacement and at laparotomy pulling on the round ligaments.

    2.       If this is unsuccessful because of contraction of the lower uterine segment, the lower uterine contraction ring is cut (Ocejo-anterior incision) or (Hautrain-posterior incision).

    Reference

    • Alama V Jr., Meyer BA. Peripartum Haemorrhage. Obstetrics and Gynaecology Clinics of North America 1999; 26: 385-98.
    • Bonnar J. Massive Obstetric Haemorrhage. Balliere's Clinical Obstetrics & Gynaecology 2000; 14:1:1-18.
    • Gilstrap LC, Rarin SM. Post Partum Haemorrhage. Clinical Obstetrics & Gynaecology 1994; 37: 824-30.

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