Uterine Inversion


Article Author:
Monika Thakur


Article Editor:
Angesh Thakur


Editors In Chief:
Tod Aeby


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
6/4/2019 5:01:25 PM

Introduction

Uterine inversion is one of the most serious complications of childbirth. Uterine inversion refers to the collapse of the fundus into the uterine cavity. Although it does not often occur, it carries a high risk of mortality due to hemorrhage and shock.[1]

Etiology

Excessive umbilical cord traction with a fundal attachment of placenta and fundal pressure in the setting of a relaxed uterus are the 2 most common proposed aetiologies for uterine inversion.

Other possible risk factors for uterine inversion include rapid labor, invasive placentation, manual removal of placenta, short umbilical cord, use of uterine-relaxing agents, uterine overdistension, fetal macrosomia, nulliparity, placenta previa, connective tissue disorders (Marfan syndrome and Ehlers-Danlos syndrome), and history of uterine inversion in the previous pregnancy. However, in the majority of cases, no risk factors are identified, thus making this condition unpredictable.[2][3][4]

Degrees of Uterine Inversion

  • Incomplete: Fundus inverts but does not herniate through the level of the internal os
  • Complete: The internal lining of the fundus crosses through the cervical os with no palpable fundus abdominally
  • Prolapsed: Entire uterus prolapsing through the cervix with the fundus passing out of the introitus

Classification

  • Acute: Twenty-four hours or less after delivery
  • Subacute Longer than 24 hours postpartum)
  • Chronic: Longer than 1 month postpartum[1][5]

Epidemiology

Uterine inversion is a rare event, complicating about 1 in 2000 to 1 in 23,000 deliveries. Ironically, most are seen with “low-risk” deliveries. The incidence is 3-times higher in India as compared to the United States. The incidence of uterine inversion has decreased 4-fold after the introduction of active management during the third stage.

Pathophysiology

Three possible events explain the pathophysiology of acute uterine inversion:

  1. A portion of uterine wall prolapses through the dilated cervix or indents forward
  2. Relaxation of part of the uterine wall
  3. Simultaneous downward traction on the fundus leading to the uterine inversion

History and Physical

Uterine inversion is a clinical diagnosis and should be suspected when fundus is not palpable abdominally along with the sudden onset of brisk vaginal bleeding, which leads to hemodynamic instability in the mother. Traditionally, the shock has been considered disproportionate to blood loss, which is possibly mediated by parasympathetic stimulation caused by stretching of tissues. However, careful evaluation of the need for the blood transfusion should be made because blood loss is massive and is greatly underestimated. The other symptoms are mainly severe lower abdominal pain with a strong bearing down sensation, though most women may not be able to complain due to severe shock. It may occur before or after placental detachment.[1][6]

Evaluation

The diagnosis is often made clinically with a bimanual examination, during which the uterine fundus is palpated in the lower uterine segment or within the vagina. If a clinical examination is equivocal, then ultrasound can be used to confirm the diagnosis.[7][1][8]

Treatment / Management

Once the diagnosis of uterine inversion is made, immediate intervention to control hemorrhage and restore hemodynamic stability in the mother is required because a delay will lead to an increase in the mortality rate appreciably. The following actions should be taken urgently and simultaneously:

  • Call for help and call for an anesthesiologist immediately.
  • Hemodynamic stability is achieved by a large bore cannula and crystalloid and blood are given to combat hypovolemia.
  • The recent uterine inversion with placenta already separated from it may often be replaced by manually pushing up on the fundus with the palm and fingers in the direction of long axis of the vagina. A delay will render replacement more difficult and also increase the risk of hemorrhage.
  • If the placenta is still attached, it is usually not removed until fluids are given, and uterine-relaxing anesthetics, for example, a halogenated inhalation agent, have been administered. Other tocolytic agents such as magnesium sulfate or beta-mimetic and nitroglycerine have been used successfully for uterine relaxation and repositioning. Any portion of inverted uterus prolapsed beyond the vagina is replaced within the vagina.
  • After the placenta is removed, steady pressure with the fist is applied to the inverted fundus in an attempt to push it up into the dilated cervix. Alternatively, 2 fingers can be extended rigidly to push the center of the fundus upward. Undue force is not applied to avoid perforation of the uterus with the fingertips. This is followed by administration of uterotonic agents which help uterine contraction, thereby preventing recurrence of the inversion.

An appropriate antibiotic is administered to prevent infection.

If manual repositioning is unsuccessful due to dense constriction ring, other options include hydrostatic reduction and surgical correction.

Hydrostatic reduction: If manual reduction alone is not successful, simple hydrostatic pressure may be of great assistance in pushing the fundus back to its normal anatomical position. Warmed sterile saline is infused into the vagina, and physician’s hand or a silicone ventouse cup is used as a fluid retainer to generate intravaginal hydrostatic pressure and resultant correction of the inversion. The bag of fluid should be elevated about 100 to 150 cm above the vagina to guarantee sufficient pressure for insufflation. It is also effective at preventing blood loss and inhibiting the uterus from inverting again. The possible complications associated with the procedure include infection, failure of the procedure, and saline embolus.

Surgical options include Huntington and Haultain procedures, laparoscopic-assisted repositioning, and cervical incisions with manual uterine repositioning. Huntington procedure involves laparotomy with pulling on the round ligaments gradually to restore the uterus to its proper position. In case the cervical ring is very tight, repositioning may be more easily achieved by incising the ring posteriorly with a vertical incision along with manual pushing of the fundus. As with manual repositioning, after replacement of the fundus, the anesthetic agent used to relax the myometrium is stopped and uterotonic therapy is administered immediately followed by repair of uterine incision. If these procedures are performed then pregnancies in the future will require a cesarean delivery.

If the placenta is not separated from the uterus then a hysterectomy may be necessary.

Differential Diagnosis

The conditions that cause a lump in the vagina and leads to postpartum collapse need to be excluded. These include:

  • Severe atony of uterus
  • Uterovaginal prolapse
  • Fibroid polyp
  • Neurogenic collapse
  • Postpartum collapse
  • Retained placenta without inversion
  • Coagulopathy

Enhancing Healthcare Team Outcomes

Uterine inversion is a true obstetric emergency that requires immediate treatment if the patient's life is to be saved. The condition is best managed by a multidisciplinary team including ICU nurses. The patient needs immediate resuscitation, patent airway, blood transfusion and either manual or surgical management.

The outcomes for most patients are guarded.[9][10]


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Uterine Inversion - Questions

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Uterine Inversion - References

References

Wendel MP,Shnaekel KL,Magann EF, Uterine Inversion: A Review of a Life-Threatening Obstetrical Emergency. Obstetrical     [PubMed]
Eddaoudi C,Grohs MA,Filali A, [Uterine inversion: about a case]. The Pan African medical journal. 2018     [PubMed]
Mishra S, Chronic Uterine Inversion Following Mid-Trimester Abortion. Journal of obstetrics and gynaecology of India. 2018 Aug     [PubMed]
Free L,Ruhotina M,Napoe GS,Beffa L,Wohlrab K, Uterine Inversion Presenting as Pelvic Organ Prolapse in a Patient with Leiomyosarcoma. Journal of minimally invasive gynecology. 2019 Mar 26;     [PubMed]
Vieira GTB,Santos GHND,Silva Júnior JBN,Sevinhago R,Vieira MIB,Souza ACS, Non-puerperal uterine inversion associated with myomatosis. Revista da Associacao Medica Brasileira (1992). 2019 Feb;     [PubMed]
Girish B,Davis AA, Chronic uterine inversion with malignancy mimicking carcinoma cervix. BMJ case reports. 2019 Feb 1;     [PubMed]
Zohav E,Anteby EY,Grin L, U-turn of uterine arteries: a novel sign pathognomonic of uterine inversion. Journal of ultrasound. 2018 Oct 3;     [PubMed]
Della Corte L,Giampaolino P,Fabozzi A,Di Spiezio Sardo A,Bifulco G, An exceptional uterine inversion in a virgo patient affected by submucosal leiomyoma: Case report and review of the literature. The journal of obstetrics and gynaecology research. 2019 Feb;     [PubMed]
Coad SL,Dahlgren LS,Hutcheon JA, Risks and consequences of puerperal uterine inversion in the United States, 2004 through 2013. American journal of obstetrics and gynecology. 2017 Sep;     [PubMed]
Oladapo OT,Akinola OI,Fawole AO,Adeyemi AS,Adegbola O,Loto OM,Fabamwo AO,Alao MO,Sotunsa JO, Active management of third stage of labor: evidence versus practice. Acta obstetricia et gynecologica Scandinavica. 2009;     [PubMed]

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