It is also known as acute inversion of the uterus. It is a rare complication of the third stage of delivery. The incidence is about 1 in 2000 deliveries. It could be partially or completely turned inside out after delivery.

There is no evidence to suggest that acute uterine inversion is caused by the mismanagement of the third stage of labour.

Clinical features and diagnosis.

There is profound shock( Reduced perfusion to the peripheral areas of the body-ie a reduction in the flow of blood to the limbs and organs etc) which is out of proportion to the amount of blood loss. The vaginal tone is increased, a physiological response to acute inversion of the uterus.

The uterus may or may not protrude through the vagina. In over 90% of cases uterine inversion is associated with haemorrhage.

Degrees of Uterine Inversion

a) Inverted fundus reaches the cervical os.

b) The whole body of the uterus is inverted up to the vulva.

c) The uterus, vagina and cervix are completely inverted.

Principles of Management

The immediate resuscitation of the patient is of utmost importance, this is achieved by the treatment of hypovolemia (reduced amount of circulating blood volume).

If the inversion of the uterus occurs at the time of delivery one should try to replace the uterus back to the normal position manually with the hands immediately.

The earlier the restoration is done the more likely that it would succeed. One should not try to remove the adherent placenta without repositioning the uterus.

Once uterine inversion has occurred one should not attempt control cord traction and counter traction (Active management of labour).

The placenta should be removed manually (see the post on retained placenta and manual removal of the placenta.)

Procedure to replace immediately:

Immediate replacement of the inverted uterus via the vagina is recommended. The part which was inverted last should be replaced last, therefore the fundus must be replaced last.

Give atropine 0.6mg intravenously and diazepam 10mg iv.

After replacement of the uterus give ergometrine 0.5mg iv, then the placenta can be removed manually.

Procedure to replace the inverted uterus in the theatre:

The uterus of only about a third of patients can be repositioned without the use of uterine relaxants. This is best done under general anaesthesia using halothane (2% or higher).

Once the uterus is repositioned the attendants hand should remain in the uterine cavity until firm contraction occurs.

Once the procedure is completed, further bleeding and recurrence of inversion can be prevented by giving syntocinon infusion 20 units in 500ml of normal saline.

Procedure to replace the uterus if the inversion takes place sometimes after delivery:

O’ Sullivan’s hydration method of replacing the uterus should be tried.

In this method about 2 liters of normal saline in body temperature is instilled into the posterior fornix of the vagina (This can be done via a rubber tubing connected to a douche can or using an infusion set).

The douche can or the saline bag should be kept more than 1 meter above the patient. The escape of the fluids should be prevented by the operators hand blocking the introitus (opening of the Vagina) or by using several green armitage forceps. After the hydrostatic reduction is complete the fluid is allowed to flow out freely. The placenta can be manually removed if it is still attached.

0.5 mg of ergometrine or 10 units of oxytocin should be given after the procedure.

Reference:

O’ Sullivan JV (1945) Acute inversion of the uterus B med J 2 ,282.

Chapter 26: Obstetric Procedures by R Johanson. Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates. Sixth Edition Edited by Keith Edmonds.

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