MANAGEMENT OF UTERINE

INVERSION
Dr Yomi Ogundapo
(MBChB Ife)
Dept of family medicine
Federal medical center ido-ekiti
Ekiti state
 OUTLINE

Introduction
Epidemiology
Classification
Aetiology
Presentation
Investigations
Management
Complications
Prognosis
Prevention
 Introduction

Prolapse of the fundus to or through the cervix so that

the uterus is in effect turned inside out.
Is a potentially life threatening complication of
childbirth.
Almost all cases occur after delivery.
But can occur even in the non-pregnant uterus in
relation to the expulsion of an intrauterine tumour.
 Epidemiology

Incidence varies widely

Varied from 1:4,000 to 1:100,000 deliveries
 Definition of some terms

Incomplete inversion describes an inverted fundus

that lies within the endometrial cavity without
extending beyond the external os.
Complete inversion describes an inverted fundus that
extends beyond the external os
A prolapsed inversion is one in which the inverted
uterine fundus extends beyond the vaginal introitus
A total inversion, usually nonpuerperal and tumor
related, results in inversion of the uterus and vaginal
wall as well.

 Classification

Based on the degree of inversion:

 1st degree-the inverted fundus extend to, but not through the
cervix
 2nd degree-the inverted fundus extend through the cervix but
remains within the vagina
 3rd degree-the inverted fundus extend outside the vagina

Incomplete- 1st
Complete-2nd & 3rd degree

Based on the time of onset:
 Acute- occurs immediately after delivery and before the cervix
constricts
 Sub-acute- once cervix constricts
 Chronic- noted >4/52 after delivery, or non-puerperal
 Aetiology

Exact cause is UNKNOWN.

Principle behind its occurrence:
 Cervix must be dilated
 Uterine fundus must be relaxed

Many cases of acute uterine inversion results from

mismanagement of third stage of labour in women
who already are at risk.
 Risk factors

Strong traction exerted on the umbilical cord

Short umbilical cord
Strong fundal pressure
Rapid emptying of uterus
Fundal implantation of the placenta
Abnormal adherence of the placenta(e.g placenta
accreata)
Previous uterine inversion
Vaginal birth after previous caeserean section
Protracted labour
Certain drugs such as magnesium sulphate
Tumors- submucuos myomas
Cervical incompetence
Uterine anomalies(e.g unicornuate uterus)
Congenital or acquired weakness of the myometrium
Chronic endometritis

 Presentation

Uterine inversion may present:

 Acutely - within 24 hours of delivery
 Sub-acutely - 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 post-

partum haemorrhage. The classic presentation is of:
 Post-partum haemorrhage
 Sudden appearance of a vaginal mass
 Cardiovascular collapse (varying degrees)

 Presentation

Symptoms
 Pain in the lower abdomen
 Sensation of vaginal fullness: with a desire to bear down after
delivery of the placenta
 Vaginal bleeding: unless the placenta is not separated

Signs
 General examination
 Shock: out of proportion to blood loss. More neurogenic due to
traction on the peritoneum & press. On the tubes , ovaries, &
maybe, the intestine. Parasympathetic effect of traction on
the ligaments supporting d uterus & maybe associated with
bradycardia.

  Abdominal examination
 Cupping of the fundus-1st &2nd degree
 Absence of the uterus-3rd degree
 Vaginal examination
 Soft purple(dark bluish-red) mass in the vagina or vulva
 NOTE:
 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.
 Investigations

Diagnosis is usually based on clinical symptoms and signs.

If not clinically very obvious, imaging is useful if patient is
clinically stable to undergo such evaluation; USS & MRI
 USS:
 Transverse image- a hypoechoic mass in the vagina with a central
hypoechoic H-shaped cavity.
 Longitudinal- U-shaped depressed longitudinal groove from the
uterine fundus to the centre of the inverted part
 MRI-
 Findings are more conspicuous
Ancillary investigations: FBC, GXM
 Management

Has 2 important components:

 Immediate treatment of Shock
 Replacement/Repositioning of the uterus

The important principles is that:

 Treatment should follow a logical progression.
 Acute and Subacute

Hypotension and hypovolaemia require aggressive fluid

and blood replacement. Steps may include:
 Get help. This should include the most experienced anaesthetic help
available.
 PCV & GXM
 Secure further intravenous access with large bore cannulae and
commence fluids. Resuscitation is usually started with crystalloid
such as normal saline or Hartmann's solution although some
people prefer colloids from the outset.
 Blood transfusion
 Analgesics
 Use warm sterile towel to apply compression while preparing for the
procedure
 Insert a urinary catheter.



Repositioning
 Manual reduction
 Sterileprocedure
 Form a fist or grad the uterus and push it through the cervix of a
lax uterus towards the umbilicus to its normal position. Use the
other hand to support the uterus.(Johnson maneuver)
 Use of 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
 Use of general anaesthesia: halothane
 Reduction by hydrostatic pressure
 O’Sullivan
hydrostatic method
 New technique
What’s his business with overload?
O’Sullivan hydrostatic method
 Materials needed:
 An assistant
 Long tube(2m) with a large nozzle
 Water reservoir/Warm Saline(2-5L)
 Put patient in trendelenburg position
 Place the nozzle of the tube in the posterior fornix
 An assistant start the douche with full pressure(at least 2m high)
 Fluid escape is prevented by blocking the introitus by using the labia
& operator’s hand
 The fluid distend the vagina, relieves the mild cervical constriction
& result in correction or replacement of the inverted uterus.
New technique
 Described by Ogueh & Ayida
 Citing difficulty in maintaining an adequate water seal to
generate the pressure required, they suggest attaching the
IV tubing to silicone cup used in vacuum extraction. By
placing the cup in the vagina, an excellent seal is created.
 NOTE:

Nitroglycerine is preferred:
 Quicker onset of uterine relaxation
 Quicker dissipation of the effect, obviating the need for
referral
 Less effect on hemodynamic than mgso4
After repositioning:
 Discontinue uterine relaxant/general anaesthesia
 Start infusion of oxytocin or ergot alkaloids
 Continue fluid and blood replacement
 Bimanual uterine compression and massage are maintained until
the uterus is well contracted and hemorrhage is ceased
 Remove placenta if retained following replacement of the
inverted uterus and oxytocics given with uterus contracted
 Careful manual exploration to rule out the possibility of genital
tract trauma
 Antibiotics- broad spectrum
 Adequate analgesics
 Oxytocics/ergot are continued for at least 24hrs.
 Monitor closely after replacement to avoid re-inversion.

 Chronic uterine inversion

 Involve surgical replacement/intervention

 2 approach:
 Abdominal
 Vaginal

 Abdominal
 Huntington’s procedure
 Haultaim’s procedure

 Vaginal
 Spinelli’s method
 Kustner’s method

 Hysterectomy: if present late with ischaemic changes of the

uterus or non-viable uterine tissues, removal of the uterus is
performed following replacement of normal anatomy.
Huntington procedure
 Locate the cup of the uterus formed by the inversion
 Dilate the constricting cervical ring digitally
 Place clamps in the cup of the inversion below the cervical
ring and gentle upward traction is applied
 Repeated clamping and traction continue until the inversion is
corrected.
Haultaim procedure
 Incision is made in the posterior portion of the inversion ring,
to increase the size of the ring and allow repositioning of the
uterus
 Further steps as in huntington procedure
Spinelli’s method
 Ant. Culpotomy is done & incision of the cervix extending into
the fundus is made before manually correcting the incision
Kustner’s method
 Post. Culpotomy is made & incison of the cervix similar to that
of Spinelli’s method
 Complication

Endomyometritis
Damage to intestines and uterine appendages

 Prognosis

Good if managed correctly

 Prevention

Many cases of acute uterine inversion result from

mismanagement of the third stage of labour in
women who are already at risk. Hence the following
maneuvers are to be avoided:
 Excessive traction on the umbilical cord
 Excessive fundal pressure
 Excessive intra-abdominal pressure
 Excessively vigorous manual removal of placenta
Thank you for listening
 References
 Stuart Campbell, Christoph Lees; Obstetrics by Ten Teachers 17th Ed
 Allan H. DeCherney
, Lauren Nathan, et al; Current Diagnosis & Treatment in Obstetrics & Gynaeco
th Ed

 D.Keith Edmunds; Dewhurst’s Textbook of Obstetrics & Gynaecology 7th Ed

 Hussain M, Jabeen T, Liaquat N, et al; Acute puerperal uterine inversion. J
Coll Physicians Surg Pak. 2004 Apr;14(4):215-7.
 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.
 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
 Ogueh O, Ayida G. Acute uterine inversion: a new technique of hydrostatic
replacement. Br J Obstet Gynaecol 1997;104:951-2
