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]
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
Classification
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.
Three possible events explain the pathophysiology of acute uterine inversion:
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]
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:
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.
The conditions that cause a lump in the vagina and leads to postpartum collapse need to be excluded. These include:
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 an interprofessional team including ICU nurses. The patient needs immediate resuscitation, patent airway, blood transfusion and either manual or surgical management.
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