Uterine inversion occurs when the placenta remains attached after childbirth and pulls the uterus inside out. It can cause life-threatening hemorrhage. Treatment involves manually pushing the uterus back into place, using drugs to relax the uterus, or hydrostatic correction with saline. If unsuccessful, surgical incision of the cervix or abdomen may be needed to replace the uterus. General measures like fluids, blood transfusion, and antibiotics are also used while monitoring for infection or re-inversion.
Uterine inversion occurs when the placenta remains attached after childbirth and pulls the uterus inside out. It can cause life-threatening hemorrhage. Treatment involves manually pushing the uterus back into place, using drugs to relax the uterus, or hydrostatic correction with saline. If unsuccessful, surgical incision of the cervix or abdomen may be needed to replace the uterus. General measures like fluids, blood transfusion, and antibiotics are also used while monitoring for infection or re-inversion.
Uterine inversion occurs when the placenta remains attached after childbirth and pulls the uterus inside out. It can cause life-threatening hemorrhage. Treatment involves manually pushing the uterus back into place, using drugs to relax the uterus, or hydrostatic correction with saline. If unsuccessful, surgical incision of the cervix or abdomen may be needed to replace the uterus. General measures like fluids, blood transfusion, and antibiotics are also used while monitoring for infection or re-inversion.
Uterine inversion occurs when the placenta remains attached after childbirth and pulls the uterus inside out. It can cause life-threatening hemorrhage. Treatment involves manually pushing the uterus back into place, using drugs to relax the uterus, or hydrostatic correction with saline. If unsuccessful, surgical incision of the cervix or abdomen may be needed to replace the uterus. General measures like fluids, blood transfusion, and antibiotics are also used while monitoring for infection or re-inversion.
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INVERSION
OF UTERUS
BY: NAMITA ARYA
INTRODUCTION Uterine inversion is a potentially life-threatening complication of childbirth. Normally, the placenta detaches from the uterus and exits the vagina around half an hour after the baby is delivered. DEFINITION Uterine inversion means the placenta remains attached, and its exit pulls the uterus inside-out. When the uterus turns inside out ,is called inversion of uterus. ETIOLOGY
Excessive umbilical cord traction
with a fundal attachment of placenta fundal pressure in the setting of a relaxed uterus are the 2 most common proposed aetiologies for uterine inversion. Other possible risk factors 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. CLASSIFICATION
Inversion Of Uterus is Classified in Mainly
3 Types : A. According Types B. According Degrees C. According the Timing of Event A. Types
1) Incomplete Inversion : When fundus
of uterus has turned inside out, but inverted fundus has not descended through Cx… 2) Complete Inversion : When the inverted fundus has passed completely through Cx to lie within the vagina or lie often outside the Vaginal Wall. B. Degrees
Firstdegree: The uterus is partially
turned out Second degree: The fundus has passed through the cervix but not outside the vagina Third degree: The fundus is prolapsed outside the vagina Fourth degree: The uterus, cervix and vagina are completely turned inside out and are visible UNIVERSALLY…..
First Degree : Incomplete Inversion
Second Degree : Complete inversion in the vagina Third Degree : Complete inversion outside the Vagina C. According to Timing of Event Acute : It occurs within 24 hrs of delivery. Sub-acute : It presents between 24 hrs & 4 wks of delivery. Chronic : It presents beyond 4 wks of delivery or in non pregnant stage. PATHOPHYSIOLOGY Three possible events explain the pathophysiology of acute uterine inversion: A portion of uterine wall prolapses through the dilated cervix or indents forward Relaxation of part of the uterine wall Simultaneous downward traction on the fundus leading to the uterine inversion SIGN AND SYMPTOMS
Hemorrhage (94%) Severe abdominal pain in 3rd stage Hypotension with Bradycardia: shock out of proportion to the blood loss (neurogenic due to increased vagal tone) Uterine fundus not palpable abdominally Mass in the vagina on vaginal examination. Sudden cardiovascular collapse Lump in the vagina Abdominal tenderness Absence of uterine fundus on abdominal palpation Shock :Shock is initially out of proportion with the amount of blood loss. Woman becomes sweaty with bradycardia, profound hypotension and rarely cardiac arrest. In short time there is marked hemorrhage and Hypovolemic shock. DIAGNOSIS The diagnosis of uterine inversion is based upon clinical findings: Bleeding, which may be severe and result in Hemorrhagic Shock Palpation of the prolapsed uterine fundus: Lower uterine segment = INCOMPLETE Vagina = COMPLETE By Intra Uterine Manual Examination TREATMENT Management The definite treatment consists of replacing the uterus to its original position by manual or hydrostatic manipulation. This controls the hemorrhage and restores hemodynamic instability. GENERAL MEASURES: General measures to resuscitate the patient and prepare for manual replacement must be instituted immediately. Call for help. A senior obstetrician, nurse, and anesthetist must be summoned. Stop oxytocin infusion Insert a large bore IV- cannula and begin fluid resuscitation. Draw blood for hematocrit, coagulation workup, and cross matching Start blood transfusion as soon as possible. REPLACEMENT OF THE UTERUS Replacement of the uterus by manual or hydrostatic method should be attempted first. Surgical procedures are warranted only if these fail. The part that came down last should be replaced first. The uterine fundus should go in last. If the placenta is attached to the uterus, ensure the following: It should not be separated till uterine relaxant is administered and replacement is about to begin. The placenta can also be removed manually after replacing the uterus. This reduces bleeding but makes replacement more difficult. MANUAL REPLACEMENT Immediate manual replacment should be attempted by placing a hand in the vagina with fingers around the inverted fundus and pushing the fundus toward the umbilicus along the axis of the vagina. If the cervix is felt as a constricting ring, one of the following uterine relaxant is administered: Glycerine trinitrate 0-200micro gram IV Terbutline 0.25 mg SC or IV MgSo4 4-6 g IV Inhalation anesthetic such as halothane or enflurane Once the uterus relaxes, manual replacement is performed. HYDROSTATIC METHOD ( O’ Sullivan’s method) The vagina filled with warm saline from a bag that is placed at a height above the patient. The obstetrician hand or a ventouse cup is used to close the introitus and retain the saline in vagina. The hydrostatic pressure of saline distends the vagina, and increases the circumference at the vaginal vault, and pushes the uterine fundus up. After the uterus is replaced, oxytocin (20 units in 500ml of saline ) is given as an infusion to promote uterine contraction and prevent recurrence of inversion. Surgical methods If manual and hydrostatic methods fail then one of the following surgical methods must be resorted to : ABDOMINAL APPROACH: -Huntington procedure: Traction on round ligaments. -Haultain procedure: Incision on the posterior uterine surface to cut the ring.
VAGINAL APPROACH: -Spinelli procedure : Incision of constricting cervical ring anteriorly.
-Cascarides procedure : Incision of constricting cervical ring
posteriorly. ABDOMINAL APPROACH The inverted uterus appears like a depression or cup within the constricting ring. The tubes, round ligaments and ovaries are pulled into the cup. In the huntington procedure, round ligament is held with babcock or Allis clamp and gentle traction applied to pull the fundus up. In haultain procedure, a vertical incision is made on the posterior uterine surface, the constricting ring is cut, and the uterine fundus is pulled up. VAGINAL APPROACH
The constricting ring formed by the
cervix is incised anteriorly (spinelli) or posteriorly (cascarides) to enable the uterus to be replaced . Vaginalsurgical procedures are used in chronic inversion. Treatment options vary, depending on the individual circumstances and the preferences of the hospital staff, but could include: Attempts to reinsert the uterus by hand. Administration of drugs to soften the uterus during reinsertion. Flushing the vagina with saline solution so that the water pressure ‘inflates’ the uterus and props it back into position (hydrostatic correction). Manual reinsertion of the uterus while the woman is under general anaesthetic. Abdominal surgery to reposition the uterus if all other attempts to reinsert it have failed. Antibiotics to reduce the risk of infection. Intravenous liquids. Blood transfusion. Intravenous administration of oxytocin to trigger contractions and stop the uterus from inverting again. Emergency hysterectomy (surgical removal of the uterus) in extreme cases where the risk of maternal death is high. Close monitoring in intensive care for a few days, if necessary.
