Uterine Inversion (Postpartum)

Published on 31/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2656 times

Chapter 225 Uterine Inversion (Postpartum)

INTRODUCTION

Description: Uterine inversion is the turning inside-out of the uterus immediately after delivery. Uncommon and often iatrogenic, this may be associated with catastrophic bleeding and cardiovascular collapse. (Rarely the condition has also been reported in nonpregnant patients with intrauterine pathology.)
Prevalence: One of 25,000 deliveries.
Predominant Age: Reproductive.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Iatrogenic (traction on the umbilical cord or downward pressure on the uterine fundus to facilitate delivery of the placenta); abnormalities of placentation (accreta, increta, percreta).
Risk factors: Uterine atony: multiparity (grand), uterine overdistention (multiple birth, polyhydramnios), prolonged labor, prolonged oxytocin stimulation, muscle-relaxant agents (MgSO4), rapid labor.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• A mass may be seen attached to or directly following the placenta as it delivers
• Bright-red vaginal bleeding
• Bradycardia from vagal stimulation
• Tachycardia, hypotension, and vascular collapse possible as a result of blood loss

DIAGNOSTIC APPROACH

Differential Diagnosis

• Uterine atony
• Retained placental fragments
• Genital tract lacerations
• Coagulopathy

Associated Conditions: Uterine atony, postpartum hemorrhage.

Workup and Evaluation

Laboratory: Hemoglobin or hematocrit to monitor status and volume of blood loss. (Acute loss may not be reflected by these measures until equilibration has occurred in 6 to 24 hours.)
Imaging: Ultrasonography may be used to verify the diagnosis, but this is unnecessary and delays the implementation of therapy.
Special Tests: None indicated.
Diagnostic Procedures: Pelvic examination.

Pathologic Findings

Inversion of the uterus.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Rapid evaluation, fluid support or resuscitation, call for anesthesia assistance.
Specific Measures: Uterine-relaxant agents (see later), manual replacement of uterine fundus (may require general anesthesia with a relaxant agent [Halothane]), may require operative intervention (replacement or hysterectomy). Once the uterine wall has relaxed, gentle manual pressure should be placed on the fundus to displace it inward and upward until its normal position can be restored and the uterus returned to its normal configuration. Uterotonic agents are then used to obtain uterine contraction and hemostasis.
Diet: Nothing by mouth until a diagnosis is established and effective treatment is rendered.
Activity: Bed rest until a diagnosis is established and effective treatment is rendered.

Drug(s) of Choice

Tocolytics: Terbutaline 0.25 mg IV (may repeat once) or nitroglycerine 100 to 250 μg IV (may repeat to a total of 1000 μg).
Contraindications: See individual agents.
Precautions: If nitroglycerine is used, blood pressure must be monitored closely (hypotension).

Alternative Drugs

Halothane general anesthesia may be required.

FOLLOW-UP

Patient Monitoring: Normal postpartum care, follow-up complete blood count as needed.
Prevention/Avoidance: Little or no traction on the umbilical cord or fundal pressure during the delivery of the placenta.
Possible Complications: Hysterectomy, hemorrhagic shock, and cardiovascular collapse.
Expected Outcome: Generally good if recognized and acted on promptly.

MISCELLANEOUS

Other Notes: Following replacement of the fundus, the possibility of uterine atony must be anticipated. If the placenta is still attached to the uterine wall, it should be left in place until after the uterine fundus has been reduced and returned to its normal location.
ICD-9-CM Code: 665.2.

image

REFERENCES

Level II

Baskett TF. Acute uterine inversion: a review of 40 cases. J Obstet Gynaecol Can. 2002;24:953.

Joshi VM, Otiv SR, Majumder R, et al. Internal iliac artery ligation for arresting postpartum haemorrhage. BJOG. 2007;114:356. Epub 2007 Jan 22

Lupovitch A, England ER, Chen R. Non-puerperal uterine inversion in association with uterine sarcoma: case report in a 26-year-old and review of the literature. Gynecol Oncol. 2005;97:938.

Level III

American College of Obstetricians and Gynecologists. Postpartum hemorrhage. ACOG Practice Bulletin 76. Obstet Gynecol. 2006;108:1039.

Brar HS, Greenspoon JS, Platt LD, Paul RH. Acute puerperal uterine inversion. New approaches to management. J Reprod Med. 1989;34:173.

Dufour P, Vinatier D, Puech F. The use of intravenous nitroglycerin for cervico-uterine relaxation: a review of the literature. Arch Gynecol Obstet. 1997;261:1.

Gowri V. Uterine inversion and corpus malignancies: a historical review. Obstet Gynecol Surv. 2000;55:703.

Hostetler DR, Bosworth MF. Uterine inversion: a life-threatening obstetric emergency. J Am Board Fam Pract. 2000;13:120.

Kovacs BW, DeVore GR. Management of acute and subacute puerperal uterine inversion with terbutaline sulfate. Am J Obstet Gynecol. 1984;150:784.

Platt LD, Druzin ML. Acute puerperal inversion of the uterus. Am J Obstet Gynecol. 1981;141:187.

Shah-Hosseini R, Evrard JR. Puerperal uterine inversion. Obstet Gynecol. 1989;73:567.

Tank Parikshit D, Mayadeo Niranjan M, Nandanwar YS. Pregnancy outcome after operative correction of puerperal uterine inversion. Arch Gynecol Obstet. 2004;269:214. Epub 2002 Nov 14

Thiery M, Delbeke L. Acute puerperal uterine inversion: two-step management with a β-mimetic and a prostaglandin. Am J Obstet Gynecol. 1985;153:891.

Watson P, Besch N, Bowes WAJr. Management of acute and subacute inversion of the uterus. Obstet Gynecol. 1980;55:12.

Wendel PJ, Cox SM. Emergent obstetric management of uterine inversion. Obstet Gynecol Clin North Am. 1995;22:261.

You WB, Zahn CM. Postpartum hemorrhage: abnormally adherent placenta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol. 2006;49:184.

Related posts:

Cervical Incompetence Forceps-Aided Delivery Anorectal Fistula Vaginitis: Bacterial (Nonspecific) and Bacterial Vaginosis Pre-Eclampsia and Eclampsia (Toxemia of Pregnancy) Breast: Galactocele