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


OUTLINE Introduction Epidemiology Classification Aetiology Presentation Investigations Management Complications Prognosis Prevention

Introduction : 

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 : 

Epidemiology Incidence varies widely Varied from 1:4,000 to 1:100,000 deliveries

Definition of some terms : 

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 : 

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

Slide 7: 

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 : 

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 : 

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

Slide 11: 

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 : 

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 : 

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.

Slide 14: 

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 : 

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 : 

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 : 

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.

Slide 18: 

Repositioning Manual reduction Sterile procedure 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? : 

What’s his business with overload?

Slide 20: 

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.

Slide 21: 

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

Slide 24: 

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 : 

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.

Slide 26: 

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

Slide 27: 

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 : 

Complication Endomyometritis Damage to intestines and uterine appendages

Prognosis : 

Prognosis Good if managed correctly

Prevention : 

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 : 

Thank you for listening

References : 

References Stuart Campbell, Christoph Lees; Obstetrics by Ten Teachers 17th Ed Allan H. DeCherney, Lauren Nathan, et al; Current Diagnosis & Treatment in Obstetrics & Gynaecology 10th 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.

Slide 36: 

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

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