MANAGEMENT OF UTERINE INVERSION : Dr Yomi Ogundapo
Dept of family medicine
Federal medical center ido-ekiti
Ekiti state MANAGEMENT OF UTERINE INVERSION OUTLINE : OUTLINE Introduction
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
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
Certain drugs such as magnesium sulphate
Tumors- submucuos myomas
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:
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
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
Soft purple(dark bluish-red) mass in the vagina or vulva
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
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
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.
Use warm sterile towel to apply compression while preparing for the procedure
Insert a urinary catheter. Slide 18: Repositioning
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
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.
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
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
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.
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
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
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