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Indian Medical Gazette

233

JUNE 2014

Case Report

Acute Inversion of Uterus in Obstetrics


Debraj Basu, RMO cum Clinical Tutor,
Tamal Kr Mondal, Senior Resident,
Varsha Saboo, Post Graduate Trainee
Department of Obstetrics and Gynaecology, R. G. Kar Medical College and Hospital, Kolkata.

Abstract
Uterine inversion is an uncommon and unpredictable
but potentially life threatening obstetric emergency. The
typical presentation is that of severe postpartum
haemorrhage and shock along with a mass either felt in the
vagina or protruding outside the introitus. Early recognition
and prompt management (by teamwork) by simultaneous
correction of shock and repositioning of the inverted uterus
are imperative in order to minimize the potential for maternal
morbidity and mortality. There is a need for skills and drills
training because of the rarity of acute inversion. Here is a
present a case report of acute inversion of uterus following
vaginal delivery and its management. The accompanying
review of the literature provides helpful insights into the
diagnosis and optimal management of this potentially life
threatening condition.
Case Report
A 24 year old P3+0 was referred from a district hospital
following vaginal delivery as a case of retained placenta
with uterine inversion. When first seen, she had severe
pallor; peripheral pulses were not palpable and blood
pressure was not recordable. Fundal height was found to
be around 24 weeks. On per vaginal examination inversion
of uterus was found inside the vagina; placenta being
adhered to the uterus.
Immediate resuscitation was started by giving intravenous fluids, uterotonics (oxytocin and methylergometrine); blood requisition was done. Simultaneously the

patient was shifted to the operation theatre and manual


repositioning of uterus was attempted, at first without
anaesthesia and then under general anaesthesia. Due to
severe oedema of the cervical ring manual repositioning
could not be done and seeing the deteriorating
haemodynamic condition of the patient decision of
emergency laparotomy was taken.
After stabilising the patient and under proper aseptic
conditions abdomen was opened by low transverse incision.
Haultaines technique applied by giving a longitudinal incision
on the posterior wall of cervical ring (Fig. 1) and the uterus
was repositioned by giving gentle upward traction with the
help of two Allis forceps. Placenta was removed. The incision
was repaired in two layers (Fig. 2). Uterine atony along with
post-partum haemorrhage was seen. Bilateral uterine-ovarian
anastomosis (at the infundibulo pelvic ligament) were ligated
followed by bilateral internal iliac artery ligation. Five ampoules
of injection carboprost were given intramurally .After
achieving proper haemostasis and giving counts abdomen
was closed. Episiotomy wound was repaired.
Post-operative period was uneventful. She was given
two units of whole blood and one unit of fresh frozen
plasma. Uterotonics and intravenous fluids were given on
the first post-operative day whereas intra venous antibiotics
were continued for three days. Patient was discharged in
good health on Day 7.
Review of Literature
Uterine inversion is defined as the turning inside out of

Address for correspondence: Dr. Debraj Basu, C/o S. S. Das, Aparajita Apts., Flat - 06, 13/4 K. B. Sarani, Mall Road, Kolkata - 700 080.
E-mail : debrajbasu@hotmail.com

Indian Medical Gazette

234

the fundus into the uterine cavity. Acute inversion is a rare


and serious obstetric emergency. Women can sink into
profound shock which can prove fatal. Immediate
management of shock and manual repositioning of the uterus
both reduce morbidity and mortality. Baskett1 reported on
a 24 year series involving 125,081 deliveries. The incidence
was 1 in 3737 for vaginal deliveries and 1 in 1860 for
caesarean deliveries.
Aetiology
Factors associated with puerperal uterine inversion2 are
some uterine structural anomalies including connective tissue
disorders like Marfans, Ehlers-Danlos syndrome etc.,
position of placenta (fundal, placenta previa), adherent
placenta, a short umbilical cord, Fetal macrosomia, in cases
of precipitate labour, Uterine atony and most important poor
management of third stage of labour (premature cord
traction prior to placental separation).
Pathophysiology
There are three possible events that explain the
pathophysiology of acute uterine inversion3:
(a) A portion of uterine wall prolapses through the dilated
cervix or indents forward, (b) relaxation of part of the
uterine wall and (c) simultaneous downward traction on
the fundus leading to inversion of the uterus.
Classification: Uterine inversion may be classified
according to either the degree (anatomical severity) and /
or timing of the inversion.

Clinical Presentation
Symptoms include severe abdominal pain, sudden
cardiovascular collapse and post-partum haemorrhage and
ensuing shock of varying severity. Signs include a lump in
the vagina with abdominal tenderness and absence of uterine
fundus on abdominal palpation. Usually there is one
polypoidal red mass in the vagina with placenta attached.
The vast majority of cases (94%) present with haemorrhage,
with or without shock. It should be noted that, initially,
shock may be neurogenic, due to the traction effect on the
surrounding peritoneum, with signs of bradycardia and
hypotension but, with time, post-partum haemorrhage will
ensue. A high index of suspicion where shock is out of
proportion to blood loss can help in making an early diagnosis
and avoiding haemorrhage. The help of ultrasonography
can be taken to confirm the diagnosis where clinical
examination is not confirmative.
Differential diagnosis include uterovaginal prolapse,
fibroid polyp, post-partum collapse, severe uterine atony,
neurogenic collapse, coagulopathy, retained placenta without
inversion.
Management
The key to a successful outcome is teamwork,
simultaneously undertaking resuscitation and repositioning
of the uterus. The quickest way to treat neurogenic shock,
however, is to replace the uterus.
Non surgical Management
1.

Johnsons manoeuvre5: Once diagnosed the uterus


should promptly be replaced digitally to its position

A. According to the degree3:

B.

1.

First (incomplete): The inverted fundus


extends to, but not beyond the cervical os.

2.

Second (incomplete): The inverted fundus


extends through the cervical ring but remains
within the vagina.

3.

Third (complete): The inverted fundus extends


down to the introitus.

4.

Fourth (total): the vagina is also inverted.

According to the timing of the inversion4:


1.

Acute: within 24 hours of delivery.

2.

Subacute: more than 24 hours post-partum.

3.

Chronic: more than a month post-partum.

JUNE 2014

Fig. 1

Indian Medical Gazette

235

JUNE 2014

introduced into the crater on each side and gentle


upward traction is exerted on the forceps, with a
further placement of forceps on the advancing
fundus. By doing this, the uterus is pulled out of
the constriction ring and restored to its normal
position10.
B.

Haultains technique: A longitudinal incision is made


on the posterior surface of the cervical ring. This
releases the constriction pressure and facilitates
uterine replacement. The rest of the steps are
similar to Huntingdons method. Once the uterus
has been repositioned, the incision site is repaired
with interrupted sutures. Uterotonics are given to
maintain contraction of the uterus11.

Fig. 2
as delay can render replacement progressively more
difficult and increase the risk of haemorrhage. It is
pivotal that manual repositioning should be
attempted without removing the placenta, if
separation has not yet occurred. Otherwise the
patient may have torrential bleeding, which could
precipitate shock.
2.

3.

OSullivans technique or Hydrostatic


repositioning: if Johnsons technique fails, this
method is attempted. In 1945 JV OSullivan
published the first report of two cases describing
hydrostatic replacement of the uterus following
acute uterine inversion6. Before attempting this
method, uterine rupture must be excluded. The
possible complications associated with hydrostatic
methods are: infection, failure of the procedure and,
theoretically, saline embolus.
Tocolysis : Bhalla R et al, have suggested rather
than using tocolytic agents in a conscious patient,
perhaps it would be better to transfer patients to
theatre relatively early for general anaesthesia8.

Surgical Management:
Practised in higher centres most commonly done
surgeries discussed here.
1.

Abdominal operations:

A. Huntingdons operation: A crater or dimple is


identified in the region of cervix, with indrawn tubes
and round ligaments. Two Allis forceps are

C. Another technique has been described by Tews et


al. in 200112. Where the constriction ring is released
by performing an anterior hysterotomy.
2.

Trans vaginal approach: The Spinelli & Kustner


techniques are trans-vaginal approaches that involve
replacing the uterine fundus through the anterior
and posterior transections of the cervix,
respectively13,14.

Recent techniques described in the literature:


A. A case of acute inversion of the uterus being
managed successfully under laparoscopic guidance
has been reported by Vijayaraghvan et al. 15,
Consideration, however, needs to be given to the
womans haemodynamic status and the possible
effects of pneumoperitoneum.
B.

Antonelli et al.16 reported a case where laparotomy


was performed and a silastic cup used from above
for the correction of complete acute inversion of
the uterus.

C. The most recent suggestion to correct placement


and manoeuvring through the constriction
ring.uterine inversion has come from Soleymani
Majid et al17, who have employed the use of a SOS
Bakri balloon to maintain the structural integrity of
the uterine body following manual repositioning.
Conclusion
Despite the fact that uterine inversion is uncommon,

236

Indian Medical Gazette

the management of acute uterine inversion should be


incorporated into skills and drills training. This will help to
minimize the morbidity as well as the mortality if the
diagnosis is delayed or missed.

Anaesthetic management of acute puerperal uterine


inversion. Br J Anaesth. 75 : 486487, 1995.

References
1.
2.

3.

4.

Baskett T.F. Acute uterine inversion: a review of


40 cases. J. Obstet Gynaecol Can. 24 : 953956, 2002.
H. Majd, T. Nawaz, L. Ismail, R. Luker, S. Kalla.
Acute uterine inversion as a cause of major postpartum haemorrhage : a case report and review of
the literature. The Internet Journal of Gynecology and
Obstetrics. Volume 12 Number 1, 2008.
Kellog F.S. Puerperal inversion of the uterus.
Classification for treatment. Am J Obstet Gynecol.
18 : 815, 1929.
Livingston S.L., Booker C., Kramer P., Dodson W.C.
Chronic uterine inversion at 14 weeks postpartum.
Obstet Gynecol. 109:555, 2007.

5.

Johnson A.B. A new concept in replacement of


the inverted uterus and report of nine cases. Am J
Obstet Gynecol. 57 : 557562, 1949.

6.

OSullivan J. Acute inversion of the uterus BMJ.


2: 282283, 1945.

7.

Paterson-Brown S. Edmonds D.K. Obstetric


emergencies Dewhursts Textbook of Obstetrics &
Gynaecology. 7th Oxford: Blackwell Scientific
Publications pp. 153, 2007.

8.

Bhalla R., Wuntakal R., Odejinmi F., Khan R.U.


Acute inversion of the uterus. The Obstetrician &
Gynaecologist. 11:1318, 2009.

9.

Abouleish E., Ali V., Joumaa B., Lopez M., Gupta D.

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10. Huntington J.L., Irving F.C., Kellogg F.S., Mass B.


Abdominal reposition in acute inversion of the
puerperal uterus. Am J Obstet and Gynaecol. 15 :
3438, 1928.
11. Haultain F. The treatment of chronic uterine
inversion by uterine hysterotomy. BMJ. 2:974-980,
1901.
12. Tews G., Ebner T., Yaman C., Sommergruber M.,
Bohaumilitzky T. Acute puerperal inversion of the
uterus treatment by a new abdominal uterus
preserving approach. Acta Obstet Gynecol Scand.
80:1039-1040, 2001.
13. Adesiyun A.G. Septic postpartum uterine inversion.
Singapore Medical Journal. 48 (10): 943, 2007.
14. Spinelli P.G. Inversione uterina. Riv Ginec Contemp
Napoli. 17:567-570, 1897.
15. Vijayaraghavan R., Sujatha Y. Acute postpartum
uterine inversion with haemorrhagic shock:
laparoscopic reduction: a new method of management.
BJOG. 113 : 11001102, 2006. doi:10.1111/j.14710528.2006.01052.x.
16. Antonelli E., Irian O., Tolck P., Morales M.
Subacute uterine inversion: description of a novel
replacement technique using the obstetric ventouse.
BJOG. 113 : 846847, 2006. doi:10.1111/j.14710528.2006.00965.x.
17. Soleymani Majd H., Pilsniak A., Reginald P.W.
Recurrent uterine inversion:a novel treatment approach
using SOS Bakri balloon. BJOG. 2009 ; doi:10.1111/
j.1471-0528.

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