Professional Documents
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233
JUNE 2014
Case Report
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
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
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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
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Fig. 1
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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.
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Surgical Management:
Practised in higher centres most commonly done
surgeries discussed here.
1.
Abdominal operations:
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