DR YOMI OGUNDAPO(MBCHB IFE)

DEPT OF FAMILY MEDICINEFEDERAL MEDICAL CENTER IDO -EKITI

EKITI STATE

MANAGEMENT OF UTERINE INVERSION

OUTLINE

Introduction Epidemiology Classification Aetiology Presentation Investigations Management Complications Prognosis Prevention

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

Incidence varies widelyVaried from 1:4,000 to 1:100,000 deliveries

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

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

vaginaIncomplete- 1st Complete-2nd & 3rd degree

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

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

Strong traction exerted on the umbilical cordShort umbilical cordStrong fundal pressureRapid emptying of uterusFundal implantation of the placentaAbnormal adherence of the placenta(e.g

placenta accreata)Previous uterine inversion

Vaginal birth after previous caeserean sectionProtracted labourCertain drugs such as magnesium sulphateTumors- submucuos myomasCervical incompetenceUterine anomalies(e.g unicornuate uterus)Congenital or acquired weakness of the

myometrium Chronic endometritis

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

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.

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

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

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

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.

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?

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.

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

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

Involve surgical replacement/intervention2 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.

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

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

Endomyometritis Damage to intestines and uterine appendages

Prognosis

Good if managed correctly

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

References

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, Lauren Nathan, et al; Current Diagnosis & Treatment in Obstetrics & Gynaecology 10th Ed

D.Keith Edmunds; Dewhurst’s Textbook of Obstetrics & Gynaecology 7th

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Ogueh O, Ayida G. Acute uterine inversion: a new technique of hydrostatic replacement. Br J Obstet Gynaecol 1997;104:951-2