Postpartum Hemorrhage - Vouchaogm.org.mo/assets/Uploads/aogm/PPH-Files/PPH-Chap-09.pdf · ACUTE UTERINE INVERSION Acute uterine inversion, defined as when the uterus is turned inside

9OBSTETRIC TRAUMA

D. G. Evans and C. B-Lynch

ACUTE UTERINE INVERSION

Acute uterine inversion, defined as when theuterus is turned inside out, is a rare but seriouscomplication of the third stage of labor. Theestimated incidence is approximately 1 in20–25 000 deliveries1–3. As the estimate of alater report was < 1 : 20004, the true incidenceis unclear because some of the milder formscorrect themselves spontaneously and are thusnot recognized or reported.

Classification

Uterine inversion may be complete or incom-plete, depending on whether the fundus haspassed through the cervix5. When the uterineinversion occurs within the first 24 h post-delivery, it is classified as acute. Inversionoccurring after the first 24 h and up to 4 weekspostpartum is classified as sub-acute, and therare chronic inversion occurs after the 4th weekpostpartum.

Etiology

The expulsion of the placenta was probablyintended by Nature to occur as a result ofgravitational forces, with the mother in thesame squatting position that is often adopted fordefecation. When the third stage is conducted inthe dorsal position, however, help may be nec-essary for placental expulsion. Accordingly, theinappropriate management of the third stage oflabor is often implicated in the etiology of acuteuterine inversion. Indeed, Crede’s method ofplacental delivery with uncontrolled cord trac-tion, referred to in most textbooks of midwiferyand older textbooks of obstetrics, may indeedincrease the risk of acute uterine inversion. The

firmly contracted uterus is used as a piston topush the placenta out, in the same manner thata piston is used to push fluid out of the barrel ofa syringe. Pressure is applied with the palm ofthe hand in the axis of the pelvic inlet, in adownward and backward direction with the aimof forcing the placenta out through the lowergenital tract. Unfortunately, application ofCrede’s maneuver when the uterus is not con-tracted may well facilitate acute inversion. Onthe other hand, the Brandt Andrews maneuver,also mentioned in standard textbooks of mid-wifery and obstetrics, a modification of Aris-totle’s method of delivering the placenta by cordtraction, recommends applying tension, but nottraction, to the umbilical cord with one hand,whilst the other hand is placed on the abdomengently moving the uterus upwards and back-wards. Today, controlled cord traction isstandard practice for the third stage of labor.

Other etiological factors include forciblyattempting to expel the placenta by using fundalpressure when the uterus is atonic, and tractionon the umbilical cord in a fundally placedplacenta when the uterus is relaxed. It may alsobe brought about by a local atony, more particu-larly of the fundal placental site together withactive contractions of the rest of the uterus.Other etiological factors include macrosomia,polyhydramnios, multiple pregnancy, primiparityand oxytocin administration5. In other instances,however, the inversion occurs spontaneouslyfrom sudden increased abdominal pressure as aresult of coughing, sneezing or straining.

Chronic inversion may result from an acuteinversion left unrecognized or from a sub-mucous fibroid which has prolapsed throughthe cervix. A placental polyp resulting from aretained cotyledon of the placenta may presentin the same fashion.

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Diagnosis

Symptoms are acute and pronounced. Gener-ally, the mother is aware of something comingdown and this is usually quickly followed byunanticipated profound shock. The uterus mayappear at the introitus outside the vagina andthe fundus is no longer palpable abdominally.In partial inversion, the fundus of the uterusmay be indented and may or may not passthrough the cervical os. In such instances, it isneither palpable abdominally nor visible at thevulva. Vaginal examination detects the invertedbody of the uterus, and, above and encircling it,the ring of the cervix. In all instances, pain maybe severe due to stretching of the infundibulo-pelvic ligaments and other viscera.

Shock is the outstanding sign, and may inpart be neurogenic due to stretching of theviscera and in part due to hemorrhage andhypovolemia. The degree of shock is propor-tional to blood loss and hemorrhage is variable,depending on whether any attempt has beenmade to remove the placenta. Some bleedingwill always be present unless the placenta iscompletely adherent to the uterine wall. It isimportant to recognize that severe hemorrhagewill accompany any attempt at removing theplacenta before the uterus is replaced5,6. Thiseventuality is a special risk if the birth has beenattended by a traditional birth attendant (TBA)in parts of the underdeveloped world.

Management

Acute uterine inversion is a true obstetricemergency6, and clearly one which may lead tosevere postpartum hemorrhage. If present andavailable, a supportive team should be sum-moned to the delivery suite for resuscitationand protocol management (see Chapter 20).Uterotomics, if started, are to be stoppedand manual replacement attempted under ade-quate and appropriate anesthesia followed bydelivery of the placenta assisted by restart ofoxytocin7.

Elevation of the foot of the delivery table orbed may relieve the tension on the viscera andreduce the pain and shock. Immediate resusci-tation with intravenous fluids is indicated vialarge-gauge venous access. Adequate analgesia

must be instituted prior to attempting replace-ment, and the bladder should be catheterized.Antibiotic prophylaxis is advisable.

Any delay increases the difficulty in replacingthe uterus, and the first health-care professionalpresent should make the initial attempt atreplacement. This will be aided if regional anes-thetic is already in place8. The placenta shouldbe left in situ and no attempt made to remove it.The portion of the uterus that came down lastshould go back first, that is, the lower segmentinitially and the fundus later. The hand is lubri-cated with hibitane cream (or other suitableantiseptic if available) and placed inside thevagina. With gentle maneuvers of the fingersaround the cervical rim and simultaneousupward pressure with the palm of the hand, theuterus is gradually replaced. The employmentof force is dangerous, as the thinned-out lowersegment may be torn or otherwise traumatized.The vaginal vault may already have been tornin some cases. The degree of shock does notdiminish until the uterus is replaced. In themajority of instances, replacement of the uterusis successful using this conservative method9.If replacement is successful, the placentashould be manually removed with the aid ofergometrine or an oxytocic infusion. In under-developed countries or in a home setting, boiledwater brought to a bearable temperature can beused to soak clean towels or cloths to assist inpushing and packing the vagina. This may facili-tate replacement attempts and control furtherblood loss. Bimanual massage of the fundusmay improve contraction.

If replacement is unsuccessful, measures torelax the cervical retraction ring should be thenext line of therapy. Beta mimetics or amylnitrite inhalation can often relax the retractionring sufficiently to allow uterine replacement9.A similar effect is seen with the administrationof halothane anesthesia, but, unfortunately, useof this agent in sufficient doses can result inthe unwanted and life-threatening complica-tions of uterine atony, hypotension and severehemorrhage. Halothane is no longer used forthese and other reasons. A 2 g intravenousbolus of magnesium sulfate can be used in thehypotensive patient (0.25 mg of intravenousterbutaline in the stable patient) to relaxthe cervical contraction ring10. Intravenous

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nitroglycerine can be tried although it is notcommonly used.

Further attempts at replacement of theuterus should take place under general anesthe-sia in an operating theater equipped and readyto perform a laparotomy. Before resorting to alaparotomy, however, the tried and testedO’Sullivan hydrostatic technique11 should beattempted. Here, the patient is first resuscitatedto restore vital signs including adequate bloodvolume and pressure. The obstetric team andanesthetist are summoned.

Adequate analgesia is essential before:

(1) Attempt at repositioning without the use ofuterine relaxant;

(2) If response is not imminent or sustained, ananesthetist should provide uterine relax-ation to facilitate repositioning and theadministration of uterotonics;

(3) General anesthesia is preferable, adminis-tered by an obstetric anesthetist. Digitalrepositioning should be maintained tosupport and establish good uterine muscletone;

(4) 1–2 liters of saline at body temperatureshould be infused into the vagina throughrubber tubes placed in the posterior fornix,whilst obliterating the introitus with theobstetrician’s hand. As the vaginal wallsdistend, the fundus of the uterus rises andthe inversion is usually promptly corrected.Once this is achieved, fluid is allowed toslowly escape from the vagina whilst theplacement of the uterine fundus is achievedand maintained.

When O’Sullivan first described this technique,he used a douche-can and wide rubber tubing todeliver the solution. More recently, a silasticvacuum cup has been used to instil the sterilesolution into the vagina12. Until replacementis effected, however, towels soaked in warmhypertonic saline solution and draped over theinverted uterus may reduce the edema whichwill inevitably occur and which further impedesreplacement of the uterus. In extremely difficultcases, replacement may require mid-line laparo-tomy, with the patient cleansed and draped inthe Lloyd Davis (frog-legged) position with a

head-down (Trendelenberg) tilt. The patient iscatheterized with an indwelling catheter andbroad-spectrum antibiotics are administered.With the bowels packed upward and away fromthe uterus, the obstetric surgeon places hishands in front and back of the lower segmentwith the finger tips between and below the levelof the inverted fundus. With progressive pres-sure on the fingertips of both hands whichflip up simultaneously, the internal dimpleis replaced progressively by the rising uterinefundus (Figure 1a–e)13. Uterine perfusionreturns with re-establishment of uterine pulsepressure.

If this technique fails, then the mid-lineabdominal incision can be extended upwards ifnecessary. The inverted uterus resembles a fun-nel; it is best to exteriorize the uterus. Instru-mental upward traction is applied to the roundligaments bilaterally using Allis or ring forceps,while the assistant exerts upward pressure onthe inverted parts from the vagina below. Thismaneuver is the Huntington technique14,15.

Failure at this stage warrants employing theHaultain technique whereby an incision is madevertically in the posterior cervix via the abdomi-nal route, following the dimple as a guide torelieve the constriction at this level. The assis-tant exerts upward pressure from the vagina toeffect reduction and replacement16.

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POSTPARTUM HEMORRHAGE

Figure 1a Acute uterine inversion



On return of the uterus to its normal posi-tion, the placenta should be removed manuallyfrom the vagina, and uterine contraction main-tained abdominally by bi-manual stimulation.Ergometrine, oxytocic intravenous infusion, ormesoprostyl can be administered. The posterioruterine incision, if used, is then repaired in lay-ers, and the abdomen closed in the usual fash-ion. The patient should be monitored in the

intensive care or the high-dependency unit for24 h.

A sub-acute inversion is managed in a similarmanner but may resolve spontaneously as theuterus involutes4.

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Figure 1b Acute uterine inversion. Finger tipsplaced below fundus of uterus to facilitate reduction

Figure 1c Acute uterine inversion. Progressivereduction with some ischemia

Figure 1d Acute uterine inversion. Return ofvascularity

Figure 1e Acute uterine inversion. Completereduction and revascularization with normal clinicalfeatures. (B-Lynch technique of non-instrumentalreduction of acute uterine inversion at laparotomy.©Copyright ’05)



In chronic inversion, the uterus involutes inits inverted position and remains in the vaginaas a soft swelling, which bleeds readily to touchand shows areas of superficial ulceration. Pro-longed inversion may result in conversion of thecolumnar epithelium of the uterine wall into astratified squamous epithelium. Replacement ofa chronic inversion can prove extremely diffi-cult, due partly to the inevitable edema presentand the friable nature of the tissues. The tech-niques adopted for replacing the acutelyinverted uterus are no longer helpful in thischronic situation. Bed rest, elevation of the footof the bed, antibiotic prophylaxis, and vaginalcleansing with hibitane packs may be helpful toreduce the edema and treat any infections, butit may eventually be necessary to perform ahysterectomy. If the chronic inversion is due tothe presence of a fibroid or a placental polyp,initial removal of the polyp by ligating andcutting the pedicle as near to the base aspossible may facilitate replacement of theinverted uterus.

RUPTURED UTERUS

Uterine rupture is a serious obstetric complica-tion with high morbidity and mortality. Indeveloped countries, the increasing number ofCesarean sections performed for minor degreesof disproportion, fetal distress or pre-eclampsiain primiparae is of considerable importance incalculating the long-term risks associated withCesarean section, particularly in terms of theincidence and risk of uterine rupture. Both theshort- and long-term risks are accentuated inresource-poor countries.

Uterine rupture may be complete when thetear extends into the peritoneal cavity, orincomplete when the serosa remains intact.The rupture may be spontaneous, traumatic orthe result of scar dehiscence and may occureither during pregnancy, early in labor orfollowing a prolonged labor17.

In developed countries, the most commoncause of uterine rupture is dehiscence of a previ-ous lower segment transverse Cesarean sectionscar. Rupture of a classical scar is eight timesmore common than that of a previous lowersegment incision, and is far more apt to occurbefore rather than during labor. Previous

rupture of a scar confers a 10–20-fold increasein risk of a subsequent rupture18,19.

Rupture of the uterus is generally sudden,accompanied by severe abdominal pain andfollowed by vascular collapse. In many cases,however, asymptomatic dehiscence takes placeduring a vaginal delivery after a previous Cesar-ean section, when the dehiscence is gradual andretraction of the uterus arrests hemorrhage fromthe wound. Because of this possibility, it isalways necessary to exclude silent dehiscenceby manual exploration of the uterus afterdelivery of the fetus when a scar is presenton the uterus.

A major factor in spontaneous uterinerupture is obstructed labor, especially in thedeveloping world when women routinelydelivery without the benefit of the presenceof trained health-care providers. Rupture maybe due to maternal or fetal causes (generallymacrosomia). Examples of maternal causes arecephalopelvic disproportion from pelvic con-traction due to developmental, constitutional ornutritional causes, abnormal presentation suchas shoulder presentation, breech or brow, per-sistent mentoposterior face presentation, trans-verse lie, fetal abnormality, hydrocephalus, fetaltumor, fetal ascites, conjoined twins, maternaltumors, intrinsic cervical lesions, extrinsic fib-roids or tumor, locked twins, and rarely uterinemisalignment such as incarcerated retroverteduterus, and pathological uterine anteversion.Additionally, grand multiparity, the use ofuterotonic drugs to induce or augment labor,placenta percreta, and intrauterine manipula-tion have all been implicated as causes ofuterine rupture19,20.

The most common predisposing cause ofrupture during pregnancy is a weak scar follow-ing a previous Cesarean section20. Rarely, rup-ture can occur following unrecognized injuryto the uterus at a previous difficult delivery.It may present with sudden severe abdominalpains and collapse, or the symptoms may pres-ent gradually, when rupture is based on scardehiscence. If the onset is gradual, diagnosismay be difficult as the abdominal pain may beslight and accompanied only by alterations inthe fetal heart tracing, maternal tachycardia andminimal vaginal bleeding. This triad is thenfollowed by patient collapse, cessation of fetal

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movement and easy palpation of the fetal partsif the fetus has been expelled completely intothe peritoneal cavity. If the patient is in a hospi-tal and the catastrophe recognized at its onset,the outcome should be the safe delivery of thebaby and repair of the uterus. If the patient isnot in a hospital, on the other hand, the catas-trophe is just that, a catastrophe of a dead childand its mother.

Uterine rupture during labor is also mostcommonly due to dehiscence of a previousCesarean scar with pain over the scar, followedby sudden severe abdominal pain and collapse.In grand multiparae with a friable inelastic uter-ine wall, rupture may occur in early labor evenwhere there has been no previous scar or diffi-cult delivery, although this eventuality is notnearly as common as rupture in the previouslyscarred uterus. Here, however, diagnosis maybe difficult initially as the presentation may beconfused with a small accidental hemorrhageand therefore missed.

Rupture after a prolonged labor is commonlydue to obstructed labor, with marked thinningof the lower segment and increased retraction ofthe upper segment resulting in the formation ofa retraction or Bandl’s ring. The tear begins inthe lower uterine segment, may extend up to thefundus or down into the vagina, or proceedlaterally into the broad ligament. If the tearis posterior, it may go through the posteriorvaginal fornix into the Pouch of Douglas(colporrhexis)20. If the rupture is in the loweranterior segment, the bladder is stripped fromits attachment to the lower segment. The perito-neum remains intact and so the rupture is char-acterized as incomplete. A multiparous patientin obstructed labor will continue to have tetaniccontractions until the uterus ruptures, whilsta primiparous patient will usually go out oflabor. Classical clinical signs of a rupture in amultiparous patient can be dramatic; abdominalpain is constant, the contractions become virtu-ally continuous initially with only short intervalsbetween them and later no interval betweencontractile forces, with the formation of aBandl’s ring followed by rupture and collapse.The contractions then usually stop20–22, thefetus is expelled into the peritoneal cavity,the fetal parts are easily palpable and the uterusadopts an altered shape.

Rarely, the uterus may rupture during earlyto mid-pregnancy or during labor in patientswho have had a previous cornual ectopic preg-nancy. Here also, the rupture is dramatic, islocated over the repair site of the ectopic andis characterized as a fundal blow-out. Suddensevere abdominal pain is experienced over thefundus of the uterus followed by collapse.

Rupture of a previously unscarred uterus isusually a catastrophic event resulting in death ofthe infant, extensive damage to the uterus and avery high risk of maternal death from blood loss.The damage to the uterus may be so extensivethat repair is impossible and a hysterectomy isrequired. In developed countries, the incidenceof ruptured uterus in an unscarred uterusis approximately 1 : 10 000 deliveries22; inthe underdeveloped countries, the data areunknown. The incidence of rupture of a uteruswith a previous Cesarean section scar is 1%22,23.A trial of labor following a previous Cesareansection increases the risk of perinatal death andrupture of the uterus compared to electiverepeat Cesarean section. In one large Canadianstudy, a trial of labor following a previousCesarean section was associated with anincreased risk of rupture (by 0.56%) but fewermaternal deaths than in an elective section (1.6vs. 5.6 per 100 000)19.

In less developed countries, the incidenceof uterine rupture varies from 1.4% to 25%,with 25% in Ethiopian women with obstructedlabor23. Uterine rupture accounted for 9.3% ofmaternal mortality in one study from India and6.2% in a study from South Africa24.

A laparotomy is indicated when rupture ofthe uterus is suspected. The patient is anesthe-tized, cleansed, draped and the bladder cathet-erized with an indwelling catheter. A mid-linelower abdominal incision should be used as thismay be extended cephalad if necessary. Thefetus should be delivered expeditiously and theuterus delivered from the abdominal incision toassist in controlling the bleeding and assessingthe situation while resuscitative measures areundertaken. In the series of over 1300 world-wide reported successful applications of theB-Lynch (Brace) suture, 25 cases were appliedfor persistent uterine atony after repair of auterine rupture. In these cases, successful bleed-ing control and hemostasis were achieved (CBL

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world-wide communication www.CBLynch.com)25.

Hysterectomy may be necessary and shouldhave been consented, if at all possible. It is notnecessary to remove the ovaries merely becausethis is easier in a crisis. As with a Cesarean hys-terectomy performed in late labor, the cervix isno longer a discrete and circumscribed solidstructure, easily delineated and permitting accu-rate placement of vaginal clamps. In the acutesituation, hemostasis and avoidance of furtherdissection are of paramount importance, andthe removal of the distal cervix is not critical.The most difficult surgical situation occurswhen the rupture is extraperitoneal into thebroad ligament, with a massive hematoma dis-torting the anatomy and obscuring the bleedingpoints. Here, it may be necessary to pack thespace, the end of the pack being brought outthrough a gap in the uterine repair20. A ballooncatheter with light traction may be used forenhanced tamponade with or without theapplication of the B-Lynch (Brace) sutureapplication26.

Other conservative surgery may be appropri-ate on occasions, for example, when simplerepair of the tear may be preferable to hysterec-tomy. With an anterior rupture, the bladdermay be involved; the appearance of hematuriais almost pathognomonic. Repair is undertakenand the bladder catheterized for 2 weeks. A pos-terior fornix rupture (colporrhexis) is relativelyeasy to repair. Incomplete rupture is not usuallyapparent until delivery has been achieved. Itwill commonly declare itself by intrapartum orpostpartum hemorrhage. It should always beexcluded by manual exploration after delivery ofthe fetus. Both bladder tears and colporrhexismay be missed if not anticipated. If this is thecase, bleeding may continue, to the surgeon’sdismay.

BLUNT ABDOMINAL TRAUMA

The three main causes of serious blunt abdomi-nal trauma in pregnancy are motor vehicleaccidents, falls and domestic or intimatepartner physical abuse. In the developed world,the most common cause of blunt abdominaltrauma is motor vehicle accidents27,28. In theless developed countries, the incidence of

domestic physical abuse or intimate partnerphysical abuse can be as high as 13.5%29.Developed countries are not immune fromthis problem, however, and a large review of theprevalence of abuse during pregnancy in theUnited States documented that between 0.9%and 20.1% of pregnant women were abused bytheir partners. This figure covers all forms ofabuse, emotional, physical and sexual30.

Direct abdominal trauma by punching orkicking the abdomen increases the risk ofadverse outcome of the pregnancy. Adverse out-comes are more common with direct physicalassaults than with motor vehicle accidents29,30.Partner abuse also tends to be a repetitive event,increasing the risk to the fetus31. In some coun-tries, partner abuse and violence against womenis accepted as a cultural norm, thus reducing thenumbers of reported cases. Even in the Chinesecommunity in Hong Kong and despite westernsocialization, it is not uncommon for women tosubmit to their husbands and endure humilia-tion for the sake of keeping their familytogether. Providing help for these pregnantwomen is challenging32.

Motor vehicle accidents account for 60–75%of cases of blunt trauma. Most injuries areminor, but, in the United States, between 1300and 3900 women each year suffer a fetal loss asa result of a motor vehicle accident27,28. Despitethe majority of the injuries being minor, thefetus is always at risk and careful assessmentmust be carried out in all cases of blunt abdomi-nal trauma resulting from motor vehicle acci-dents. Assessments must be frequent andrepeated with special attention to conditionscommonly seen after such trauma. Theseinclude abruptio placentae, preterm labor,uterine rupture, fetomaternal hemorrhage,direct fetal injury and fetal demise33.

The pattern of injury following automobileaccidents depends on the type of seat beltrestraints. An unbelted driver or passenger isusually ejected from the vehicle or sustainsinjuries when they hit the interior of the car.The injuries are mainly to the face, head, chest,abdomen and pelvis. With shoulder andabdominal restraints, rib, sternum and clavicu-lar fractures are common, whereas in thelap-only belted, lumbar spine and hollow viscusinjuries are more frequent. Sharp objects in the

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pockets of the clothing on the person can causeadditional trauma; a fountain pen may perforatethe lungs or heart. Even bulky outdoor over-clothing represents a hazard. With thick cloth-ing, there is a short distance between the bodyof the person and the restraint. On impact, theweight of the body causes acceleration forwards.The speed of contact between the personand the restraint can compound the damagesustained to the body.

During the first trimester, the uterus iswell protected within the pelvis and sustainsvery little damage from blunt trauma. Withadvancing pregnancy, however, the uterusbecomes an abdominal organ and thereforemore susceptible to trauma. The blood supplyto the pelvis is markedly increased the moreadvanced the pregnancy, giving rise to retro-peritoneal hemorrhage which can be life-threatening. Bowel injuries are less common, asthe bowel occupies the upper abdominal spacelater in pregnancy, is a more movable entity andis not in the direct line of the trauma.

Assessing the extent of trauma can be diffi-cult, as clinical signs initially may be sparse.Patients should be assessed frequently to detectdeterioration in their condition. The presence ofbony injuries should raise suspicion of intra-peritoneal hemorrhage: rib fractures are associ-ated with liver and spleen injuries and pelvicfractures with retroperitoneal hemorrhage andinjury to the genitourinary system.

Difficulty is often encountered in detecting asmall amount of bleeding into the peritonealcavity. As blood may be non-irritant, ultrasoundexamination may be equivocal, and CT scan-ning exposes the fetus to a large radioactivedose. The decision to proceed to a laparotomymay therefore be entirely based on clinicaljudgement.

The most common cause of fetal deathin non-fatal accidents is abruptio placentae. Inminor injuries, the incidence is between 1 and5%, in contrast to major trauma where the inci-dence may be as high as 30%. At the time ofimpact, the intrauterine pressure may be as highas ten times the pressure reached at the height ofa labor contraction. Blunt trauma causes theuterus to compress and then expand andthe placenta shears away from the uterinewall. The degree of separation may bear no

relationship to the degree of trauma; abruptionmay occur with very little evidence of injury tothe mother. It usually, but not always, followssoon after the trauma.

Vaginal bleeding, abdominal pain, increaseduterine tone, uterine tenderness, high frequencycontractions, and abnormal fetal cardiotoco-graphy are the classical clinical signs of a placen-tal abruption. In a posteriorly inserted placenta,severe backache and vaginal bleeding maybe significant symptoms. The bleeding may berevealed or concealed within the uterus. Ifconcealed, in severe cases, the uterus becomeswoody hard as described by Couvelaire, bloodhaving been extravasated into the muscular wallof the uterus. Fetal parts are impossible to feeland the patient’s condition rapidly deterioratesdue to hypovolemia and pain.

The management of abruptio placentaedepends on the severity of the abruption, thenature of the general injuries sustained, the con-dition of the fetus and the duration of the preg-nancy. The trauma surgeon and the obstetricianshould work together in managing the patient.Establishing wide-bore intravenous access isessential. The hematologist should also beinvolved. A complete thrombophilia screenshould be requested and cross-matched bloodorganized, together with fresh frozen plasma.

A preterm uncompromised fetus should beobserved by continuous cardiotocography for aminimum of 6–12 h or by a Pinard stethoscopein less developed communities and, if the gesta-tion is under 34 weeks, the mother should begiven corticosteroids to mimimize the adverseeffect of prematurity on lung maturation. If thefetus is previable and compromised, vaginaldelivery is the safest for the mother.

In a term pregnancy with abruptio andan uncompromised fetus, vaginal delivery is anoption. However, Cesarean section is advised ifthe fetus is compromised. If the fetus, on theother hand, has died, induction of labor andvaginal delivery are appropriate and safe for themother.

Preterm labor following blunt abdominaltrauma may be precipitated by extravasationof blood into the myometrium stimulating uter-ine contraction. Prostaglandin release may stim-ulate uterine activity. Preterm labor requiringtocolysis occurs in 10–30% of cases of blunt

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abdominal trauma, but less than 1% deliverbefore 34 weeks. Tocolytics should be usedguardedly, lest they mask the sign of abruption.Contractions following blunt abdominal traumaabate without treatment in 90% of cases. Alltocolytics have side-effects which the obstetri-cian should be familiar with: beta mimeticsinduce tachycardia and may mask the earlysigns of abruption; non-steroidal anti-inflammatory agents affect platelet and renalfunction; and calcium channel blockers causehypertension. The fetal heart rate and theuterine contractions should be continuouslymonitored34.

Uterine rupture is a rare (1%) occurrence inblunt abdominal trauma; when it does occur, itis usually in association with a fractured pelvis.The site of rupture is commonly the fundus ofthe uterus or the site of a previous uterine scar.Fetal mortality in such cases is 100%, andmaternal mortality 10%35–38. Diagnosis may bedifficult with vague abdominal pain, uterinetenderness, but with easily palpable fetal parts,and a poor trace or absence of a fetal heart oncardiotocography. Fetal demise and maternalshock are more dramatic presentations.

If suspected, exploratory laparotomy in thepresence of the trauma surgeon is indicated.Uterine repair should be undertaken only if thepatient is hemodynamically stable. If not, hys-terectomy should be performed. However, therisk of a rupture in a subsequent pregnancy ishigh, and the patient and her family should beadvised this at an appropriate time.

Fetal injury occurs very infrequently follow-ing blunt abdominal trauma. Fracture of thelong bones or the skull is the most commoninjury and occurs in approximately 1% of cases.If the fetus is distressed, immediate delivery iscalled for. In the preterm non-compromisedfetus, delivery may be delayed, but serialmonitoring is advised39,40.

Fetomaternal hemorrhage occurs in up to30% of cases of blunt abdominal trauma, espe-cially if the placenta is situated anteriorly. Mostfetuses will have a normal outcome, althoughanemia, supraventricular tachycardia and fetaldemise can occur depending on the extentof the fetomaternal hemorrhage41,42. Victims ofblunt abdominal trauma should be screened forRhesus factor, and all Rhesus-negative mothers

given Anti-D immunoglobulin to prevent sensi-tization. Sensitization can occur as early as the5th week of pregnancy. A Kleihauer–Betke testis essential to assess the magnitude of thefetomaternal hemorrhage and adjust the dose ofAnti-D immunoglobulin accordingly.

In all cases of blunt abdominal injuries, fetalassessment is of paramount importance. Cardio-tocography is the most sensitive method ofimmediate fetal surveillance. Ultrasonographyis only accurate in predicting 40% of cases ofabruption. Uterine activity is the most sensitiveindicator for predicting abruption followingblunt abdominal trauma. Frequent contractionshave an adverse effect on fetal outcome.

As a guideline, patients who have sustainedblunt abdominal trauma, but have no abdomi-nal tenderness, no vaginal bleeding and nocontractions should be monitored 2-hourly for6–12 hours. Patients with abdominal tender-ness, vaginal bleeding and contractions shouldbe monitored continuously43,44.

References

1. Spain AW. Acute inversion of the uterus. J ObstetGynaecol Br Empire 1946;53:219

2. Das P. Inversion of the uterus. J Obstet GynaecolBr Empire 1940;47:525–48

3. Fahmy M. Acute inversion of the uterus. Int JSurg 1977;62:100

4. Watson P, Besch N, Bowes WA. Management ofacute and subacute puerperal inversion of theuterus. Obstet Gynecol 1980;55:12

5. Brar HS, Greenspoon JS, Platt LD, Paul RH.Acute puerperal uterine inversion. J Reprod Med1989;34:173–7

6. Wendel PJ, Cox SM. Emergent obstetric man-agement of uterine inversion. Obstet Gynecol ClinN Am 1995;22:261–74

7. Abouleish E, Ali V, Joumaa B, et al. Anaestheticmanagement of acute puerperal uterine inver-sion. Br J Anaesth 1995;75:486–7

8. Catanzarite VA, Moffitt KD, Baker ML, et al.New approach to the management of acutepuerperal uterine inversion. Obstet Gynecol 1986;68(Suppl):7–10

9. Clark SL. Use of ritodrine in uterine inversion.Am J Obstet Gynecol 1984;151:705

10. Grossman RA. Magnesium sulphate for uterineinversion. J Reprod Med 1981;26:261–2

11. O’Sullivan JV. Acute inversion of the uterus. BrMed J 1945;ii:282–3

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12. Ogueh O, Ayida G. Acute uterine inversion: anew technique of hydrostatic replacement. Br JObstet Gynaecol 1997;104,951–2

13. B-Lynch C. Non instrumental atraumaticstepwise reduction of acute uterine inversion.In press

14. Huntington JL. Acute inversion of the uterus.Boston Med Surg J 1921;184:376–80

15. Huntington JL, Irving PC, Kellogg PS. Abdomi-nal reposition in acute inversion of the puerperaluterus. Am J Obstet Gynecol 1928;15:34–40

16. Haultain FWN. The treatment of chronic uter-ine inversion by abdominal hysterotomy with asuccessful case. Br Med J 1901;ii:974

17. Schrinsky DC, Benson RC. Rupture of thepregnant uterus: a review. Obstet Gynaecol Surv1978;33:217–32

18. Ritchie EH. Pregnancy after rupture of the preg-nant uterus. J Obstet Gynaecol Br Commonwealth1971;78:642–8

19. Aguero O, Kizer S. Obstetric prognosis of therepair of uterine rupture. Surg Gynaecol Obstet1968;127:528–30

20. Hudson CN. Obstructed labour and its sequelae.In Lawson JB, Harrison KA, Bergstrom S, eds.Maternity Care in Developing Countries. London:RCOG Press, 2001

21. Wen SW, Rusen ID, Walker M, et al. Compari-son of maternal mortality and morbidity betweentrial of labor and elective Caesarean amongwomen with previous caesarean delivery. Am JObstet Gynecol 2004;19:1263–9

22. Miller DA, Goodwin TM, Cherman RB, OaulRH. Intrapartum rupture of the unscarreduterus. Obstet Gynecol 1997;89:671–3

23. Gaym A. Obstructed labour in a district hospital.Ethiop Med J 2002;40:11

24. Rajaram P, Agarwal A, Swain S. Determinants ofmaternal mortality: a hospital based study fromSouth India. Ind J Matern Child Health1995;6:7–10

25. B-Lynch C. Persistent uterine atony aftersuccessful repair of ruptured uterus treated byBrace suture, world-wide reports and personalcommunication. www.cblynch.com

26. Danso D, Reginald P. Intrauterine balloon cath-eter with B-Lynch suture. Br J Obstet Gynaecol2002;109:963

27. Esposito TJ, Gens DR, Smith IG, Scorpio R,Buchman T. Trauma during pregnancy. Areview of 79 cases. Arch Surg 1991;126:1073–8

28. Hoff WS, D’Amelio LF, Tinkoff GH, et al.Maternal predictors of fetal demise in traumaduring pregnancy. Surg Gynecol Obstet 1991;172:175–80

29. Valladares E, Pena R, Oersson LA, Hogberg U.Violence against pregnant women: prevalence andcharacteristics. A population-based study in Nic-aragua. Br J Obstet Gynaecol 2005;112:1234–48

30. Gazmararian JA, Lazorick S, Spitz AM, BallardTJ, Saltzman LE, Marks JS. Prevalence of vio-lence against women: a review of the literature.JAMA 1996;275:1915–20

31. Godwin TM, Breen MT. Pregnancy outcomeand feto-maternal hemorrhage after non cata-strophic trauma. Am J Obstet Gynecol 1990;162:665–71

32. Tiwari A, Leung WC, Leung TW, Humphreys J,Parker B, Ho PC. A randomised controlled trialof empowerment training for Chinese abusedpregnant women in Hong Kong. Br J ObstetGynaecol 2005;112:1249–56

33. Connolly A, Katz VL, Bash KL, McMahon MJ,Hansen WF. Trauma and pregnancy. Am JPerinatol 1997;14:331–6

34. Elliott M. Vehicular accidents and pregnancy.Aust NZ J Obstet Gynaecol 1966;6:279–86

35. Williams JK, McClain L, Rosemurgy AS, Colo-rado NM. Evaluation of blunt abdominal traumain the third trimester of pregnancy: maternal,and fetal considerations. Obstet Gynecol 1990;75:33–7

36. American College of Obstetricians and Gynecol-ogists. Trauma during pregnancy. ACOG Tech-nical Bulletin No. 161, November 1991,Washington DC

37. Mighty H. Trauma in pregnancy. Crit Care Clin1994;10:623–34

38. Dahmus MA, Sibai BN. Blunt abdominaltrauma. Are there any predictive factors forabruptio placentae or maternal-fetal distress. AmJ Obstet Gynecol 1993;169:1054–9

39. Lavin JP, PolSky SS. Abdominal trauma duringpregnancy. Clin Perinatol 1983;10:423–38

40. Goodwin TM, Breen MT. Pregnancy outcomeand feto-maternal hemorrhage after non-catastrophic trauma. Am J Obstet Gynecol 1990;162:665–71

41. Pearlman MD, Tintinalli JE, Lorenz RP. Aprospective controlled study of outcome aftertrauma during pregnancy. Am J Obstet Gynecol1990;162:1502–10

42. Rose PG, Strohm PL, Zuspan FP. Fetomaternalhemorrhage following trauma. Am J ObstetGynecol 1985;153:844–7

43. Pearlman MD, Phillips ME. Safety belt use dur-ing pregnancy. Obstet Gynecol 1996;88:1026–9

44. Pearlman MD, Tintinalli JE, Lorenz RP. Blunttrauma during pregnancy. N Engl J Med1991;323:1609–13

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Postpartum Hemorrhage - Vouchaogm.org.mo/assets/Uploads/aogm/PPH-Files/PPH-Chap-09.pdf · ACUTE UTERINE INVERSION Acute uterine inversion, defined as when the uterus is turned inside