Inversion of the uterus
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Uterine inversion is a rare complication where the uterus turns inside out, and can be partial or complete. It occurs in around 1 in 20,000 deliveries and is usually acute and complete. There are three degrees - first involves dimpling of the fundus, second passes through the cervix into the vagina, and third is complete outside the vulva. Treatment involves urgent manual replacement or hydrostatic replacement under anesthesia to prevent shock, hemorrhage, infection and other complications. Proper management of the third stage of labor can prevent induced inversions.
Inversion of the uterus
- 1. BY, MS.PRIYANKA GOHIL M.Sc. (N) OBG, phD Scholar in Nursing
- 2. “It is an extremely rare but a life- threatening complication in third stage in which the uterus is turned inside out partially or completely.”
- 3. The incidence is about 1 in 20,000 deliveries. The obstetric inversion is almost always an acute one and usually complete.
- 6. FIRST DEGREE There is dimpling of the fundus, which still remains above the level of internal os. SECOND DEGREE The fundus passes through the cervix but lies inside the vagina. THIRD DEGREE (COMPLETE) The endomatrium with or without the attached placenta is visible outside the vulva. The cervix and part of the vagina may also be involved in the process.
- 9. SPONTANEOUS Spontaneous inversion of the uterus is rare but if present, than it can be due to local atony of the placental site over the fundus associated with sharp rise of intra-abdominal pressure just like in case of sneezing, coughing or bearing down effort. It is sometimes linked with: 1. Short cord 2. Placena accreta 3. Fundal attachment of the placenta
- 10. INDUCED This is mostly a cause of mismanagement of third stage of labour. The factors that may aggravate it are: 1.Pull on cord while uterus is atonic 2.Improper Crede's expression on atonic uterus 3.Improper of faulty technique used in manual removal of placenta. 4.Short cord pulling on the fundus during delivery 5.Forced expulsion of placenta by putting downward pressure on uterus.
- 11. Uterine over enlargement Prolonged labour Fetal macrosomia Uterine malformations Morbid adherent placenta Short umbilical cord Tocolysis Manual removal of placenta It is more common in women with collagen disease like Ehler Danlos Syndrome.
- 12. 1. Shock is extremely profound, mainly of neurogenic origine due to... a) Tension on the nerves due to stretching of the infundibulopelvic ligament b) Pressure on the ovaries as they are dragged with the fundus through the cervical ring c) Peritoneal irritation 2. Hemorrhage, especially after detachment of placenta
- 13. 3. Pulmonary embolism 4. If left uncared for, it may lead to... a. Infection b. Uterine sloughing c. a chronic one
- 14. SYMPTOMS Inversion develops shortly during/after 3rd stage of labour In acute inversion, there is extreme shock out of proportion to blood loss. In chronic inversion symptoms are... a. Persistant vaginal bleeding b. Pelvic pain c. Feeling of something coming down per vagina d. Difficulty in passing urine
- 15. SIGNS There may evidence of shock Anemia is present from mild to moderate degree In first degree inversion, there is cupping of fundus Bimannual examination shows protrusion of fundus inside the uterine cavity.
- 16. In second degree, the fundus cannot be felt, bimannually round and firm swelling with soft bleeding surface is face protruding through the cervix in the vagina and swelling remains often covered with placenta. In 3rd degree - per abdomen, fundus cannot be felt. The mass protrude outs the vulva. Sonography can confirm the diagnosis when clinical examination is not clear.
- 17. As it is commonly met in unfavorable surroundings, the prognosis is extremely gloomy. Even if the patient survives, infection, sloughing of the uterus and chronic inversion with ill health may occur.
- 18. Do not employ any method to expel the placenta out when the uterus is relaxed. Pulling the cord simultaneous with fundal pressure should be avoided. Manual removal should be done in a manner as it should be.
- 19. Call for extra help Before the shock develops, urgent manual replacement even without anesthesia, if it is not readily available, is the essence of treatment for a skilled accoucheur.
- 20. PRINCIPLE STEPS To replace that part first which is inverted last with the placenta attached to the uterus by steady firm pressure exerted by the fingers. To apply counter support by the other hand placed on the abdomen. After replacement, the hand should remain inside the uterus until the uterus becomes contracted by parenteral oxytocin or PGF2α.
- 23. The placenta is to be removed manually only after the uterus becomes contracted. The placenta may however be removed prior to replacement.., a. To reduce the bulk, which facilitate replacement b. If partially separated, to minimize the blood loss Usual treatment of shock including blood transfusion should be arranged simultaneously.
- 24. AFTER THE SHOCK DEVELOPS Principle steps The treatment of shock be instituted with an urgent normal saline drip and blood transfusion To push the uterus inside the vagina if possible and pack the vagina with antiseptic roller gauze. Foot end of the bed is raised. Replacement of the uterus either mannually or hydrostatic method (O'sullivan's) under general anesthesia is to be done along with resuscitative measures.
- 25. Hydrostatic method is quite effective and less shock producing. The inverted uterus is replaced into the vagina. Warm sterile fluid (up to 5 liters) is gradually instilled into the vagina through a douche nozzle. The vaginal orifice is blocked by operator's palms supplemented by labial apposition around the palm by assistant. Alternatively a silicon cup (vacum extraction cup) is placed into the vagina. The douche intravaginal pressure leads to replacement of the uterus
- 27. SUBACUTE STAGE To improve the general condition by blood transfusion Antibiotics are given to control sepsis Reposition of the uterus either mannually or by hydrostatic method may be tried If fails, reposition may be done by abdominal operation (Haultaion's operation)