MANAGEMENT OF ACUTE UTERINE INVERSION BY DR SHASHWAT JANI

1. Acute Uterine Inversion
What to do & What not to do ?
Dr. Shashwat Jani.
M.S. ( Gynec ).
Diploma in Advance Endoscopy ( France ) .
Assistant Prof., Smt. N.H.L. Mun. Medical College,
Ahmedabad, Gujarat.
Mobile : +91 99099 44160.
E- mail : drshashwatjani@gmail.com

2. Definition
 When Uterus Turns Inside Out, It Is Called
Uterine Inversion.
 Uterine inversion is the folding of the fundus
into the uterine cavity in varying degrees.
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3. Incidence
Varies between 1 : 2000 to 1 : 35,000
deliveries.
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4. Incidence
 Rarely , it Can occur
even in the non-pregnant
uterus in relation to the
expulsion of an
intrauterine tumor…!!!
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5. CLASSIFICATION
A. TYPES :
1) Incomplete Inversion :
When fundus of uterus has turned inside out,
like toe of socks, but inverted fundus has not
descended through cx…
2) Complete Inversion :
When the inverted fundus has passed
completely through cx to lie within the vagina or lie
often outside the introitus.
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6. B. Degrees
 First degree: The uterus is partially turned out
 Second degree: The fundus has passed
through the cervix but not outside the vagina
 Third degree: The fundus is prolapsed
outside the vagina
 Fourth degree: The uterus, cervix and vagina
are completely turned inside out and are
visible
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7. Universally…
 First Degree : Incomplete Inversion
 Second Degree : Complete inversion in the
vagina
 Third Degree : Complete inversion outside the
introitus
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8. C. In relation to time interval between its
diagnosis & time of delivery :
 Acute : It occurs within 24 hrs of delivery.
 Sub-acute : It presents between 24 hrs & 4 wks of
delivery.
 Chronic : It presents beyond 4 wks of delivery or in
non pregnant stage.
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9. Causes…
 For the uterus to be inverted, must be
relaxed or local atony of uterus at the site of
placental insertion especially fundal.
 There should be fundal insertion of placenta.
 Either of above two along with :
Spontaneous OR Iatrogenic causes.
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10. Spontaneous (40%):
 Abnormal short umbilical cord or functionally
shortened by being wrapped around the fetal body.
 Sudden rise in intra abdominal pressure due to
maternal coughing or vomiting.
 Morbid adherence of fundally implanted
placenta
 Connective tissue disorder such as Marphan’s
syndrome.
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11. B. Iatrogenic
Due to mismanagement of third stage of labor…
 Pulling the cord when the uterus is atonic while
combined with fundal pressure
 Crede’s Expression while the uterus is relaxed
 Faulty technique in manual removal of placenta
While separating retained placenta from the wall,
a portion may remain attached and as the placenta is
withdrawn, the fundus is also withdrawn.
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12. Patho physiology
 In complete inversions, once the
fundus passes through the cervix, the
cervical tissues function as a
constricting band and edema rapidly
forms.
 The prolapsed mass then
progressively enlarges and
increasingly obstructs venous and
finally arterial flow, contributing to
the edema.
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13. Clinical Presentation
 Large boggy mass appears at introitus with or without
placenta attached
Other signs and symptoms are as follows –
 Severe and sustained hypogastric pain in 3rd stage of labor
 Shock
Shock is initially out of proportion with the amount of
blood loss.
Woman becomes sweaty with bradycardia, profound
hypotension and rarely cardiac arrest.
 In short time there is marked hemorrhage and hypovolumic
shock.
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14. • P/A :
In incomplete uterine inversion: fundus of uterus may appear
to be normal. Only in thin woman it is possible to feel fundal
dimple of incomplete inversion.
In complete inversion : uterus is not palpable per abdomen.
At Vulva,
a pear shaped mass is seen protruding outside vulva with
broad end pointing downwards, looking reddish purple in
color
• Bimanual Examination -
Confirm the diagnosis by detecting inverted body of the
uterus and above encircling it, the ring of cervix.
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15. DIFFERENTIAL DIAGNOSIS
 Inversion of uterus
 Uterine rupture.
 Prolapse of uterine tumor (submucous fibroid).
 Large endometrial polyp.
 Passage of succenturiate lobe of placenta.
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Management

17. Prevention
 Do not employ any method to expel the
placenta when the uterus is relaxed
 Patient should not be instructed to change
her position.
 Pulling the cord simultaneously with fundal
pressure should be avoided
 Manual removal of placenta should be done
in proper manner.
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18. 1) Starting from the edge of placenta ,
2) The placenta is separated by
a) keeping the back of the hand in contact with the
uterine wall.
b) with slicing movement of the hand.
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19. Mx of Acute Inversion of Uterus
• Delay in treatment increases the mortality, So number
of steps are taken immediately and simultaneously.
Before shock develops :
• When one is on the spot when the inversion happens
TRY IMMEDIATE MANUAL REPLACEMENT, even without
anesthesia if not easily available.
Principle :
“ The part of the uterus which has come
down last , should go back first. “
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20. Procedure
• If the diagnosis is made immediately after the
inversion has occurred, then that same degree of
relaxation of myometrium and cervix (which is
required for the inversion to occur) will allow
uterine replacement easily…
1. The gloved hand is lubricated with suitable
antiseptic cream and placed inside the vagina.
2. The uterine fundus with or without the attached
placenta, is cupped in the palm of the hand. The
fingers and thumb of the hand are extended to
identify margins of the cervix.
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21. 3. The whole uterus is
lifted upwards towards
and beyond umbilicus
4. Additional pressure is
exerted with the
fingertips systematically
and sequentially to push
and squeeze the uterine
wall back through the
cervix.
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22. 5. Sustained pressure for 3-5 mins to
achieve complete replacement
6. Apply counter support by the other hand
placed on the abdomen
7. Once the fundus has been replaced keep the
hand in the uterus while rapid infusion of
oxytocin is given to contract the uterus.
Initially, bimanual compression aids in
control of further hemorrhage until uterine
tone is recovered.
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23. 8. When the uterus is felt contracting, the hand
is slowly withdrawn.
If placenta is attached, it is to be removed only
after the uterus becomes contracted.
If the placenta is partially attached , it should
be peeled out before replacement of uterus.
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24. If the patient comes late :
Within 1 -2 minutes, from the occurrence of inversion, the cervix
and lower segment clamps down inverted part of the uterus.
increasing congestion, Edema of the inverted fundus.
makes manual replacement without anesthesia difficult.
If first attempt at immediate manual replacement of
uterus fails, move to the following sequence …
1. Call assistance
Anesthesiologist (assistance of nurse and obstetricians SOS)
2. Elevation of the foot of the delivery table may relieve the
tension on the viscera and reduce the pain and shock
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25. 3. Establish two wide bore i.v. cannulae.
Send blood for for grouping and cross match.
Rapidly run in 1-2 L of crystalloid.
Because though initially shock is neurogenic
type, hypovolumia will follow due to hemorrhage.
4. Catheterize.
5. Prophylactic antibiotics are given
6. If pain is a dominant symptom, small doses of i.v.
Morphine or Pentazocine with Atropine is given.
7. If the inverted uterus is prolapsed beyond the vagina,
it is replaced within the vagina
8. Patient is shifted to OT.
9. Anaesthesia
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26. General Anesthesia :
• Shock and with cardiovascular instability. G.A. is preferred.
• For this one of the fluorinated hydrocarbons are preferred
(Halothne, Sevofurane, Isoflurane) to aid uterine relaxation.
• Halothane is associated with rare myocardial
irritability/arrythmia and hepatotoxicity. Therefore other two
are preferred .
Epidural/ Spinal Anaesthesia :
• With normal vital signs, spinal anaesthesia can be given or if
the patient is already in epidural anaesthesia, then it maybe
continued.
• When anesthetic facilities are not available, replacement
will have to be undertaken and combination of i.v. narcotics,
combined paracervical and pudendal block and inhalation
anesthesia as available and feasible.
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27. 10. If G.A. does not produce adequate uterine
relaxation or if patient is in regional anaesthesia,
tocolysis is necessary.
• If the patient is hypotensive, MgSO4 2 gm i.v. bolus is
given to relax cervical contraction ring.
• If the patient is stable NTG is given…
1 Ampoule of NTG ( 5mg in 1ml solution) is diluted in 100ml
NS. This gives concentration of 50 μg/ml.
 Draw 20ml in syringe
 4ml given i.v. (i.e. 200μgm) and repeat it at 2 mins interval SOS
in normotensive patient
 2ml given i.v. (100μgm) and repeat it at 2 mins interval in
hypotensive patient after correcting hypovolumia
 In all the cases where oxytocin or prostaglandin has been
given previously higher doses of NTG is required.
 Onset of action – 90sec and lasts for 1-2 mins
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28. Maternal side effect :
- Peripheral vasodilatation and reduced venous tone
- so Rapid infusion with crystalloid is needed in pts who are
hypovolemic
• Peripheral vasodilatation responds to adrenaline.
• Uterine relaxation responds to oxytocin.
• TERBUTALINE CAN BE USED AS TOCOLYTICS AGENT.
11. Manual replacement of uterus.
As described before
12. As soon as the uterus is restored to its normal
configuration
-- The agent used for uterine relaxation is stopped
-- Simultaneously oxytocin is started to contract the uterus.
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29. 13. If there is delay in presentation of the patient i.e. more than
2 hrs or if manual replacement fails then…
O’Sullivan’s hydrostatic replacement technique
is used:
Pre-requisites:
• Make sure that the uterus and vagina have no lacerations.
• If there are found, should be sutured.
Principle:
• Install large volume of saline at body temperature (3-5lt) into upper
vagina
• This distends the upper fornices, which serves to pull open the
cervical ring
• This allows replacement of uterine fundus
Procedure :
• Until replacement is effected, a towel soaked with warm hypertonic
saline is draped over the inverted uterus to reduce the oedema.
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30. • Use douche and rubber
tubing with warm sterile fluid at
3 feet height or 1 litre bags of
warm saline with a pressure
infuser.
• Rubber tubing is placed in
posterior fornix by one hand
which also cups the fundus.
• The other hand seals the
introitus around the wrist so that
there is no leakage of fluid.
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31. • Alternatively the tubing can be attached to
sialistic vacuum extracter cup which is placed
inside introitus and may provide better seal.
• As the vaginal wall distends, there is increase in
intravaginal pressure, the fundus of uterus rises
and inversion is corrected
• Once this is achieved, fluid is allowed to
escape slowly from vagina.
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32. 14. In rare delayed cases, manual
replacement with or without hydrostatic
technique may be unsuccessful.
In such cases, Surgical replacement will
have to be done…
Procedure:
• Patient is cleaned and draped in Lloyd Davis
position
( frog legged ) with head down (Trendelenberg)
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33.  Catheterisation
 Midline laparotomy done
 Bowels packed upwards and away from uterus
 The obstetric surgeon places his/her hands in
front and back of the lower segment with the
fingertips below the level of inverted fundus.
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34. With progressive pressure on the finger tips of
both hands which flip up simultaneously.
The internal dimple is replaced with rising
fundus.
 Uterine perfusion returns.
• If this technique fails, Huntington’s Operation :
In this following steps are taken:
• Exteriorize the uterus
• Cervical ring may be stretched
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35. • Locate the cup of the uterus
formed by the inversion
• Dilate the constricting cervical
ring digitally
• Stepwise traction on the funnel
of the inverted uterus or the
round ligament is given with
Allis forceps .
• Reapplied progressively as
fundus emerges.

36. (A) Obstetric ventouse
applied on the inverted
uterine fundus.
(B) Reduction of the
inverted uterus after
traction with the
ventouse.
Instead of allies forceps
alternatively vaccum cup can
be used in HUNTINGTON
PROCEDURE 36

37. HAULTAIN’S PROCEDURE :
Incision is made posteriorly
through the cervix,
relieving cervical constriction
to increase the size of the
ring and allowing traction on
the round ligament for the
replacement of uterus with
subsequent repair of incision
from inside the abdomen.
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38. • Spinellis’s method
• Kustner’s method
• Hysterectomy
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Vaginal route

39. SPINELLI’S METHOD
• Anterior Colpotomy is done and incision on
the constricting cervical ring is given for
the replacement of uterus .

40. KUSTNER’S METHOD
• Posterior Colpotomy is done and incision of the
cervix similar to that of spinelli’s method.
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41. Hysterectomy
Failure of conservative surgery
Family is completed
sepsis
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42. Post Operative :
Whatever method for uterine replacement is used ,
It should be followed by…
1. Oxytocics to keep uterus is well contracted for 8 – 12hrs.
Oxytocin drip
15-methyl PGF2α
Ιnitially, after correction of inversion, inj. 15-methyl PGF2α
(carboprost) given in dose of 0.25mg i.m. or
intramyometrially (0.25mg diluted in 5 ml and given at two
sites is uterine fundus).
Duration of action: 6 hrs
2. Broad Spectrum Antibiotics given, if it is not given before.
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43. COMPLICATIONS OF
INVERSION OF UTERUS.
 Postpartum hemorrhage due to uterine atony.
 Hypovolaemic shock and all its consequence.
 Vasovagal shock (due to severe pain).
 Endometritis (sepsis).
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44.  Infection of adnexa.
 Necrosis of adnexa (ovaries) due to
compression of ovaries as they drawn inside.
 Damage to intestine / septic paralytic ileus.
 Chronic inversion.
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45. • Recurrence of inversion.
• Increased risk of rupture of uterus in next
pregnancy (when surgical procedure done for
inversion).
• Increased risk of C-section in subsequent
delivery.
• Chronic pelvic pain -> if chronic inversion is not
treated.
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46. PREVENTION
• Many cases of acute uterine
inversion result mainly from
mismanagement of the third
stage of labour in women who
are already at risk.
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47. MANEUVERS : TO BE AVOIDED
• Excessive traction on the umbilical cord
• Excessive fundal pressure
• Excessive intra-abdominal pressure
• Excessively vigorous manual removal of placenta.
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48. Recently...
• Vijayaraghvan et al. 26 reported a case where
acute inversion of the uterus was managed
under laparoscopic guidance, citing the
advantages of laparoscopic surgery as the
reason for the procedure.
• Consideration, however, needs to be given to
the woman’s hemodynamic status and the
possible effects of pneumoperitoneum.
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49. 49
(A) Laparoscopic appearance of the inverted uterus.
(B) A 5-mm forceps being used to press down on the top of the inverted uterus.
(C) Partial reduction achieved; further reduction was completed using a 10-mm blunt-tipped
Teflon rod to press down on the top of the inverted uterus.
(D) Complete reduction achieved.

50. 50Dr Shashwat Jani. 9909944160.