AutorInformation
Panchbudhe Shruti*, More Vibha*,
Mali Kimaya*, Satia MN
(* Assistant Professor, ** Professor.
Department of Obstetrics and Gynecology, Seth
G.S. Medical
College and K.E.M
Hospital , Mumbai , India
Abstract
Acute uterine inversion has a rare
occurrence and is a catastrophic obstetric emergency. The condition should be
recognized quickly and managed appropriately by a multi-disciplinary team, in
order to minimize maternal morbidity and mortality. We report a case of acute uterine
inversion with obstetric hemorrhage and shock, the etiology for inversion being
mismanagement of third stage of labor in a case of adherent placenta. A
diagnosis of morbid adherent placenta should be borne in mind, in cases where
there is retained placenta in the third stage of labor, to avoid unforeseen
complications. This report highlights the importance of this condition and
provides optimal management of this potentially life threatening
condition.
Introduction
Acute uterine inversion is a remote
complication of third stage of labor. It is said to have occured when the
fundus of the uterus collapses into the endometrial cavity, thus turning the
uterus inside out. It may be either a complete or incomplete variety of
inversion. In complete type the uterine fundus extends beyond the external os
and in incomplete type the fundus lies within the endometrial cavity. A
prolapsed type is also described in which the uterine fundus lies outside the
vaginal introitus. It is usually caused by improper obstetric manipulation
during vaginal or cesarean delivery and in most of the cases it is a
catastrophe of the third stage of labor. The clinical picture typically is that
of hemorrhage and shock. Maternal mortality can be as high as 15%.[1]
The incidence of uterine inversion varies according to geographical location
and ranges from 1:25001 to 1:20000.[2,3] Uterine inversion is also
classified according to the extent and severity of the inversion into first
degree (fundus reaching up to the internal os), second degree (corpus or body
of the uterus is inverted up to the internal os) and third degree (uterus along
with cervix and vagina are inverted and are visible outside). Timing of the
uterine inversion is also important. Based upon the timing of inversion it is
classified into acute (which occurs within 24 hours of birth), subacute (occurring
after 24 hours but within 4 weeks after birth) and chronic (which occurs after
4 weeks).
Case Report
A 23 year old woman, Para3, Living 3,
day one of full-term normal vaginal delivery was referred from a peripheral
hospital to tertiary care institute in view of acute postpartum uterine
inversion with severe hemorrhage and shock. Patient had a uneventful full term
vaginal delivery and delivered a male child of 3.5 kg. Following delivery of
the baby, the third stage of labor was prolonged for one hour and placenta was
removed by on duty staff nurse by traction on the umbilical cord which had lead
to placental separation with uterine inversion and postpartum haemorrhage.
Manual reposition of uterine inversion was attempted in the same hospital, which
filed. The details of the same were not available. The patient arrived 4 hours
later to our institute. She was in agonizing pain with severe pallor, with
pulse rate of 155 bpm and blood pressure of 70/50 mm Hg. Per abdomen examination showed cupping at the fundus with uterine size of 12 week. Speculum examination
revealed a fleshy mass (inverted uterus) upto the cervical os with fresh
bleeding. Antishock measures were taken and antibiotic therapy was instituted. A
Foley’s catheter was passed into the bladder. Her hemoglobin was 4.4 g%. Her
coagulation profile were normal. Blood transfusion was started. During examination under general
anesthesia a small defect was felt at the uterine fundus more on the left side
and hence a diagnosis of uterine rupture with inversion was made. An
exploratory laparotomy was performed. Operative findings revealed uterus
inverted in the fundal region with bilateral fallopian tubes, ovaries and round
ligaments dragged upto the uterovesical fold of peritoneum, and 200 ml of hemoperitoneum. Huntington procedure was performed for correction of uterine inversion
in which Allis’ forceps were placed in the cup of the inversion and gentle
upward traction was applied.[4] In view of tight constriction ring, simultaneously
vaginal assistance was also obtained by pushing up the fundus with the palm of the hand and fingers in the
direction of long axis of cervix. Repeated
clamping and traction was continued until the inversion was corrected. After correction of uterine
inversion a complete uterine rupture of 5 cm was noted at
the uterine fundus. Uterus was pale and flabby and bleeding was present from
the rupture site. Hence an obstetric hysterectomy was performed. Approximate blood loss was 1.5 liters and
duration of surgery was 2 hours. Intraoperatively and postoperatively 6 units of
blood, 4 units of fresh frozen plasma and 2 units of cryoprecipitate were
given. Postoperative course was uneventful and patient was
discharged on day 7 of surgery. Histopathology of the hysterectomised uterine
specimen showed villi penetrating the myometrium suggesting of placenta accreta with rupture uterus.
Figure 1. Per speculum view showing
uterine inversion (arrow) with active bleeding.
Figure 2. Intraoperative finding showing uterine inversion in the fundal region with bilateral
fallopian tubes, ovaries and round ligaments dragged upto the uterovesical fold
of peritoneum.
Figure 3. Complete uterine rupture of 5 cm noted in the fundal region
with active bleeding present from the rupture site and atonic uterus. A. Side
view; B. Front view.
Discussion
Puerperal uterine inversion is due to displacement of the fundus of the
uterus, usually occurring during the third stage of labour. It is classified as
complete if the fundus passes through the cervix, or incomplete if it remains
above this level. The most common cause is mismanagement of third stage of
labor in which premature traction is applied on the umbilical cord before
placental separation. Spontaneous inversion is thought to occur due to localized atony on
the placental side of the uterine fundus, and an increase in the intraabdominal
pressure during bearing down, coughing or sneezing. The various predisposing
factors includes morbidly adherent placenta, short umbilical cord, fundal
pressure, implantation of the placenta at the uterine fundus, rapid or long
labors, injudicious use of oxytocics, previous history of uterine inversion,
congenital weakness of the uterine musculature as in collagen tissue disorders
like Ehler Danlos syndrome and certain tocolytic drugs like magnesium sulphate. The diagnosis of acute postpartum uterine inversion is mainly clinical,
based on three elements - hemorrhage, shock and a strong pelvic pain. The initial type of shock is usually
neurogenic type due to vagal stimulation associated to nervous tissue contained
in the uterine ligaments leading to bradycardia and hypotension; but it is
always better to be prepared for hemorrhagic and hypovolemic type of shock that
will follow in many cases. The amount of hemorrhage is
directly proportional to the duration of uterine inversion. In our case, shock
was not only due to uterine inversion but could also have been due to the uterine rupture which might have
occurred due to excessive force applied for correcting uterine inversion before
patient was shifted to our institute.
The initial gold standard treatment of uterine inversion is maternal
resuscitation along with manual uterine reposition, as delay can make
reposition difficult due to formation of constriction ring and edema and it
also increases the ongoing hemorrhage. Manual reposition of the uterus is
usually aided by pharmacologic agents, anesthetic or tocolytic drugs which
causes uterine relaxation. Agents causing uterine contraction are given after
correction of the inversion to prevent reinversion and also to decrease the blood
loss. The Huntington
References
1. Hostetler DR, Bosworth MF. Uterine inversion: a
life-threatening obstetric emergency. J Am Board Fam Pract 2000;13:120-3.
2. You WB, Zahn CM. Postpartum Hemorrhage: Abnormally
Adherent Placenta, Uterine Inversion, and Puerperal Hematomas. Clin Obstet Gynecol 2006;49(1):184-97.
3. Mirza FG, Gaddipati S. Obstetric Emergencies. Seminars in Perinatology. 2009;33:97-103.
4.
Huntington JL “Abdominal reposition
in acute inversion of the puerperal uterus,” Am J Obstet Gynecol 1928;15:34–40.
Citation
Panchbudhe
S, More V, Mali K, Satia MN