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INVERSION OF UTERUS

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INVERSION OF UTERUS

DEFINITION:
  • It is an extremely rare but a life-threatening complication in third stage in which the uterus is turned inside out partially or completely.

CLASSIFICATION:

 According Types :

  • Incomplete Inversion : When fundus of uterus has turned inside out, like toe of socks, but inverted fundus has not descended through Cx
  • Complete Inversion : When the inverted fundus has passed completely through Cx to lie within the vagina or lie often outside the Vaginal Wall.

According Degrees:

First degree: 

  • The uterus is partially turned out
  •  Incomplete Inversion:Inverted fundus up to cervix 

Second degree: 

  • The fundus has passed through the cervix but not outside the vagina
  • Complete inversion in the vagina:Body of uterus protrudes through cervix into vagina

Third degree: 

  • The fundus is prolapsed outside the vagina 
  • Complete inversion outside the Vagina:Prolapse of inverted uterus outside vulva

Fourth degree: 

  • The uterus, cervix and vagina are completely turned inside out and are visible
  • According to Timing of Event
    • 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.
ETIOLOGY:
  • Excessive cord traction
  • Excessive fundal pressure 
  • Placenta accreta
  • Congenital predisposition
    • Fundal implantation of placenta
    • Either Spontaneous OR Iatrogenic causes.

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.

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 
PATHOPHYSIOLOGY:
  • Portion of uterine wall prolapses through the dilated cervix or indents forward?
  • Relaxation of part of the uterine wall?
  • Simultaneous downward traction on the fundus?
  • Leading to inversion of the uterus 
SIGNS & SYMPTOMS:
  • Hemorrhage (94%)
  • Severe abdominal pain in 3rd stage
  • Uterine fundus not palpable abdominally
  • Mass in the vagina on vaginal examination.
  • Sudden cardiovascular collapse
  • Lump in the vagina
  • Abdominal tenderness
  • Absence of uterine fundus on abdominal palpation
  • Shock is initially out of proportion with the amount of blood loss
  • Bradycardia, profound hypotension and rarely cardiac arrest.
  • Hemorrhage and Hypovolemic shock.

DIAGNOSIS

The diagnosis of uterine inversion is based upon clinical findings:

  • Bleeding, which may be severe and result in Hemorrhagic Shock
  • Palpation of the prolapsed uterine fundus:
  • Lower uterine segment: INCOMPLETE
  • Vagina:COMPLETE
  • By Intra Uterine Manual Examination
MANAGEMENT:
  • Replacement of the uterus using hydrostatic method (O’Sullivan’s)?
  • After replacement keep hand inside uterus till it contracts?
  • Remove placenta manually?
  • Blood transfusion(to treat shock)
  • Inverted fundus lies on the palm of the hand with the finger placed near uterocervical junction?
  • Pressure is exerted on the fundus?
  • Returns into the vagina?
  • Vagina is packed with antiseptic roller gauze
Hydrostatic method:
  • 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 supplementedby labial apposition around the palm by an assistant.
  • Alternatively vacuum extraction cup(douche ) is placed into the vagina at height of 3 feet above the uterus.
  • The water distends the vagina and the consequent increased intravaginal pressure leads to replacement of the uterus.

Exam Important

  • After a full term normal delivery patient went into shock. Most probable cause is Inversion of uterus
  • Common cause of death in inversion of uterus Hemorrhage
  • Complication of manual removal of placenta is Inversion of uterus
  • Inversion of the uterus, a complication is noticed in Third satge of labour
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