Inversion Of Uterus

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 Question
 
  • 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
Don’t Forget to Solve all the previous Year Question asked on Inversion Of Uterus

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