Inversion Of Uterus

INVERSION OF UTERUS

Q. 1

After a full term normal delivery patient went into shock. Most probable cause is ‑

 A

Inversion of uterus

 B

PPH

 C Amniotic fluid embolism
 D Eclapsia
Q. 1

After a full term normal delivery patient went into shock. Most probable cause is ‑

 A

Inversion of uterus

 B

PPH

 C Amniotic fluid embolism
 D Eclapsia
Ans. A

Explanation:

Inversion of uterus ?? ‘c’ i.e., Amniotic fluid embolism [Ref: Munroken’s operative obstetrics 10/e p 69, 476; Ian Donald, Renu Mishra 6/e p 626-630]

  • The patient went into unexplained shock after postpartum.
  • Both uterine inversion and amniotic fluid embolism can cause unexplained shock.
  • Uterine inversion is more common and important cause of unexplained shock than amniotic fluid embolism.

Munrokerr’s operative obstetrics says

  • “In all cases of unexplained shock after delivery make a careful vaginal examination to exclude the possibility of occult rupture of the uterus, partial uterine inversion or pelvic hematonza”.

Munrokerr further adds

Uterine inversion is the most important cause of unexplained shock

Three degrees of inversion are generally described.

i)    Where the inverted .fundus reaches the internal os

ii)     Where the whole body of the uterus is inverted upto the internal os.

iii)      Where uterus, cervix and vagina are completely inverted

Symptoms of uterine inversion

  • Symptoms of uterine inversion are not always well defined.
  • If however the inversion occurs quickly or is of severe degree there is .feelling of something coming down and pain followed by collapse and hemorrhage of variable severity.
  • When the inversion is of lesser degree and is contained within the vagina or when the .fundus does not come beyond the os externum, only pain and hemorrhage may be present.
  • Inversion is also the most important cause of unexplained shock

–  In these cases the shock is not primarily due to loss of blood or trauma but is really of neurogenic origin.

–  In this connection it has been suggested by several authors that as one or both ovaries may be pulled into the invagination, pressure on them may be responsible for shock.

–  The traction on the infundibulopelvic ligaments, peritoneum and broad ligaments stimulate the “parasympathetic system” producing shock.

Amniotic fluid embolism may also cause unexplained shock

-Amniotic fluid embolism is brought about by the uterine contractions forcing the liquor amni with its contained particles of meconium, lanugo, and vernix caseosa into a patent uterine sinus from where it is carried into the lungs. – We have opted for uterine inversion as it is the more common cause for unexplained shock.

Postpartum collapse from Ian Donald 6/e edited by Renu Mishra

  • Postpartum maternal collapse is serious obstetric complication
  • Majority of these cases occur as hemorrhage that is revealed.
  • But a small minority of cases of collapse after deliver occur without obvious vaginal bleeding but these are the ones that pose a greater challenge .for diagnosis and management.

The conzmon causes of postpartum collapse without bleeding are  Eclampsia

– Uterine rupture

– Vasovagal .syncope

– Pulmonary embolism (Amniotic fluid embolism)

– Septic shock

– Uterine inversion

Renu Mishra further adds

“Acute inversion of the uterus should be one of the first possibilities to cross the obstetricians mind in case of unexplained shock”

Amniotic fluid embolism

  • It is a life threatening complication of pregnancy with an extremely high mortality rate. 300
  • The pathogenesis of the condition is not clear.
  • Amniotic fluid probably enter the maternal venous circulation through a breach in the barrier b/w the maternal vasculature and the amniotic fluid most likely from the placental site or at the site of a uterine trauma after the membranes have ruptured.
  • Classically amniotic fluid embolism presents during labour or immediately after the delivery with sudden onset maternal collapse associated with tachyapnea, cyanosis, hypotension, altered mental DIC.
  • So, there is nothing to differentiate between uterine inversion and amniotic fluid embolism in terms of clinical presentation.
  • We have opted for uterine inversion as it seems to be the more important and more common cause of unexplained shock.
  • But we are still not sure

– A patient with amniotic fluid embolism will always present in this manner i.e., unexplained death following normal de livery .

– On the other hand uterine inversion commonly present as life threatening post partum hemorrhage. – It may present as unexplained shock but this is not its usual presentation.

– If there is a case of postpartum collapse and no other significant findings are present the first diagnosis that comes to the mind is embolism.

– All other causes of postpartum collapse will have some clinical .feature which would point towards to cause. Clinically most of the obstetricianl would suspect amniotic fluid embolism if any other abnormality is absent in case post partum collapse.


Q. 2

Common cause of death in inversion of uterus :

 A

Neurogenic shock

 B

Hemorrhage

 C

Pulmonary embolism

 D

Infection

Q. 2

Common cause of death in inversion of uterus :

 A

Neurogenic shock

 B

Hemorrhage

 C

Pulmonary embolism

 D

Infection

Ans. B

Explanation:

Hemorrhage


Q. 3

Complication of manual removal of placenta is/are:

 A

Subinvolution

 B

Inversion of uterus

 C

Incomplete removal of placents

 D

All of the above

Q. 3

Complication of manual removal of placenta is/are:

 A

Subinvolution

 B

Inversion of uterus

 C

Incomplete removal of placents

 D

All of the above

Ans. D

Explanation:

All of the above


Q. 4

Inversion of the uterus, a complication is noticed in:

September 2011

 

 A

1st satge of labour

 B

IInd stage of labour

 C

IIIrd stage of labor

 D

Post partum period

Q. 4

Inversion of the uterus, a complication is noticed in:

September 2011

 

 A

1st satge of labour

 B

IInd stage of labour

 C

IIIrd stage of labor

 D

Post partum period

Ans. C

Explanation:

Ans. C: IIIrd stage of labour

Inversion of the uterus is a rare but a life threatening complication in IIIrd stage in which uterus is turned inside out partially or completely

Uterine inversion:

  • Inside out turning of uterus
  • Results from mismanaged 3rd stage of labour
  • MC complication associated with inversion: Haemorrhage


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