|Year : 2015 | Volume
| Issue : 1 | Page : 52-55
Acute uterine inversion: A case report and literature review
OA Ojabo1, AG Adesiyun2, DI Ifenne1, S Hembar-Hilekan1, H Umar2
1 Department of Obstetrics and Gynaecology, College of Health Sciences, Benue State University, Makurdi, Nigeria
2 Department of Obstetrics and Gynaecology,Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||13-Mar-2015|
O A Ojabo
Department of Obstetrics and Gynaecology, College of Health Sciences, Benue State University, Makurdi
Source of Support: None, Conflict of Interest: None
Acute inversion is a rare but serious obstetric emergency. Women can rapidly develop profound shock which can prove fatal if not treated appropriately. A young multiparous woman was rushed to the obstetric unit of the hospital with a history of delivery at home under the supervision of her husband a few hours before presenting with a mass protruding from the vagina and associated severe vaginal bleeding. On examination, she was noticed to have complete uterine inversion of the uterus. She was promptly resuscitated with intravenous fluids and the uterus was manually replaced immediately. She was further managed with analgesics, uterotonic agents, antibiotics and three pints of blood was transfused. She made uneventful recovery and she was discharged from the hospital after 3 days. Uterine inversion is rare, therefore a strong clinical suspicion and prompt intervention in the form of immediate replacement of the uterus, blood transfusion, intravenous fluids with the use of broad spectrum antibiotics can be life-saving. The management of acute uterine inversion should be incorporated into skills and drills training.
Keywords: Acute uterine inversion, management of third stage, multipara, obstetric shock, post-partum bleeding, post-partum complications, post-partum hemorrhage
|How to cite this article:|
Ojabo O A, Adesiyun A G, Ifenne D I, Hembar-Hilekan S, Umar H. Acute uterine inversion: A case report and literature review. Arch Int Surg 2015;5:52-5
|How to cite this URL:|
Ojabo O A, Adesiyun A G, Ifenne D I, Hembar-Hilekan S, Umar H. Acute uterine inversion: A case report and literature review. Arch Int Surg [serial online] 2015 [cited 2023 Dec 2];5:52-5. Available from: https://www.archintsurg.org/text.asp?2015/5/1/52/153166
| Introduction|| |
Uterine inversion is defined as 'the turning inside out of the fundus into the uterine cavity'. Acute inversion is a rare but serious obstetric emergency. Women can rapidly develop profound shock which can prove fatal.  Immediate management of shock and manual repositioning of the uterus both reduce morbidity and mortality. The incidence of acute uterine inversion following vaginal delivery is 1 in 3737, and following Cesarean section, 1 in 1860.  Following the institution of active management of the third stage of labor in 1988, uterine inversion following vaginal delivery fell 4.4-fold from 1 in 2,304 to 1 in 10,044. , Post-partum hemorrhage complicated 65% of cases of acute uterine inversion, and 47.5% required blood transfusion. The incidence is higher among women whose deliveries are conducted by unskilled attendants especially where active management of the third stage of labor is not routinely practiced. Before modern management, mortality rates following acute uterine inversion were reported to have been as high as 80%. ,
Mismanagement of the third stage of labor is the commonest cause of acute uterine inversion. However, other risk factors have been cited including uterine atony, fundal implantation of a morbidly adherent placenta, manual removal of the placenta, precipitate labor, a short umbilical cord, placenta praevia and connective tissue disorders. ,,,, It must be emphasized, however, that, in up to 50% of cases, no risk factors are identified and there is no mismanagement of the third stage. 
| Case Report|| |
A 35-year-old para 6 + 0, 6 alive woman was rushed into the emergency unit with complaints of a mass protruding from the vagina following child birth at home about 3 hours before presentation. There was profuse vaginal bleeding. Attempts to replace the mass by the accoucheur, the husband failed. Though the husband attended to her in all her previous deliveries which were uneventful at home, he lacks any formal training as a birth attendant. Antenatal care and labor were uneventful until after delivery of the baby when, the placenta failed to be expelled spontaneously. She was given a herbal preparation following which the cord was held and traction was applied. This resulted in delivery of the placenta but a huge mass was noticed outside the introitus.
On examination, the patient was pale and very anxious, pulse rate (PR) was 96 bpm, moderate volume, and the blood pressure (BP) was 110/70 mmHg. Abdominal examination revealed slight suprapubic fullness with moderate tenderness. The suprapubic mass was due to bladder distension and the fundus of the uterus was not palpable. Pelvic examination revealed a polypoidal red mass protruding from the vagina and there was no active bleeding. The placenta was not attached and the mass was not edematous. The perineum was intact. A diagnosis of complete acute uterine inversion with moderate anemia was made and she was immediately resuscitated with one litre of normal saline administered intravenously. Intravenous pentazocine 30 mg was also given. Blood was taken for grouping and cross-matching of three pints. A Foley's urethral catheter was inserted.
Under aseptic conditions in the labor ward, the patient was placed in the lithotomy position and the prolapsed uterus was manually replaced into the vagina and then carefully reduced into the abdomen by gently pressing first on that part of the corpus which was inverted last, followed by the fundus through the dilated cervix. A hand placed on the lower abdomen anteriorly elevated the uterus into the abdomen. Twenty IU of oxytocin was given as a bolus to initiate uterine contraction and another 40 IU was added to a litre of normal saline. She was given intravenous broad spectrum antibiotics and tetanus prophylaxis. Oxytocin infusion was maintained for 24 hours. She was transfused with three pints of blood as an urgent hemoglobin (Hb) check revealed her Hb to be 7.8 gm/dl.
She made uneventful recovery and was discharged home on oral antibiotics, hematinics and advised on contraception and the need for adequate antenatal care and hospital delivery in case she conceives.
| Discussion|| |
Acute uterine inversion is a relatively rare obstetric emergency but it demands prompt management when it occurs in order to prevent a fatal outcome that delay can cause. The incidence is higher in remote rural areas of developing countries where access to emergency obstetrics care is still inadequate.  Mismanagement of the third stage of labor such as premature traction on umbilical cord and fundal pressure before separation of placenta is the commonest cause of acute uterine inversion. This can happen when delivery is conducted by an untrained accoucheur, a situation more likely to occur in developing countries as in this case.  In our patient, the inappropriate use of herbal concoction, which probably contained some uterotonic substances, may have further increased the risk of developing this condition. Many other risk factors have been cited, ,,, but none was identified in this case. About 94% of cases present with hemorrhage, with or without shock. The shock may be initially neurogenic with signs of bradycardia and hypotension but, with time, postpartum hemorrhage (PPH) will ensue. Fortunately, our patient was not in shock at presentation and the prompt resuscitation with normal saline probably prevented shock from developing. In a study of 28 cases, a lower incidence of shock and hemorrhage (28.5%) was observed.  Our patient did not present in shock despite having bled profusely at home. It is noteworthy that she was not bleeding actively at the time she was examined. Perhaps the reported blood loss was exaggerated by the unskilled birth attendant.
The key to a successful outcome is teamwork, as resuscitation and repositioning of the uterus have to be undertaken simultaneously. Uterine replacement should be attempted promptly. This is best done manually, as delay can render replacement progressively more difficult and increase the risk of hemorrhage.  In 1949, Johnson described the procedure commonly used for manual replacement of the uterus, now known as the Johnson manoeuvre. The principle behind this is that 'the uterus has to be lifted into the abdominal cavity above the level of the umbilicus before repositioning can occur. The passive action of uterine ligaments will rectify the uterine inversion'.  The chance of success following immediate reduction is in the range 43-88%.  In Johnson's description, the whole hand, plus two-thirds of the forearm, is placed in the vagina. Holding the fundus in the palm and keeping the tips of the fingers at the uterocervical junction, the fundus is raised above the level of the umbilicus. It may be necessary to apply digital pressure constantly, sometimes for several minutes. This places the uterine ligaments under tension. The tension generated relaxes and widens the cervical ring and facilitates the passage of the fundus through the ring. The inversion is, thus, corrected. If repositioning takes place before edema of the uterus and a contraction ring develops, the procedure is relatively easy to perform.
Once uterine replacement is successful, the uterus should be held in place for a few minutes and uterotonics administered to promote contraction of the uterus and to prevent re-inversion. Appropriate antibiotic cover is required to prevent infection. If the placenta has not yet separated, it should only be removed after repositioning of the uterus and when complete correction of the inversion has taken place in order to avoid shock and torrential bleeding.
If manual replacement fails, the hydrostatic method should be used as recommended by the World Health Organization (WHO).  Before attempting this method, uterine rupture must be excluded. The procedure is performed in an operating theatre with the woman in the lithotomy position. Warm sterile water or isotonic sodium chloride solution is rapidly instilled into the vagina via a rubber tube or intravenous giving set, while the accoucheur's hand blocks the introitus. The fluid distends the vagina and pushes the fundus upwards into its natural position by hydrostatic pressure. The bag of fluid should be elevated approximately 100-150 cm above the level of the vagina to ensure sufficient pressure for insufflation. The problem with this method is the difficulty in maintaining a tight seal at the introitus. This can be overcome by the use of a silastic ventouse cup, although a hand may still be necessary to ensure a tight seal.  The possible complications associated with hydrostatic methods are: Infection, failure of the procedure and, theoretically, saline embolus. , Although as much as five litres of fluid has been recommended as the infusion volume, there have been no reported cases of saline embolus or pulmonary edema.
In the presence of a constriction ring, reduction of uterine inversion can be very difficult. Tocolysis has a role in relaxing the uterus before manual replacement or use of the hydrostatic method. The adverse effect of tocolytic-mediated reduction in uterine tone, however, is an aggravation of postpartum hemorrhage, which is especially undesirable in the presence of shock. If manual replacement fails, general anesthesia is required. The advantage of general anesthesia is in addition to maternal pain relief, it promotes uterine relaxation.  Use of an intrauterine Rusch balloon catheter (Modified hydrostatic method) has also been reported. 
When the above measures fail surgical reduction becomes necessary. Surgical techniques that have been used include the Huntinton's operation and Haultain's operation and via laparoscopic guidance.  In the Huntingdon' operation, the abdomen is opened and the inversion site is exposed. A crater will be noted in the region of the cervix, with indrawn tubes and round ligaments. Two Allis forceps are introduced into the crater on each side and gentle upward traction is exerted on the forceps, with a further placement of forceps on the advancing fundus. By doing this, the uterus is pulled out of the constriction ring and restored to its normal position. In Haultain's operation, the cervical ring is incised posteriorly with a longitudinal incision. The rest of the steps are similar to Huntingdon's method. Once the uterus has been repositioned all incisions in the cervix, uterus and vagina are closed with interrupted sutures. Uterotonics are given to maintain contraction of the uterus.
Vijayaraghvan et al., 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. Antonelli et al., reported a case where laparotomy was performed and a silastic cup used from above for the correction of complete acute inversion of the uterus. The stated advantages of using a silastic cup were that it was gentler on the tissues and afforded easy placement and manoeuvring through the constriction ring. ,
| Conclusion|| |
Uterine inversion is an unusual and potentially life-threatening complication of third stage of labor. The morbidity and mortality associated with this complication can be decreased by prompt diagnosis and early initiation of pertinent treatment. Availability of skilled attendance with active management of the third stage of labor will go a long way in further reducing the incidence and fatality associated with acute uterine inversion. Proper education and training regarding placental delivery, diagnosis and management of uterine inversion should be given to traditional birth attendants and family physicians, so that this potentially life-threatening condition can be prevented. The management of acute uterine inversion should be incorporated into skills and drills training.
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