Inversion of the Uterus

Inversion of the Uterus

Inversion means that the uterus has turned inside out partially or completely. In serious cases the inner surface of the fundusappears at the vaginal outlet. In less severe instances the fundus is dimpled.

Causes

·        Exerting  controlled  cord  traction  when  the  uterus  is

related especially if the placenta is centrally sited in the fundus.

·        Foreseeable attempting to expel the placenta by using fundal pressure when the uterus is atonic

·        Combining fundal pressure and cord tract in to deliver the placenta

·        Precipitate delivery with patient in standing position

The first three of these causes are the result of mismanagement and are therefore avoidable

Types of uterine inversion

Types of uterine inversion are characterized by the degree and the types of froce causing the inversion.

Complete inversion collapse of the entire uterus through thecervix into the vagina.

Incomplete or partial inversion of the fundus, with outextension beyond the external cervical

Forced inversion caused by excessive pulling of the cord orvigorous manual expression of the placenta or clots from an atonic uterus

Spontaneous inversion is due to increased abdominalpressure because of bearing down, coughing, or sudden abdominal muscle contraction.

Recognition

Sudden onset of shock is the out standing sign accompanied by sever gain which is caused by the ovaries being dragged in to the inverted fundus.

Bleeding may or may not be present depending upon the degree of placental adherence to the uterine wall.

The cause may not always be readily apparent as only in extreme cases is the fundus visible out side the vagina. Partial inversion may be present where the fundus does not pass through the cervix; it may however have extruded into the vagina.

Up on palpation a concave shape will be feet at the fundus; if the inversion is complete, none of the uterus will be palpable. A vaginal examination will reveal the inversion.

Management

Pressure is applied first to the part nearest the cervix, working up wards to the fundus on the principle of “last out, first in”. No attempt is made to remove the placenta until the uterus is the right way out, otherwise hemorrhage can not be controlled. If reinvasions not promptly performed, blood loss may be rapid and extreme, resulting in hypovolemic shock.

An inverted uterus can not contract and retract. Urgent assistance must be summoned mean while.

If replacement of a totally inverted uterus is not possible it should be gently placed inside the vagina to relieve traction on the ovaries and fallopian tube. When the uterus is successfully replaced, oxytocin is administered to stimulate uterine tone and avoid recurring inversion. Raising the foot of bed will also help to relieve the tension and alleviate shock.

Hydrostatic pressure method - several litres of warm saline or interavenous solution are run into the vagina via a douche nozzle head in the posterior fornix. The operator's forearm effectively seals the vaginal out let. As the fluid pressure with in the vagina rises, the uterus returns to its normal position.

Intravenous ergometrine 0.25 mg should be given to secure a good contraction before the hand is with drawn. Antibiotictherapy may be initiated to prevent or minimize risk of infection from exposure of the uterine lining and extensive manipulation.

General anesthesia may be needed to relax the uterus sufficiently to allow late replacement. In rare instances the uterus can not be reinvented and emergency hysterectomy is necessary to prevent profound blood loss.