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9

OBSTETRIC TRAUMA D. G. Evans and C. B-Lynch

ACUTE firmly contracted is used as a piston to push the out, in the same manner that Acute uterine inversion, defined as when the a piston is used to push fluid out of the barrel of uterus is turned inside out, is a rare but serious a syringe. Pressure is applied with the palm of complication of the third stage of labor. The the hand in the axis of the pelvic inlet, in a estimated incidence is approximately 1 in downward and backward direction with the aim 20–25 000 deliveries1–3. As the estimate of a of forcing the placenta out through the lower later report was < 1 : 20004, the true incidence genital tract. Unfortunately, application of is unclear because some of the milder forms Crede’s maneuver when the uterus is not con- correct themselves spontaneously and are thus tracted may well facilitate acute inversion. On not recognized or reported. the other hand, the Brandt Andrews maneuver, also mentioned in standard textbooks of mid- Classification wifery and , a modification of Aris- totle’s method of delivering the placenta by cord Uterine inversion may be complete or incom- traction, recommends applying tension, but not plete, depending on whether the fundus has traction, to the with one hand, 5 passed through the cervix . When the uterine whilst the other hand is placed on the abdomen inversion occurs within the first 24 h post- gently moving the uterus upwards and back- delivery, it is classified as acute. Inversion wards. Today, controlled cord traction is occurring after the first 24 h and up to 4 weeks standard practice for the third stage of labor. postpartum is classified as sub-acute, and the Other etiological factors include forcibly rare chronic inversion occurs after the 4th week attempting to expel the placenta by using fundal postpartum. pressure when the uterus is atonic, and traction on the umbilical cord in a fundally placed placenta when the uterus is relaxed. It may also Etiology be brought about by a local atony, more particu- The expulsion of the placenta was probably larly of the fundal placental site together with intended by Nature to occur as a result of active contractions of the rest of the uterus. gravitational forces, with the mother in the Other etiological factors include macrosomia, same squatting position that is often adopted for , multiple , primiparity defecation. When the third stage is conducted in and administration5. In other instances, the dorsal position, however, help may be nec- however, the inversion occurs spontaneously essary for placental expulsion. Accordingly, the from sudden increased abdominal pressure as a inappropriate management of the third stage of result of coughing, sneezing or straining. labor is often implicated in the etiology of acute Chronic inversion may result from an acute uterine inversion. Indeed, Crede’s method of inversion left unrecognized or from a sub- placental delivery with uncontrolled cord trac- mucous fibroid which has prolapsed through tion, referred to in most textbooks of midwifery the cervix. A placental polyp resulting from a and older textbooks of obstetrics, may indeed retained cotyledon of the placenta may present increase the risk of acute uterine inversion. The in the same fashion.

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Diagnosis must be instituted prior to attempting replace- ment, and the bladder should be catheterized. Symptoms are acute and pronounced. Gener- Antibiotic prophylaxis is advisable. ally, the mother is aware of something coming Any delay increases the difficulty in replacing down and this is usually quickly followed by the uterus, and the first health-care professional unanticipated profound shock. The uterus may present should make the initial attempt at appear at the introitus outside the and replacement. This will be aided if regional anes- the fundus is no longer palpable abdominally. thetic is already in place8. The placenta should In partial inversion, the fundus of the uterus be left in situ and no attempt made to remove it. may be indented and may or may not pass The portion of the uterus that came down last through the cervical os. In such instances, it is should go back first, that is, the lower segment neither palpable abdominally nor visible at the initially and the fundus later. The hand is lubri- vulva. Vaginal examination detects the inverted cated with hibitane cream (or other suitable body of the uterus, and, above and encircling it, antiseptic if available) and placed inside the the ring of the cervix. In all instances, pain may vagina. With gentle maneuvers of the fingers be severe due to stretching of the infundibulo- around the cervical rim and simultaneous pelvic ligaments and other viscera. upward pressure with the palm of the hand, the Shock is the outstanding sign, and may in uterus is gradually replaced. The employment part be neurogenic due to stretching of the of force is dangerous, as the thinned-out lower viscera and in part due to hemorrhage and segment may be torn or otherwise traumatized. hypovolemia. The degree of shock is propor- The vaginal vault may already have been torn tional to blood loss and hemorrhage is variable, in some cases. The degree of shock does not depending on whether any attempt has been diminish until the uterus is replaced. In the made to remove the placenta. Some bleeding majority of instances, replacement of the uterus will always be present unless the placenta is is successful using this conservative method9. completely adherent to the uterine wall. It is If replacement is successful, the placenta important to recognize that severe hemorrhage should be manually removed with the aid of will accompany any attempt at removing the or an oxytocic infusion. In under- placenta before the uterus is replaced5,6. This developed countries or in a home setting, boiled eventuality is a special risk if the birth has been water brought to a bearable temperature can be attended by a traditional birth attendant (TBA) used to soak clean towels or cloths to assist in in parts of the underdeveloped world. pushing and packing the vagina. This may facili- tate replacement attempts and control further blood loss. Bimanual massage of the fundus Management may improve contraction. Acute uterine inversion is a true obstetric If replacement is unsuccessful, measures to emergency6, and clearly one which may lead to relax the cervical retraction ring should be the severe postpartum hemorrhage. If present and next line of therapy. Beta mimetics or amyl available, a supportive team should be sum- nitrite inhalation can often relax the retraction moned to the delivery suite for resuscitation ring sufficiently to allow uterine replacement9. and protocol management (see Chapter 20). A similar effect is seen with the administration Uterotomics, if started, are to be stopped of halothane anesthesia, but, unfortunately, use and manual replacement attempted under ade- of this agent in sufficient doses can result in quate and appropriate anesthesia followed by the unwanted and life-threatening complica- delivery of the placenta assisted by restart of tions of , hypotension and severe oxytocin7. hemorrhage. Halothane is no longer used for Elevation of the foot of the delivery table or these and other reasons. A 2 g intravenous bed may relieve the tension on the viscera and bolus of magnesium sulfate can be used in the reduce the pain and shock. Immediate resusci- hypotensive patient (0.25 mg of intravenous tation with intravenous fluids is indicated via terbutaline in the stable patient) to relax large-gauge venous access. Adequate analgesia the cervical contraction ring10. Intravenous

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nitroglycerine can be tried although it is not head-down (Trendelenberg) tilt. The patient is commonly used. catheterized with an indwelling catheter and Further attempts at replacement of the broad-spectrum antibiotics are administered. uterus should take place under general anesthe- With the bowels packed upward and away from sia in an operating theater equipped and ready the uterus, the obstetric surgeon places his to perform a laparotomy. Before resorting to a hands in front and back of the lower segment laparotomy, however, the tried and tested with the finger tips between and below the level O’Sullivan hydrostatic technique11 should be of the inverted fundus. With progressive pres- attempted. Here, the patient is first resuscitated sure on the fingertips of both hands which to restore vital signs including adequate blood flip up simultaneously, the internal dimple volume and pressure. The obstetric team and is replaced progressively by the rising uterine anesthetist are summoned. fundus (Figure 1a–e)13. Uterine perfusion Adequate analgesia is essential before: returns with re-establishment of uterine pulse pressure. (1) Attempt at repositioning without the use of If this technique fails, then the mid-line uterine relaxant; abdominal incision can be extended upwards if (2) If response is not imminent or sustained, an necessary. The inverted uterus resembles a fun- anesthetist should provide uterine relax- nel; it is best to exteriorize the uterus. Instru- ation to facilitate repositioning and the mental upward traction is applied to the round administration of uterotonics; ligaments bilaterally using Allis or ring forceps, while the assistant exerts upward pressure on (3) General anesthesia is preferable, adminis- the inverted parts from the vagina below. This tered by an obstetric anesthetist. Digital maneuver is the Huntington technique14,15. repositioning should be maintained to Failure at this stage warrants employing the support and establish good uterine muscle Haultain technique whereby an incision is made tone; vertically in the posterior cervix via the abdomi- (4) 1–2 liters of saline at body temperature nal route, following the dimple as a guide to should be infused into the vagina through relieve the constriction at this level. The assis- rubber tubes placed in the posterior fornix, tant exerts upward pressure from the vagina to whilst obliterating the introitus with the effect reduction and replacement16. obstetrician’s hand. As the vaginal walls distend, the fundus of the uterus rises and the inversion is usually promptly corrected. Once this is achieved, fluid is allowed to slowly escape from the vagina whilst the placement of the uterine fundus is achieved and maintained. When O’Sullivan first described this technique, he used a douche-can and wide rubber tubing to deliver the solution. More recently, a silastic vacuum cup has been used to instil the sterile solution into the vagina12. Until replacement is effected, however, towels soaked in warm hypertonic saline solution and draped over the inverted uterus may reduce the which will inevitably occur and which further impedes replacement of the uterus. In extremely difficult cases, replacement may require mid-line laparo- tomy, with the patient cleansed and draped in the Lloyd Davis (frog-legged) position with a Figure 1a Acute uterine inversion

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Figure 1b Acute uterine inversion. Finger tips Figure 1d Acute uterine inversion. Return of placed below fundus of uterus to facilitate reduction vascularity

Figure 1c Acute uterine inversion. Progressive Figure 1e Acute uterine inversion. Complete reduction with some ischemia reduction and revascularization with normal clinical features. (B-Lynch technique of non-instrumental On return of the uterus to its normal posi- reduction of acute uterine inversion at laparotomy. tion, the placenta should be removed manually ©Copyright ’05) from the vagina, and main- tained abdominally by bi-manual stimulation. Ergometrine, oxytocic intravenous infusion, or intensive care or the high-dependency unit for mesoprostyl can be administered. The posterior 24 h. uterine incision, if used, is then repaired in lay- A sub-acute inversion is managed in a similar ers, and the abdomen closed in the usual fash- manner but may resolve spontaneously as the ion. The patient should be monitored in the uterus involutes4.

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In chronic inversion, the uterus involutes in rupture of a scar confers a 10–20-fold increase its inverted position and remains in the vagina in risk of a subsequent rupture18,19. as a soft swelling, which bleeds readily to touch Rupture of the uterus is generally sudden, and shows areas of superficial ulceration. Pro- accompanied by severe abdominal pain and longed inversion may result in conversion of the followed by vascular collapse. In many cases, columnar epithelium of the uterine wall into a however, asymptomatic dehiscence takes place stratified squamous epithelium. Replacement of during a after a previous Cesar- a chronic inversion can prove extremely diffi- ean section, when the dehiscence is gradual and cult, due partly to the inevitable edema present retraction of the uterus arrests hemorrhage from and the friable nature of the tissues. The tech- the wound. Because of this possibility, it is niques adopted for replacing the acutely always necessary to exclude silent dehiscence inverted uterus are no longer helpful in this by manual exploration of the uterus after chronic situation. Bed rest, elevation of the foot delivery of the when a scar is present of the bed, antibiotic prophylaxis, and vaginal on the uterus. cleansing with hibitane packs may be helpful to A major factor in spontaneous uterine reduce the edema and treat any infections, but rupture is obstructed labor, especially in the it may eventually be necessary to perform a developing world when women routinely hysterectomy. If the chronic inversion is due to delivery without the benefit of the presence the presence of a fibroid or a placental polyp, of trained health-care providers. Rupture may initial removal of the polyp by ligating and be due to maternal or fetal causes (generally cutting the pedicle as near to the base as macrosomia). Examples of maternal causes are possible may facilitate replacement of the cephalopelvic disproportion from pelvic con- inverted uterus. traction due to developmental, constitutional or nutritional causes, abnormal presentation such as shoulder presentation, breech or brow, per- RUPTURED UTERUS sistent mentoposterior face presentation, trans- is a serious obstetric complica- verse lie, fetal abnormality, hydrocephalus, fetal tion with high morbidity and mortality. In tumor, fetal ascites, conjoined twins, maternal developed countries, the increasing number of tumors, intrinsic cervical lesions, extrinsic fib- Cesarean sections performed for minor degrees roids or tumor, locked twins, and rarely uterine of disproportion, or pre- misalignment such as incarcerated retroverted in primiparae is of considerable importance in uterus, and pathological uterine anteversion. calculating the long-term risks associated with Additionally, grand multiparity, the use of Cesarean section, particularly in terms of the uterotonic drugs to induce or augment labor, incidence and risk of uterine rupture. Both the placenta percreta, and intrauterine manipula- short- and long-term risks are accentuated in tion have all been implicated as causes of resource-poor countries. uterine rupture19,20. Uterine rupture may be complete when the The most common predisposing cause of tear extends into the peritoneal cavity, or rupture during pregnancy is a weak scar follow- incomplete when the serosa remains intact. ing a previous Cesarean section20. Rarely, rup- The rupture may be spontaneous, traumatic or ture can occur following unrecognized injury the result of scar dehiscence and may occur to the uterus at a previous difficult delivery. either during pregnancy, early in labor or It may present with sudden severe abdominal following a prolonged labor17. pains and collapse, or the symptoms may pres- In developed countries, the most common ent gradually, when rupture is based on scar cause of uterine rupture is dehiscence of a previ- dehiscence. If the onset is gradual, diagnosis ous lower segment transverse Cesarean section may be difficult as the abdominal pain may be scar. Rupture of a classical scar is eight times slight and accompanied only by alterations in more common than that of a previous lower the fetal heart tracing, maternal tachycardia and segment incision, and is far more apt to occur minimal vaginal bleeding. This triad is then before rather than during labor. Previous followed by patient collapse, cessation of fetal

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movement and easy palpation of the fetal parts Rarely, the uterus may rupture during early if the fetus has been expelled completely into to mid-pregnancy or during labor in patients the peritoneal cavity. If the patient is in a hospi- who have had a previous cornual ectopic preg- tal and the catastrophe recognized at its onset, nancy. Here also, the rupture is dramatic, is the outcome should be the safe delivery of the located over the repair site of the ectopic and baby and repair of the uterus. If the patient is is characterized as a fundal blow-out. Sudden not in a hospital, on the other hand, the catas- severe abdominal pain is experienced over the trophe is just that, a catastrophe of a dead child fundus of the uterus followed by collapse. and its mother. Rupture of a previously unscarred uterus is Uterine rupture during labor is also most usually a catastrophic event resulting in death of commonly due to dehiscence of a previous the infant, extensive damage to the uterus and a Cesarean scar with pain over the scar, followed very high risk of from blood loss. by sudden severe abdominal pain and collapse. The damage to the uterus may be so extensive In grand multiparae with a friable inelastic uter- that repair is impossible and a hysterectomy is ine wall, rupture may occur in early labor even required. In developed countries, the incidence where there has been no previous scar or diffi- of ruptured uterus in an unscarred uterus cult delivery, although this eventuality is not is approximately 1 : 10 000 deliveries22;in nearly as common as rupture in the previously the underdeveloped countries, the data are scarred uterus. Here, however, diagnosis may unknown. The incidence of rupture of a uterus be difficult initially as the presentation may be with a previous Cesarean section scar is 1%22,23. confused with a small accidental hemorrhage A trial of labor following a previous Cesarean and therefore missed. section increases the risk of perinatal death and Rupture after a prolonged labor is commonly rupture of the uterus compared to elective due to obstructed labor, with marked thinning repeat Cesarean section. In one large Canadian of the lower segment and increased retraction of study, a trial of labor following a previous the upper segment resulting in the formation of Cesarean section was associated with an a retraction or Bandl’s ring. The tear begins in increased risk of rupture (by 0.56%) but fewer the lower uterine segment, may extend up to the maternal deaths than in an elective section (1.6 fundus or down into the vagina, or proceed vs. 5.6 per 100 000)19. laterally into the broad ligament. If the tear In less developed countries, the incidence is posterior, it may go through the posterior of uterine rupture varies from 1.4% to 25%, vaginal fornix into the Pouch of Douglas with 25% in Ethiopian women with obstructed (colporrhexis)20. If the rupture is in the lower labor23. Uterine rupture accounted for 9.3% of anterior segment, the bladder is stripped from maternal mortality in one study from India and its attachment to the lower segment. The perito- 6.2% in a study from South Africa24. neum remains intact and so the rupture is char- A laparotomy is indicated when rupture of acterized as incomplete. A multiparous patient the uterus is suspected. The patient is anesthe- in obstructed labor will continue to have tetanic tized, cleansed, draped and the bladder cathet- contractions until the uterus ruptures, whilst erized with an indwelling catheter. A mid-line a primiparous patient will usually go out of lower abdominal incision should be used as this labor. Classical clinical signs of a rupture in a may be extended cephalad if necessary. The multiparous patient can be dramatic; abdominal fetus should be delivered expeditiously and the pain is constant, the contractions become virtu- uterus delivered from the abdominal incision to ally continuous initially with only short intervals assist in controlling the bleeding and assessing between them and later no interval between the situation while resuscitative measures are contractile forces, with the formation of a undertaken. In the series of over 1300 world- Bandl’s ring followed by rupture and collapse. wide reported successful applications of the The contractions then usually stop20–22, the B-Lynch (Brace) suture, 25 cases were applied fetus is expelled into the peritoneal cavity, for persistent uterine atony after repair of a the fetal parts are easily palpable and the uterus uterine rupture. In these cases, successful bleed- adopts an altered shape. ing control and hemostasis were achieved (CBL

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world-wide communication www.CBLynch. domestic physical abuse or intimate partner com)25. physical abuse can be as high as 13.5%29. Hysterectomy may be necessary and should Developed countries are not immune from have been consented, if at all possible. It is not this problem, however, and a large review of the necessary to remove the ovaries merely because prevalence of abuse during pregnancy in the this is easier in a crisis. As with a Cesarean hys- United States documented that between 0.9% terectomy performed in late labor, the cervix is and 20.1% of pregnant women were abused by no longer a discrete and circumscribed solid their partners. This figure covers all forms of structure, easily delineated and permitting accu- abuse, emotional, physical and sexual30. rate placement of vaginal clamps. In the acute Direct abdominal trauma by punching or situation, hemostasis and avoidance of further kicking the abdomen increases the risk of dissection are of paramount importance, and adverse outcome of the pregnancy. Adverse out- the removal of the distal cervix is not critical. comes are more common with direct physical The most difficult surgical situation occurs assaults than with motor vehicle accidents29,30. when the rupture is extraperitoneal into the Partner abuse also tends to be a repetitive event, broad ligament, with a massive hematoma dis- increasing the risk to the fetus31. In some coun- torting the anatomy and obscuring the bleeding tries, partner abuse and violence against women points. Here, it may be necessary to pack the is accepted as a cultural norm, thus reducing the space, the end of the pack being brought out numbers of reported cases. Even in the Chinese through a gap in the uterine repair20. A balloon community in Hong Kong and despite western catheter with light traction may be used for socialization, it is not uncommon for women to enhanced tamponade with or without the submit to their husbands and endure humilia- application of the B-Lynch (Brace) suture tion for the sake of keeping their family application26. together. Providing help for these pregnant Other conservative surgery may be appropri- women is challenging32. ate on occasions, for example, when simple Motor vehicle accidents account for 60–75% repair of the tear may be preferable to hysterec- of cases of blunt trauma. Most injuries are tomy. With an anterior rupture, the bladder minor, but, in the United States, between 1300 may be involved; the appearance of hematuria and 3900 women each year suffer a fetal loss as is almost pathognomonic. Repair is undertaken a result of a motor vehicle accident27,28. Despite and the bladder catheterized for 2 weeks. A pos- the majority of the injuries being minor, the terior fornix rupture (colporrhexis) is relatively fetus is always at risk and careful assessment easy to repair. Incomplete rupture is not usually must be carried out in all cases of blunt abdomi- apparent until delivery has been achieved. It nal trauma resulting from motor vehicle acci- will commonly declare itself by intrapartum or dents. Assessments must be frequent and postpartum hemorrhage. It should always be repeated with special attention to conditions excluded by manual exploration after delivery of commonly seen after such trauma. These the fetus. Both bladder tears and colporrhexis include abruptio placentae, preterm labor, may be missed if not anticipated. If this is the uterine rupture, fetomaternal hemorrhage, case, bleeding may continue, to the surgeon’s direct fetal injury and fetal demise33. dismay. The pattern of injury following automobile accidents depends on the type of seat belt restraints. An unbelted driver or passenger is BLUNT ABDOMINAL TRAUMA usually ejected from the vehicle or sustains The three main causes of serious blunt abdomi- injuries when they hit the interior of the car. nal trauma in pregnancy are motor vehicle The injuries are mainly to the face, head, chest, accidents, falls and domestic or intimate abdomen and pelvis. With shoulder and partner physical abuse. In the developed world, abdominal restraints, rib, sternum and clavicu- the most common cause of blunt abdominal lar fractures are common, whereas in the trauma is motor vehicle accidents27,28. In the lap-only belted, lumbar spine and hollow viscus less developed countries, the incidence of injuries are more frequent. Sharp objects in the

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pockets of the clothing on the person can cause relationship to the degree of trauma; abruption additional trauma; a fountain pen may perforate may occur with very little evidence of injury to the lungs or heart. Even bulky outdoor over- the mother. It usually, but not always, follows clothing represents a hazard. With thick cloth- soon after the trauma. ing, there is a short distance between the body Vaginal bleeding, abdominal pain, increased of the person and the restraint. On impact, the uterine tone, uterine tenderness, high frequency weight of the body causes acceleration forwards. contractions, and abnormal fetal cardiotoco- The speed of contact between the person graphy are the classical clinical signs of a placen- and the restraint can compound the damage tal abruption. In a posteriorly inserted placenta, sustained to the body. severe backache and vaginal bleeding may During the first trimester, the uterus is be significant symptoms. The bleeding may be well protected within the pelvis and sustains revealed or concealed within the uterus. If very little damage from blunt trauma. With concealed, in severe cases, the uterus becomes advancing pregnancy, however, the uterus woody hard as described by Couvelaire, blood becomes an abdominal organ and therefore having been extravasated into the muscular wall more susceptible to trauma. The blood supply of the uterus. Fetal parts are impossible to feel to the pelvis is markedly increased the more and the patient’s condition rapidly deteriorates advanced the pregnancy, giving rise to retro- due to hypovolemia and pain. peritoneal hemorrhage which can be life- The management of abruptio placentae threatening. Bowel injuries are less common, as depends on the severity of the abruption, the the bowel occupies the upper abdominal space nature of the general injuries sustained, the con- later in pregnancy, is a more movable entity and dition of the fetus and the duration of the preg- is not in the direct line of the trauma. nancy. The trauma surgeon and the obstetrician Assessing the extent of trauma can be diffi- should work together in managing the patient. cult, as clinical signs initially may be sparse. Establishing wide-bore intravenous access is Patients should be assessed frequently to detect essential. The hematologist should also be deterioration in their condition. The presence of involved. A complete thrombophilia screen bony injuries should raise suspicion of intra- should be requested and cross-matched blood peritoneal hemorrhage: rib fractures are associ- organized, together with fresh frozen plasma. ated with liver and spleen injuries and pelvic A preterm uncompromised fetus should be fractures with retroperitoneal hemorrhage and observed by continuous for a injury to the genitourinary system. minimum of 6–12 h or by a Pinard stethoscope Difficulty is often encountered in detecting a in less developed communities and, if the gesta- small amount of bleeding into the peritoneal tion is under 34 weeks, the mother should be cavity. As blood may be non-irritant, ultrasound given corticosteroids to mimimize the adverse examination may be equivocal, and CT scan- effect of prematurity on lung maturation. If the ning exposes the fetus to a large radioactive fetus is previable and compromised, vaginal dose. The decision to proceed to a laparotomy delivery is the safest for the mother. may therefore be entirely based on clinical In a term pregnancy with abruptio and judgement. an uncompromised fetus, vaginal delivery is an The most common cause of fetal death option. However, Cesarean section is advised if in non-fatal accidents is abruptio placentae. In the fetus is compromised. If the fetus, on the minor injuries, the incidence is between 1 and other hand, has died, induction of labor and 5%, in contrast to major trauma where the inci- vaginal delivery are appropriate and safe for the dence may be as high as 30%. At the time of mother. impact, the intrauterine pressure may be as high Preterm labor following blunt abdominal as ten times the pressure reached at the height of trauma may be precipitated by extravasation a labor contraction. Blunt trauma causes the of blood into the myometrium stimulating uter- uterus to compress and then expand and ine contraction. release may stim- the placenta shears away from the uterine ulate uterine activity. Preterm labor requiring wall. The degree of separation may bear no tocolysis occurs in 10–30% of cases of blunt

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abdominal trauma, but less than 1% deliver given Anti-D immunoglobulin to prevent sensi- before 34 weeks. Tocolytics should be used tization. Sensitization can occur as early as the guardedly, lest they mask the sign of abruption. 5th week of pregnancy. A Kleihauer–Betke test Contractions following blunt abdominal trauma is essential to assess the magnitude of the abate without treatment in 90% of cases. All fetomaternal hemorrhage and adjust the dose of tocolytics have side-effects which the obstetri- Anti-D immunoglobulin accordingly. cian should be familiar with: beta mimetics In all cases of blunt abdominal injuries, fetal induce tachycardia and may mask the early assessment is of paramount importance. Cardio- signs of abruption; non-steroidal anti- tocography is the most sensitive method of inflammatory agents affect platelet and renal immediate fetal surveillance. Ultrasonography function; and calcium channel blockers cause is only accurate in predicting 40% of cases of hypertension. The fetal heart rate and the abruption. Uterine activity is the most sensitive uterine contractions should be continuously indicator for predicting abruption following monitored34. blunt abdominal trauma. Frequent contractions Uterine rupture is a rare (1%) occurrence in have an adverse effect on fetal outcome. blunt abdominal trauma; when it does occur, it As a guideline, patients who have sustained is usually in association with a fractured pelvis. blunt abdominal trauma, but have no abdomi- The site of rupture is commonly the fundus of nal tenderness, no vaginal bleeding and no the uterus or the site of a previous uterine scar. contractions should be monitored 2-hourly for Fetal mortality in such cases is 100%, and 6–12 hours. Patients with abdominal tender- maternal mortality 10%35–38. Diagnosis may be ness, vaginal bleeding and contractions should difficult with vague abdominal pain, uterine be monitored continuously43,44. tenderness, but with easily palpable fetal parts, and a poor trace or absence of a fetal heart on cardiotocography. Fetal demise and maternal References shock are more dramatic presentations. 1. Spain AW. Acute inversion of the uterus. J Obstet If suspected, exploratory laparotomy in the Gynaecol Br Empire 1946;53:219 presence of the trauma surgeon is indicated. 2. Das P. Inversion of the uterus. J Obstet Gynaecol Uterine repair should be undertaken only if the Br Empire 1940;47:525–48 patient is hemodynamically stable. If not, hys- 3. Fahmy M. Acute inversion of the uterus. Int J terectomy should be performed. However, the Surg 1977;62:100 risk of a rupture in a subsequent pregnancy is 4. Watson P, Besch N, Bowes WA. Management of high, and the patient and her family should be acute and subacute puerperal inversion of the advised this at an appropriate time. uterus. Obstet Gynecol 1980;55:12 5. Brar HS, Greenspoon JS, Platt LD, Paul RH. Fetal injury occurs very infrequently follow- Acute puerperal uterine inversion. J Reprod Med ing blunt abdominal trauma. Fracture of the 1989;34:173–7 long bones or the skull is the most common 6. Wendel PJ, Cox SM. Emergent obstetric man- injury and occurs in approximately 1% of cases. agement of uterine inversion. Obstet Gynecol Clin If the fetus is distressed, immediate delivery is N Am 1995;22:261–74 called for. In the preterm non-compromised 7. Abouleish E, Ali V, Joumaa B, et al. Anaesthetic fetus, delivery may be delayed, but serial management of acute puerperal uterine inver- monitoring is advised39,40. sion. Br J Anaesth 1995;75:486–7 Fetomaternal hemorrhage occurs in up to 8. Catanzarite VA, Moffitt KD, Baker ML, et al. 30% of cases of blunt abdominal trauma, espe- New approach to the management of acute cially if the placenta is situated anteriorly. Most puerperal uterine inversion. Obstet Gynecol 1986; 68(Suppl):7–10 will have a normal outcome, although 9. Clark SL. Use of ritodrine in uterine inversion. anemia, supraventricular tachycardia and fetal Am J Obstet Gynecol 1984;151:705 demise can occur depending on the extent 10. Grossman RA. Magnesium sulphate for uterine 41,42 of the fetomaternal hemorrhage . Victims of inversion. J Reprod Med 1981;26:261–2 blunt abdominal trauma should be screened for 11. O’Sullivan JV. Acute inversion of the uterus. Br Rhesus factor, and all Rhesus-negative mothers Med J 1945;ii:282–3

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