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Uterine Inversion: a Life-Threatening Obstetric Emergency

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Uterine Inversion: a Life-Threatening Obstetric Emergency J Am Board Fam Pract: first published as 10.3122/15572625-13-2-120 on 1 March 2000. Downloaded from Uterine Inversion: A Life-Threatening Obstetric Emergency Dawn R. Hostetler, MD, and Michael F. Bosworth, DO Background: Acute puerperal uterine inversion is a rare but potentially life-threatening complication in which the uterine fundus collapses within the endometrial cavity. Although the cause of uterine inver­ sion is unclear, several predisposing factors have been described. Maternal mortality is extremely high unless the condition is recognized and corrected. Methods: MEDUNE was searched from 1966 to the present using the key phrase "uterine inversion." Nonpuerperal uterine inversion case reports were excluded from review except when providing infor­ mation on classification and diagnostic techniques. A summarized case involving uterine inversion and a review of the classification, etiology, diagnosis, and management are reported. Results and Conclusions: Although uncommon, if left unrecognized, uterine inversion will result in severe hemorrhage and shock, leading to maternal death. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as magnesium sulfate and terbutaline, or haloge­ nated anesthetics may be administered to relax the uterus to aid in reversal. Intravenous nitroglycerin provides an alternative to the tocolytics and offers several pharmacodynamic advantages. Treatment with hydrostatic pressure may be attempted while waiting for medications to be administered or for general anesthesia to be induced. In the most resistant of inversions, surgical correction might be re­ quired. (J Am Board Fam Praet 2000;13:120-3.) Uterine inversion during the acute postpartum pe­ Methods riod is a relatively rare complication. Severe post­ Using "uterine inversion" as the key phrase, MED­ partum hemorrhage and shock result from the LINE was searched from 1966 to the present. Ar­ uterine fundus collapsing. If unrecognized, this ob­ ticles pertaining strictly to non puerperal uterine stetric emergency could cause serious morbidity or inversions were excluded from review, with the death. The reported incidence of uterine inversion exception of those providing information on clas­ varies considerably in the literature. Most com­ sification and diagnostic techniques. A case involv­ monly, the frequency is reported to be approxi­ ing complete uterine inversion complicated by per­ http://www.jabfm.org/ mately 1 in 2000 deliveries; however, a range of 1 in sistent postpartum hemorrhage and resulting in 4000 to 1 in several hundred thousand can be hysterectomy is described. A review of the classifi­ 1 2 found. • Maternal mortality has been reported to cation, etiology, diagnosis, and management is re­ be as high as 15%.3 ported from the available literature. Treatment options for this obstetric complica­ tion are also quite varied. Several pharmacologic Case Report on 30 September 2021 by guest. Protected copyright. methods, as well as manual and surgical options, A 22-year-old woman, gravida 4, para 2, abortus 1, have been described for correcting an inversion. came to the hospital with premature rupture of The most important aspect of treatment remains membranes but no contractions at 35 weeks' ges­ immediate recognition and prompt attention to its tation. A sonogram done to confirm dates at 17 management. Following is a case report of com­ weeks additionally showed a posterior, low-lying plete uterine inversion with a discussion of classi­ placenta. Her prenatal care began at 7 weeks. At 28 fication, etiology, diagnosis, and methods of treat­ weeks, however, she changed providers from ob­ ment for this life-threatening obstetric event. stetric management to her family physician. Her prenatal course was otherwise unremarkable. The patient's obstetric history included postpartum Submitted, revised, 11 January 2000. hemorrhage after her third pregnancy, attributed From the Dayton Community Family Practice Residency to retained placenta. Management required dilation (DRH, MFB), Dayton, Ohio. Address reprint requests to Dawn R. Hostetler, MD, Brownsburg Medical Group, 1375 and curettage and transfusion of 2 units of packed North Green Street, Suite 100, Brownsburg, IN 46112. red blood cells. 120 JABFP March-Apri12000 Vol. 13 No.2 J Am Board Fam Pract: first published as 10.3122/15572625-13-2-120 on 1 March 2000. Downloaded from An obstetrician was consulted to address man­ The uterine fundus that has inverted and lies within agement of the preterm premature rupture of the endometrial cavity without extending beyond membranes. The decision was made to augment the external os is called an incomplete inversion. labor, and the patient began the second stage of Complete inversion describes an inverted fundus labor within 3 hours of starting oxytocin. A 241O-g that extends beyond the external os.4 A prolapsed male infant, who had Apgar scores of 8 and 9, was inversion is one in which the inverted uterine fun­ delivered uneventfully. Four minutes later, the pla­ dus extends beyond the vaginal introitus.3 A total centa was delivered, but it was adherent to a com­ inversion, usually nonpuerperal and tumor related, pletely inverted uterus. The placental membranes results in inversion of the uterus and vaginal wall as promptly filled with blood, which produced a large well.4 In terms of onset of the inversion, acute mass effect at the vaginal introitus and made man­ describes the event occurring before cervical ring ual reduction impossible without initially removing contraction. If the cervical ring has contracted, a the placenta. The obstetrician was called for assis­ subacute inversion has occurred. The inversion is tance, and the patient was taken to the operating classified as chronic if 4 weeks have elapsed before room for manual removal of the placental mem­ the event.2,4-6 ' branes and reduction of the inversion after starting general anesthesia with halothane. Etiology The patient was transferred to the recovery \Vhy uterus inversion occurs is unclear. The most room and monitored closely for symptoms of shock likely cause is strong traction on the umbilical cord, related to the massive blood loss experienced from particularly when the placenta is in a fundal loca­ the inversion. Prophylactic antibiotics were started, tion, during the third stage of labor.7 Other factors and 5 L of intravenous fluids with oxytocin, 4 units might include excessive fundal pressure; relaxed of packed red blood cells, and 3 ampules of carbo­ uterus, lower uterine segment and cervix; placenta prost tromethamine were used throughout the pa­ accreta, particularly involving the uterine fundus; tient's immediate postoperative period. Reevalua­ short umbilical cord; congenital weakness or anom­ tion by the consultants for persistent bleeding and alies of the uterus; and antepartum use of magne­ 5 continued symptoms of shock resulted in the deci­ sium sulfate or oxytocin. ,7,8 Other reports suggest sion to perform an emergency hysterectomy. Find­ primiparity and rapid emptying of the uterus after ings at time of surgery included an incomplete prolonged distention as possible predisposing fac­ inversion of the uterus that was not diagnosed pre­ tors.4-6 operatively on abdominal examination. http://www.jabfm.org/ Postoperatively the patient was observed in the Diagnosis intensive care unit. She was given fresh frozen Diagnosis of uterine inversion is usually based on plasma, blood transfusions, and colloidal fluids in clinical signs and symptoms. 'When there is com­ attempts to stabilize her blood pressure and prevent plete inversion, the diagnosis is most easily made by disseminated intravascular coagulation. By the next palpating the inverted fundus at the cervical os or morning she was hemodynamically stable and was vaginal introitus, as in the case described above. In on 30 September 2021 by guest. Protected copyright. transferred to a medical unit. Because of a persis­ incomplete inversion, palpating the fundal wall in tently low platelet count and low hematocrit levels, the lower uterine segment and cervix might be however, she required further transfusions of required for diagnosis. Profuse bleeding, absence of packed red blood cells and platelets. The patient uterine fundus, or an obvious defect of the fundus was released from the hospital on day 5. on abdominal examination, as well as evidence of A pathology report of the placenta was not ob­ shock with severe hypotension, will further provide s tained, but the uterine specimen from the hyster­ the clinician with diagnostic clues. ,9 ectomy showed evidence of placenta accreta in the Although clinical symptoms will provide the di­ fundus of the uterus. agnosis in most cases, radiographic methods to di­ agnose inversion have also been described in the Discussion literature. Hsieh and Lee10 describe the sono­ Classification graphic findings of uterine inversion discovered Uterine inversion is classified not only by the de­ incidentally in an acute incident. In the transverse gree of inversion but by the time of onset as well. images was visualized "a hyperechoic mass in the Uterine Inversion 121 J Am Board Fam Pract: first published as 10.3122/15572625-13-2-120 on 1 March 2000. Downloaded from vagina with a central hypoechoic H-shaped cavity." anesthesia has fewer potential adverse effects on Longitudinal images showed a U-shaped "de­ hemodynamics than do the l3-adrenergic tocolytics.9 pressed longitudinal groove from the uterine fun­ Hydrostatic pressure, cited commonly in the dus to the center of the inverted part." Magnetic British literature, is another method used to repo­ resonance imaging (MRI) of inversion has also sition the uterus when inversion has occurred. In been reported. The appearance of the uterus is this method, first described by O'Sullivan in the similar to that found in sonographic imaging; how­ British Medical Journal in 1945, a bag of warmed ever, MRl findings are much more conspicuous.3 fluid is hung on a pole used for intravenous fluids Thus radiographic imaging can help when the di­ above the level of the patient and allowed to flow, agnosis is uncertain after examination, and the pa­ via tubing, into the vagina.
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