Uterine Inversion

Question 1

What is uterine inversion?

Answer 1

• it is described as the passage of the uterine fundus through the endometrial cavity and cervix turning the uterus inside out
• incidence around 1:20000

Question 2

How can uterine inversion be classified by timing?

Answer 2

• acute uterine inversion —> occurs either at the 3rd stage of labour or within 24 hours of delivery
• subacute uterine inversion —> occurs after 24 hours and within 4 weeks after delivery
• chronic inversion —> occurs after 30 days post partum, rare

Question 3

How can uterine inversion be classified by severity?

Answer 3

• 1st degree —> the inverted fundus extends to but not through the cervix
• 2nd degree —> the inverted uterus extends through the cervix but remains within the vagina
• 3rd degree —> the inverted uterus extends down outside the vagina to the introitus
• 4th degree —> the vagina and uterus are inverted

Question 4

What are the risks and predisposing factors?

Answer 4

• mismanagement of 3rd stage of labour
  —> excessive and or premature CCT before signs of separation
  —> carrying out CCT on a relaxed uterus
  —> use of fundal pressure with or without cord traction
• fundal implantation of the placenta
• connective tissue disorders e.g. Marfan syndrome, Ehlers-Danlos syndrome
• congenital abnormalities of the uterus
• retained placenta and abnormal adherence of the placenta
• short umbilical cord
• excessive fundal pressure
• fetal macrosomia
• primigravida
• overstretched uterus
• certain drugs such as those promoting tocolysis
• vacuum extraction
• retained placenta
• precipitate labour

Question 5

What are the main signs and symptoms?

Answer 5

• shock —> thought to be due in part to the parasympathetic response to the traction of the uterine suspensory ligaments
• severe pain —> usually in the pelvic region an can be described as severe cramping or lower back pain accompanied by a bearing-down sensation, this is due to the traction on the infundibulopelvic ligaments, round ligaments and the ovaries
• bleeding
• lump in vagina
• abdominal tenderness
• absence of uterine fundus on palpation
• polypoidal red mass in the vagina with placenta attached
• may be confirmed on vaginal examination or may be visible

Question 6

How should it be managed in hospital?

Answer 6

• call for help (SOAPS, 3 buzzers, 2222)
• lie the woman flat, give facial oxygen 10L/min, inform woman and partner, alert theatre team, maternal observations
• site 2 X IV cannulas, send bloods (fbc, clotting, X match 4 units of blood), commence 2L IV crystalloid
• attempt immediate replacement of the uterus —> the midwife inserts their hand into the vagina and cups the fundus of the uterus in the palm of their hand, pressure is then applied back up and along the long axis of the vagina towards the posterior fornix of the vagina
• if unsuccessful —> transfer to theatre, consider uterine relaxants e.g. terbutaline, re-attempt replacement or use hydrostatic method
• if successful —> uterine inversion is associated with atonic uterus in more that 90% of cases
  —> therefore, give oxytocic bolus IM
  —> commence 40IU syntocinon
• do not remove placenta until in theatre
• consider tranexamic acid alongside uterotonics if pph occurs
• consider further uterotonics as required

Question 7

How should it be managed at home?

Answer 7

• call 999, time critical paramedic ambulance
• attempt immediate replacement, oxytocic should be administered if successful
• IV access, fluids if possible
• maternal observations

Question 8

What should happen after the uterus is replaced?

Answer 8

• once replaced it should be held in position for a few minutes to promote uterine contraction and prevent re-inversion
• the use of a bakri balloon catheter may be useful
• administer oxytocics
• antibiotics should be prescribed and administered
• document
• debrief k