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Obstetrics Simplified - Diaa M. EI-Mowafi

Acute Inversion of the Uterus

Definition

The body of the uterus is partially or completely turned inside out.

Incidence

Very rare about 1: 20.000 deliveries.

Aetiology

  • Spontaneous inversion caused by:
    • Precipitate labour.
    • Traction on a short cord by the foetus.
    • Straining or coughing while the uterus is lax, particularly if the cervix is torn or gaped.
    • Submucous fundal myoma.
  • Iatrogenic inversion caused by:
    • pressure on the fundus or,
    • traction on the cord while the uterus is lax.

Degrees

  • First degree: The fundus is just depressed.
  • Second degree: The inverted fundus protrudes through the cervix.
  • Third degree: The whole uterus, including the cervix, is inverted and may drag the vagina and appear outside the vulva.

N.B.

  • Incomplete inversion: First or second degree.
  • Complete inversion: Third degree.

Clinical Picture

Symptoms

  • Pain: in the lower abdomen.
  • Sensation of vaginal fullness: with a desire to bear down after delivery of the placenta.
  • Vaginal bleeding: unless the placenta is not separated.
  • Subacute inversion: There is minimal symptoms and the condition is discovered later when the patient develops blood stained offensive vaginal discharge due to infection.

Signs

  • General examination:
    • Shock is out of proportion to the amount of blood loss as it is more neurogenic due to traction on the peritoneum and pressure on tubes, ovaries and may be the intestine.
  • Abdominal examination:
    • Cupping of the fundus -------- in the 1st and 2nd degrees.
    • Absence of the uterus --------- in the 3rd degree.
  • Vaginal examination:
    • In the 2nd and 3rd degrees the inverted uterus appears as a soft purple mass in the vagina or at the vulva.

Management

  • Anti - shock measures.
  • Manual reduction:
    • After resuscitation, the inverted uterus is reduced manually under anaesthesia, but do not delay reduction as the uterus will be oedematous and difficult to be replaced.
    • The part inverted last is replaced first so fundus is replaced finally.
    • If the placenta is still attached it is removed.
    • Massage the uterus and give ergometrine, IV oxytocin drip and antibiotics.
  • Hydrostatic reduction:
    • Replacement is possible by fluid pressure with warm saline delivered into the vagina through a wide bore tube from a container held at a height of about 60 cm. The vaginal introitus is closed by holding the labia major together.
  • Surgical reduction:
    • It is indicated in subacute and chronic inversions.
    • The cervix is incised posteriorly or anteriorly either vaginally or abdominally to reposite the uterus.

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