Uterine inversion
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"uterine inversion" management
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I now have thorough coverage from multiple authoritative sources. Here is the complete, well-organized response:
Uterine Inversion
Definition
Uterine inversion is a rare but potentially life-threatening obstetric emergency in which the uterine fundus collapses into or through the uterine cavity, turning the uterus "inside out." It occurs during stage 4 of labor (immediately postpartum) and is one of the recognized causes of postpartum hemorrhage (PPH).
- Rosen's Emergency Medicine, p. 3421
- Creasy & Resnik's Maternal-Fetal Medicine, p. 948
Incidence
Complicates approximately 1 in 2000 deliveries. Despite its rarity, it carries a maternal mortality rate of up to 15% from associated hemorrhage and shock.
Classification
| Type | Description |
|---|---|
| Incomplete (partial) | Inverted fundus does NOT extend beyond the external cervical os; may be occult |
| Complete | Inverted fundus extends beyond the cervix, typically visible as a beefy-red mass at the vaginal introitus |
| Prolapsed | Uterus extends outside the vaginal introitus |
| Chronic | Inversion present for >4 weeks (rare, often non-obstetric) |
Pathophysiology
The prevailing theory involves fundal placental implantation (occurs in ~10% of pregnancies but is found in virtually all reported acute cases). Fundal implantation causes thinning of the myometrium at the implantation site. As the placenta separates, the thin fundal myometrium invaginates, and the uterus "delivers itself inside out." Any additional mechanical force (cord traction, fundal pressure) in a uterus already predisposed by this anatomy accelerates the process.
- Creasy & Resnik, p. 948
Risk Factors
- Excessive/traction on the umbilical cord (especially with fundal placenta)
- Vigorous fundal pressure during delivery
- Placenta accreta (abnormal adherence)
- Uterine atony
- Fundal implantation of placenta
- Congenital uterine structural anomalies
- Connective tissue disorders
- Use of magnesium sulfate antepartum
- Primiparity
- Grand multiparity
Clinical Features
| Feature | Details |
|---|---|
| Pain | Sudden, severe abdominal/pelvic pain |
| Bleeding | Profuse vaginal bleeding - PPH is the hallmark |
| Examination | Uterine fundus absent on abdominal palpation; beefy-red mass visible at or beyond cervical os / introitus (complete) |
| Hemodynamic instability | Shock (both hypovolemic from blood loss AND neurogenic/vasovagal from peritoneal traction) |
| Occult presentation | Partial inversion may only be found on bimanual or speculum exam; suspect when fundus cannot be palpated abdominally in a patient with PPH |
Key clinical pearl: uterine inversion should always be suspected in a postpartum patient with PPH + inability to palpate the uterine fundus abdominally.
Diagnosis
- Clinical examination (bimanual, speculum) is primary
- Ultrasound (transvaginal or transabdominal) can confirm the diagnosis, especially for incomplete/occult inversions
- Tintinalli's Emergency Medicine, p. 686
Management
1. Immediate Resuscitation
- Call for help - this requires a team (OB, anesthesia, nursing)
- Aggressive IV fluid resuscitation (large-bore IV access, blood products as needed)
- Do NOT remove oxytocics without repositioning first, but IMMEDIATELY STOP all uterotonic agents upon diagnosis (cervical contraction will impede repositioning)
2. Manual Repositioning (Johnson Technique) - First-Line
The best chance of success is immediately after inversion occurs, before a cervical ring develops and edema sets in.
- Do NOT remove the placenta if it is still attached - removal while inverted causes excessive hemorrhage
- Grasp the uterus in the palm, with thumb anteriorly
- Apply gentle but firm, persistent upward pressure on the fundus, pushing it back through the introitus and up into the abdomen (indirect traction on round ligaments accomplishes the reinversion)
- Maintain firm manual pressure until the cervical ring contracts around a properly positioned uterus
3. Pharmacologic Uterine Relaxation (If Initial Attempt Fails)
If a cervical ring has formed and blocks repositioning, tocolysis is needed:
| Agent | Dose |
|---|---|
| Terbutaline | 0.25 mg IV or SC |
| Magnesium sulfate | 4-6 g IV over 15-20 min |
| Nitroglycerin | IV bolus (rapid onset, short duration) |
| Halogenated anesthetic agents | Via anesthesia team - used when above fail |
Once repositioned: stop muscle relaxants, restart oxytocin and prostaglandins, and maintain manual pressure until cervical ring re-contracts.
4. After Repositioning
- Placenta can now be removed manually
- Assess for: uterine perforation, retained placenta, vaginal/cervical lacerations
- Administer oxytocin/prostaglandins to prevent uterine atony
5. Surgical Options (If All Else Fails)
If manual reinversion fails, proceed to laparotomy:
| Procedure | Description |
|---|---|
| Huntington procedure | Grasp round ligaments ~1 inch into the inverted uterus; exert upward traction while assistant elevates from below vaginally |
| Haultain procedure | If fundus is too tightly trapped in cervical ring - make a posterior longitudinal incision through the cervix/fundus to allow room, then reinvert and close (leaves a classical cesarean scar posteriorly) |
| Hysterectomy | Last resort in refractory, life-threatening hemorrhage |
A Rüsch balloon catheter can also be used to correct inversion; gentle insertion is mandatory given the soft, friable postpartum tissue.
- Rosen's Emergency Medicine, pp. 3421-3422
- Creasy & Resnik's Maternal-Fetal Medicine, pp. 948-949
- Tintinalli's Emergency Medicine, p. 686
Complications of Delayed/Untreated Inversion
- Tissue edema increases cervical constriction, making reinversion progressively more difficult
- Tissue necrosis of the inverted fundus
- Bladder or urethral injury
- Acute tubular necrosis, pituitary necrosis (Sheehan syndrome), ARDS - all sequelae of prolonged puerperal shock
- Maternal death
Prognosis
If recognized and corrected promptly, there are no long-term sequelae and future pregnancies are not necessarily compromised. Delayed recognition and treatment is associated with significantly higher morbidity and mortality.
Sources: Rosen's Emergency Medicine | Creasy & Resnik's Maternal-Fetal Medicine | Tintinalli's Emergency Medicine | Textbook of Family Medicine, 9e
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