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Acute postpartum uterine inversion: report of two cases

2007; Elsevier BV; Volume: 17; Issue: 1 Linguagem: Inglês

10.1016/j.ijoa.2007.03.014

1532-3374

Davide Durì, U. Cugini, Monica Olivuzzi, Giovanni Del Frate,

Trauma Management and Diagnosis

Uterine inversion is a rare cause of obstetric shock that poses several problems to the obstetric anaesthesiologist. There is relatively little in the anaesthetic literature about management because of the rarity of the condition. We report two cases where anaesthetic involvement was necessary. The first was a 31-year-old woman (G2, P1) who was admitted to hospital two days after her expected date of delivery. She had previously given birth to a healthy child by emergency caesarean section. In this second pregnancy a healthy female weighing 3250 g with Apgar scores of 9 and 10 at 1 and 5 min respectively, delivered spontaneously after a 6-h labour. Delivery of the placenta was spontaneous with no cord traction but was apparently incomplete, resulting in haemorrhage, requiring intravenous oxytocin (30 units) given slowly over 10 min, and ergometrine 0.4 mg. The duty anaesthetist was called to provide sedation for manual removal of remaining placental tissue. Propofol 100 mg was given but during the attempts at manual removal second-degree uterine inversion was diagnosed. Blood loss was estimated at 600 mL and the woman’s blood pressure was noted to be 100/60 mmHg with a heart rate of 120 beats/min. General anaesthesia was induced with propofol 200 mg and tracheal intubation facilitated with vecuronium. Anaesthesia was maintained with 60% nitrous oxide in oxygen with i.v. fentanyl 5 μg.kg−1h−1. Blood gas analysis showed a haemoglobin of 3.8 g/dL and pH 7.22 with a base excess of–14.2 mmol/L. After induction of anaesthesia manual reduction of the uterine inversion was attempted but was unsuccessful. A laparotomy was then performed and Huntington’s procedure attempted but uterine atony persisted and was unresponsive to additional i.v. oxytocin (10 units), manual massage and intramyometrial sulprostone 500 μg. Uterine tamponade was attempted but atony and bleeding persisted and consequently a subtotal hysterectomy was performed. During the operation colloid 1500 mL, crystalloid 2000 mL, plasma 1200 mL and 8 units of blood were administered. Following surgery the woman was transferred to the intensive care unit at which time her haemoglobin was 11.8 g/dL. The next day she was transferred to the postnatal ward at which time her haemoglobin was 8.8 g/dL. She went on to make an uneventful recovery. Histological examination of the uterus revealed no abnormality. The second case was a 26-year-old woman (G2, P0) who presented in labour at 37 weeks’ gestation. Following a three-hour labour a healthy female baby was delivered spontaneously. The baby weighed 2940 g and had Apgar scores of 9 and 10 at 1 and 5 min respectively. Intravenous oxytocin (5 units) was administered after delivery. Delivery of the placenta was spontaneous with no cord traction but the placenta was apparently incomplete and second-degree uterine inversion was immediately noted. Immediate manual reduction was attempted but was unsuccessful. Blood loss was estimated at 800 mL. The woman was transferred to the operating room where general anaesthesia was induced with thiopental 125 mg, diazepam 4 mg, droperidol 2.5 mg and vecuronium 6 mg. The tracheal was intubated and anaesthesia maintained with 50% nitrous oxide in oxygen, and droperidol 2.5 mg/h and i.v. fentanyl .5 μg.kg−1h−1. At induction the blood pressure was 80/60 mmHg and the heart rate 150 beats/min. A laparotomy was performed during which the uterus was successfully replaced, controlling the postpartum haemorrhage. A total of 1000 mL of colloid and 2000 mL of crystalloid were administered. Following surgery the woman was transferred to the postnatal ward. Her haemoglobin was 5.4 g/dL and three units of blood were given which resulted in an increase to 8.9 g/dL. The patient subsequently underwent two normal vaginal deliveries without complication. There is a wide variation in the reported incidence of acute puerperal uterine inversion, from 1 in 551 after caesarean section,[1]Ogueh O. Ayida G. Acute uterine inversion: a new technique of hydrostatic replacement.Br J Obstet Gynaecol. 1997; 104: 951-952Crossref PubMed Scopus (43) Google Scholar to 1 in 57393 following vaginal delivery.[2]Morini A. Angelici R. Giardini G. Acute puerperal uterine inversion: a report of 3 cases and an analysis of 358 cases in the literature.Minerva Ginecol. 1994; 46: 115-127PubMed Google Scholar The degree of uterine inversion may be classified into four groups: 1st degree: fundus extends to the level of cervix; 2nd degree: fundus extends below the cervix but not to the introitus; 3rd degree: fundus extends to introitus; and 4th degree: associated with vaginal inversion. Factors associated with uterine inversion include pathologic conditions of the uterus,3Agarwal S. Minocha B. Dewan R. Uterine inversion and concomitant perforation following manual removal of placenta.Int J Gynecol Obstet. 2005; 88: 144-145Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 4Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar fundal implantation of the placenta,[4]Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar antepartum use of magnesium sulphate,3Agarwal S. Minocha B. Dewan R. Uterine inversion and concomitant perforation following manual removal of placenta.Int J Gynecol Obstet. 2005; 88: 144-145Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 5Dayan S.S. Schwalbe S.S. The use of small-dose intravenous nitroglycerin in a case of uterine inversion.Anesth Analg. 1996; 82: 1091-1093PubMed Google Scholar administration of oxytocin[3]Agarwal S. Minocha B. Dewan R. Uterine inversion and concomitant perforation following manual removal of placenta.Int J Gynecol Obstet. 2005; 88: 144-145Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and umbilical cord traction with vigorous fundal pressure, especially in cases of a fundal placenta.3Agarwal S. Minocha B. Dewan R. Uterine inversion and concomitant perforation following manual removal of placenta.Int J Gynecol Obstet. 2005; 88: 144-145Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 4Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar, 5Dayan S.S. Schwalbe S.S. The use of small-dose intravenous nitroglycerin in a case of uterine inversion.Anesth Analg. 1996; 82: 1091-1093PubMed Google Scholar It is also more frequent in primiparas and in women previously delivered by caesarean section.[6]Rodriguez M.H. Wang R. Clark S.L. Phelan J.P. Previous cesarean birth: management considerations in the patient with acute puerperal uterine inversion.Am J Obstet Gynecol. 1984; 150: 433-435Crossref PubMed Scopus (4) Google Scholar Despite the many conditions associated with uterine inversion, risk assessment is often lacking, making the condition usually unexpected at the time of presentation. The classical presentation is a displaced uterus while delivering the placenta, usually in association with pain, haemorrhage and possible bradycardia. Haemorrhage and the parasympathetic effect of traction on the ligaments supporting the uterus can quickly lead to shock, though sometimes symptoms and signs may be misleading, especially in non-acute inversion.[6]Rodriguez M.H. Wang R. Clark S.L. Phelan J.P. Previous cesarean birth: management considerations in the patient with acute puerperal uterine inversion.Am J Obstet Gynecol. 1984; 150: 433-435Crossref PubMed Scopus (4) Google Scholar If immediate reduction is unsuccessful, which may occur in up to 43%,[4]Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar it is suggested that the placenta is left in place to avoid further bleeding and the patient resuscitated before further attempts at reduction.[4]Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar In both of our cases, at the time uterine inversion was diagnosed the placenta had already been removed. Tocolytic drugs that have been successfully used to aid uterine replacement include magnesium sulphate,[4]Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar glyceryl trinitrate,4Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar, 5Dayan S.S. Schwalbe S.S. The use of small-dose intravenous nitroglycerin in a case of uterine inversion.Anesth Analg. 1996; 82: 1091-1093PubMed Google Scholar, 7Riley E.T. Flanagan B. Cohen S.E. Chitkara U. Intravenous nitroglycerin: a potent uterine relaxant for emergency obstetric procedures. Review of literature and report of three cases.Int J Obstet Anesth. 1996; 5: 264-268Abstract Full Text PDF PubMed Scopus (24) Google Scholar β2 agonists such as terbutaline[4]Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar and ritodrine[4]Beringer R.M. Patteril M. Puerperal uterine inversion and shock.Br J Anaesth. 2004; 92: 439-441Crossref PubMed Scopus (29) Google Scholar and amyl nitrite by inhalation.7Riley E.T. Flanagan B. Cohen S.E. Chitkara U. Intravenous nitroglycerin: a potent uterine relaxant for emergency obstetric procedures. Review of literature and report of three cases.Int J Obstet Anesth. 1996; 5: 264-268Abstract Full Text PDF PubMed Scopus (24) Google Scholar, 8Weiss H. Diaz F.R. Uterine inversion after nitroglycerin use during cesarean delivery.Int J Obstet Anesth. 1996; 5: 269-271Abstract Full Text PDF PubMed Scopus (9) Google Scholar All may be given in addition to general anaesthesia with volatile agents.[7]Riley E.T. Flanagan B. Cohen S.E. Chitkara U. Intravenous nitroglycerin: a potent uterine relaxant for emergency obstetric procedures. Review of literature and report of three cases.Int J Obstet Anesth. 1996; 5: 264-268Abstract Full Text PDF PubMed Scopus (24) Google Scholar Glyceryl trinitrate offers advantages over other agents because of its rapid onset and reduced maternal tachycardia. It can be administered sublingually or intravenously but its use is controversial in hypovolaemic patients, although not all authors consider vasodilatation following its use clinically relevant.[7]Riley E.T. Flanagan B. Cohen S.E. Chitkara U. Intravenous nitroglycerin: a potent uterine relaxant for emergency obstetric procedures. Review of literature and report of three cases.Int J Obstet Anesth. 1996; 5: 264-268Abstract Full Text PDF PubMed Scopus (24) Google Scholar Uterine inversion itself has been reported as a complication following the intravenous use of glyceryl trinitrate for uterine relaxation during caesarean delivery.[8]Weiss H. Diaz F.R. Uterine inversion after nitroglycerin use during cesarean delivery.Int J Obstet Anesth. 1996; 5: 269-271Abstract Full Text PDF PubMed Scopus (9) Google Scholar An attempt to perform manual reduction with tocolytics would appear justified, although there is no clinical trial demonstrating the superiority of any one tocolytic agent. No tocolytics were administered in the cases presented. Regional anaesthesia may be used in patients who are shocked, especially if a difficult intubation is suspected.[7]Riley E.T. Flanagan B. Cohen S.E. Chitkara U. Intravenous nitroglycerin: a potent uterine relaxant for emergency obstetric procedures. Review of literature and report of three cases.Int J Obstet Anesth. 1996; 5: 264-268Abstract Full Text PDF PubMed Scopus (24) Google Scholar Some authors report the use of epidural anaesthesia when a catheter has previously been used for labour analgesia.5Dayan S.S. Schwalbe S.S. The use of small-dose intravenous nitroglycerin in a case of uterine inversion.Anesth Analg. 1996; 82: 1091-1093PubMed Google Scholar, 9Harnett M.J.P. Segal S. Presence of placental tissue is necessary for TNG to provide uterine relaxation.Anesth Analg. 2000; 91: 1038-1044Crossref PubMed Scopus (3) Google Scholar General anaesthesia is, however, preferred where there is haemodynamic instability. Blood loss during uterine inversion varies from 500 to 2500 mL,[10]Brar H.S. Greenspoon J.S. Platt L.D. Paul R.H. Acute puerperal uterine inversion. New approaches to management.J Reprod Med. 1989; 34: 173-177PubMed Google Scholar but it is easily underestimated, as in our first case where there was a significant lactic acidosis. Several methods have been suggested to improve blood loss estimation in obstetric haemorrhage.11Bose P. Regan F. Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions.Br J Obstet Gynaecol. 2006; 113: 919-924Crossref Scopus (260) Google Scholar, 12Tourne G. Collet F. Lasnier P. Seffert P. Usefulness of a collecting bag for diagnosis of post-partum haemorrhage.J Gynecol Obstet Biol Reprod. 2004; 33: 229-234Crossref PubMed Google Scholar The rarity of this condition makes it impossible to identify risk factors and the best pharmacological treatment to allow reduction. The use of tocolyics is recommended only on the basis of case reports, and their side effects might raise concerns in shocked obstetric patients. Haemorrhage is usually underestimated and needs aggressive treatment. Clinical conditions may sometimes allow the use of regional anaesthesia.