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Inversion of the uterus: a serious complication at childbirth

2004; Informa; Volume: 84; Issue: 1 Linguagem: Inglês

10.1111/j.0001-6349.2005.0254b.x

1600-0412

Milan Milenković, Jarl A. Kahn,

Pregnancy and preeclampsia studies

Inversion of the uterus is a rare and dramatic complication of childbirth. Puerperal inversion of the uterus is classified as acute if the inversion occurs immediately after childbirth, chronic after a minimum of 30 days and subacute in the period in between (1). Uterine inversion, occurring within 24 h of delivery, can be divided into four degrees: uterine fundus extends to the level of the cervix in the first degree; below the cervix but not to the introitus vagina in the second degree; in complete uterine inversion the fundus extends either to the introitus (third degree) or below the introitus with the vagina inverted as well (fourth degree) (1,2). An inversion is termed spontaneous if there were no manipulations of the uterus during labor and no external force has been applied (1). When inversion occurs it is necessary to react immediately. We present two cases of acute uterine inversion, one by manual reposition and one by laparotomy. In both cases there was inversion of third degree with blood loss and shock in progress. Treatment is discussed. A 27-year-old primipara woman had a spontaneous vaginal delivery without any interventions after 40 weeks of gestation. The labor lasted 4 h. Ten minutes later the placenta was delivered spontaneously together with a profuse hemorrhage, and the inverted uterus was visual at the introitus vagina (third degree). The woman was in pain and became hypotensive. In general anesthesia manual reinversion was unsuccessful. A tight ring was found above the cervix. Laparotomy was performed, where both ligaments rotunda were grasped to steady the uterus, and with an Allis forceps the uterus was repositioned, stepwise, into the anatomic position. The circulation to the uterus seemed not to be compromised. Oxytocin was injected into the myometrium. Antibiotic therapy was started and the woman was discharged in good condition after 8 days. A 21-year-old primigravida woman was delivered at 36 weeks of gestation from a breech position. The labor lasted 3 h and 5 min. Oxytocin was administered during the last part of delivery. The placenta was delivered spontaneously 10 min later with some "cord traction." Heavy bleeding started and shock developed. On vaginal examination, the uterine fundus was seen at the level of introitus (third degree of uterine inversion). Shock therapy was started together with general anesthesia, and tocolysis was started. The cervix was grasped with a ring-forceps and pulled downwards, simultaneously the inverted part was pushed upwards to the normal position, step by step. After reposition, oxytocin was administered. Antibiotic treatment was given. The patient was discharged from the hospital after 6 days in good health. The incidence of inversion of the uterus varies from 1 in 8537 in Indian hospitals to 1 in 23 127 in the USA and 1 in 27 902 in British hospitals (3). Van Vugt et al. report 13 cases in 363 362 childbirths (1). We report two cases in 50 000 deliveries. The most common expression of uterine inversion is vaginal bleeding, pain and shock. Late signs are infection, superficial necrosis of the inverted part of the uterus and urinary complications (1). Watson et al., in his study of 18 patients, reported hemorrhage (94%) and shock (39%) (1). Van Vugt et al. described the following predisposing factors: the quality of the uterine wall and ligaments, a wide aperture through which the inverted part can pass, a weak abdominal wall, placental insertion in the uterine fundus and low parity and young age. The following factors can provoke an inversion: high intraabdominal pressure, traction of the umbilical cord, external forces and acting directly on the uterus (1). While mismanagement of the third stage of labor has been stressed as a causative factor, it should be remembered that cases of uterine inversion are few in relation to the total number of patients who receive active management in all stages of labor (5). In our two cases the placenta was delivered spontaneously. Some authors recommend removal of the placenta before repositioning the uterus. However, removal of the placenta prior to replacement causes some risk as the myometrium is easily torn, bleeding may be increased and shock aggravated while the maternal sinuses are exposed to sepsis (5). The incidence of uterine inversion during cesarean section is not known, but is reported to be extremely rare (6,7). O'Connor has reported a few cases of recurrent postpartum uterine inversion (8). Treatment of acute inversion requires the immediate implementation of shock therapy, immediate repositioning of the uterus and antibiotic therapy (3,4). The methods for replacing the inverted part can be divided into four groups: repositioning by nonsurgical techniques; abdominal operative repositioning—Huntington and Haultain methods; vaginal operative repositioning–the Spinelli method; and hysterectomy (1). During manual replacement tocolysis is recommended to relax the cervical ring and aid repositioning and general anesthesia. In the Huntington surgical procedure the cup of the uterine inversion is identified at laparotomy; Allis forceps are placed within the dimple of the inverted fundus and gentle upward traction is exerted on the clamps, with a further placement of forceps on the advancing fundus (1,2,5). Haultain's technique involves incising the cervical ring posteriorly with a longitudinal incision and facilitates uterine replacement by the Huntington method. After replacement is complete, the uterus is repaired in two or three layers (1,2,5). By using vaginal Spinelli surgical repositioning, an incision is made median in the inverted part and lengthened until the inversion ring is cleaved. If this is done anteriorly, it is necessary to displace the bladder first (1). O'Sullivan originally described a technique of replacing the inverted uterus using hydrostatic pressure. This method consists of occluding the vaginal introitus to allow the gravity-aided infusion of warm saline initially to distend the vagina and subsequently to push the fundus back to its original position (9). To prevent an early recurrence, several authors recommend a tamponade (1). In conclusion, early diagnosis, immediate treatment of shock and replacement of the inverted uterus are essential in this rare but dramatic situation. Avoidance of mismanagement of the third stage is recommend.