Acute Puerperal Uterine Inversion

Acute puerperal uterine inversion is inversion of the uterus within 24 hours of birth, usually at the third stage, when the fundus is pulled through the cervix by cord traction or pushed by fundal pressure. It occurs in about 1 in 2000 to 1 in 6000 births, and is a major obstetric emergency causing sudden severe haemorrhage and shock. Delay in replacement raises the risk of death.

• Risk factors: fundal placenta, cord traction before separation, fundal pressure, uterine atony, short cord, accreta spectrum, precipitate labour, magnesium sulphate.
• Neurogenic shock from traction on the pelvic nerves out of proportion to blood loss.
• Immediate replacement before the cervix contracts is the key.

Women have sudden severe pain and collapse after delivery or during placenta delivery, with heavy bleeding, a mass at the vulva or in the vagina, and loss of the fundus on abdominal palpation. They may be pale, bradycardic and hypotensive.

• Smooth mass with or without the placenta attached.
• Fundus not felt or indented on the abdomen.
• Differential diagnosis: prolapsed fibroid, retained placenta in the vagina, vaginal haematoma, uterine rupture, severe atony with shock, amniotic fluid embolism.
• Complications: haemorrhagic and neurogenic shock, DIC, uterine necrosis, sepsis, recurrence, hysterectomy, maternal death.

The diagnosis is clinical, and treatment starts without waiting for tests.

• Abdominal palpation for loss of the fundus; vaginal examination for a smooth mass; pulse (may be slow), blood pressure, blood loss, level of consciousness.
• Haemoglobin, platelets, clotting screen, group and cross-match 4 units.
• Bedside ultrasound (absent fundus) if the diagnosis is doubtful.
• Examination of the placenta only after replacement.

The principle is immediate manual replacement, resuscitation and uterotonics after replacement, with theatre if replacement fails.

• Supportive: call for help at once; stop traction and fundal pressure and stop oxytocin until replacement; two large-bore cannulae; Ringer's lactate 1 to 2 litres rapidly; oxygen 10 to 15 L/minute; leave the placenta in place until replacement; shift to theatre; blood transfusion for shock; keep the hand in the uterus after replacement until it contracts.
• Pharmacological: glyceryl trinitrate 400 to 800 micrograms sublingual or 50 to 200 micrograms IV, or terbutaline 0.25 mg subcutaneous, for relaxation; sevoflurane general anaesthesia if relaxation fails; after replacement: oxytocin 10 IU IM and infusion of 40 IU in 1 litre Ringer's lactate at 250 mL per hour, ergometrine 0.2 mg IM (not in hypertension), misoprostol 800 micrograms sublingual; atropine 0.5 mg IV for bradycardia; cefazolin 2 g IV plus metronidazole 500 mg IV once, then amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days; tranexamic acid 1 g IV over 10 minutes.
• Procedures: manual replacement (Johnson manoeuvre) with the palm pushing the fundus up through the cervix toward the umbilicus, then holding it for 3 to 5 minutes; hydrostatic replacement (O'Sullivan) with warm sodium chloride 0.9 percent 2 to 3 litres into the posterior fornix; laparotomy with traction on the round ligaments (Huntington) or incision of the posterior ring (Haultain); hysterectomy for necrosis or failed replacement.
• Red flags: shock, bradycardia, bleeding, mass at the vulva, absent fundus, failed replacement within 15 minutes.
• Follow-up: observation of pulse, blood pressure and bleeding every 15 minutes for 2 hours then 4-hourly for 24 hours; haemoglobin at 24 hours; ultrasound at 1 week; review at 6 weeks; plan later births with active third stage and no cord traction before separation.