Uterine inversion is an extremely rare but life-threatening complication during childbirth in which the uterus is turned inside out partially or completely. It occurs in approximately 1 in 20000 deliveries.
Inversion often starts with a dimple in the fundus (top of the uterus) of the uterus and may continue till the uterus completely turns inside out.
In the most serious cases, the inner surface of the fundus appears at the vaginal outlet as in total inversion. In less severe cases, the fundus is dimpled which is known as a partial inversion.
Degree of inversion of the uterus
There are three degrees of uterine inversion depending on the position of the uterus and its projection in other organs.
First degree- In this degree, there is a dimpling of the fundus that remains above the top part of the cervix.
Second degree- The top part of the uterus passes through the cervix but lies inside the vagina.
Third degree (complete inversion)- In this stage, the uterus and cervix are completely inverted and the fundus protrudes outside the vaginal opening. The endometrium with or without the attached placenta is visible outside the vulva.
Classification of inversion according to the timing of the event-
Acute inversion occurs within the first 24 hours. Subacute inversion occurs after the first 24 hours and within 4 weeks. Chronic inversion occurs after 4 weeks and is very rare.
The causes of uterine inversion may include-
- Mismanagement of the third stage of labour, involving excessive cord traction to deliver the placenta
- Pulling the cord when the uterus is not well contracted, especially when combined with fundal pressure
- The wrong technique involved in manual removal of the placenta
- Abnormally adherent placenta (placenta accreta)
- Short umbilical cord
- Sudden emptying of a distended uterus
- Fetal macrosomia (big baby)
- Fundal attachment of the placenta
- Localised atony on the placenta site over the fundus
If the third stage of labour is managed carefully, uterus inversion can be prevented.
The major symptoms of uterine inversion may include shock and haemorrhage (severe blood loss). Severe blood loss can occur within a range of 800 to 1800 ml. There is persistent vaginal bleeding and pelvic pain. A woman may have difficulty in passing urine.
Shock and sudden onset of pain occur due to stretching of the pelvic nerves and the ovaries being pulled as the top of the uterus inverts. The dropping of blood pressure occurs due to excessive blood loss.
The fundus of the uterus cannot be palpable on abdominal examination and a mass can be felt on vaginal examination.
There are some ways by which uterine inversion can be prevented which involves-
- Avoid pulling the cord simultaneously with fundal pressure
- Don’t attempt to expel the placenta out when the uterus is relaxed
- Proper techniques are adopted to remove the placenta manually
The immediate treatment involves the manual replacement of the uterus to prevent excessive blood loss.
To reposition the uterus, the top of the uterus is gently pushed with the placenta attached to the uterus by firm pressure. If you try to remove the placenta at this stage may result in uncontrollable bleeding. After replacement, the hands should remain inside the uterus until the uterus becomes contracted. Inj. Methergine is given. If this works, the risk to the mother can be reduced.
An intravenous cannula should be inserted and fluids are started along with oxytocin to maintain the contraction so the blood loss can be minimised and helps to keep the uterus in place.
If manual replacement fails, surgical intervention is required to reposition the uterus. Emergency laparotomy can be performed by making an incision on the abdominal wall and replacement of the uterus is done.
In case of excessive blood loss, blood transfusions are given and antibiotics are prescribed to control sepsis.
In the above post, we have discussed the inversion of the uterus. It is a puerperal complication and very life-threatening during which the uterus is turned inside out partially or completely. It is usually caused due to mismanagement of the third stage of labour during childbirth. It can be managed by manual replacement of the uterus or by surgical method.