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NEENU JACOB

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INTRODUCTION It is a rare but potentially life threatening

situation in which ,the uterine position ischanged from its normal situation

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DEFINITION OF INVERSION OF UTERUS Uterine inversion is a condition where the

uterus becomes turned inside out, with thefundus prolapsing through the cervix.

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Types of inversionIt has been classified on the basis of its duration

and degrees

a, Acute inversion:Occurs immediately afterdelivery and before the cervix constricts (most

common >95%) occurs within 24 hoursb Subacute inversion: Occurs after the cervix

constricts after 24 hours but before 4 weeks

c,Chronic inversion: Inversion noted 4 weeks afterdelivery; rare incidence 1:2000 deliveries

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Management of uterine inversion involvestwo important components: Immediate treatment of Shock

Replacement/Repositioning of the uterus

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Send blood for cross matching and start atransfusion in time

Analgesics

Use warm sterile towel to apply compressionwhile preparing for the procedure

Insert a urinary catheter

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REPOSITIONINGManual reductionIt is a sterile procedure. It is as follows;

Push the fundus with the palm of the hand,along the direction of the vagina towards the

posterior fornix. Apply counter support withother hand placed on the abdomen . Afterreplacement ,the hand should remain inside theuterus until the uterus becomes contracted byparentral oxytocin. The placenta is to be removed

manually only after the uterus becomescontracted.

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Use of tocolytics: to allow uterine relaxation.For example:

Nitroglycerin (0.25-0.5 mg) intravenouslyover 2 minutes Or terbutaline 0.1-0.25 mgslowly intravenously Or magnesium sulphate4-6 g intravenously over 20 minutes

Use of general anaesthesia: halothane

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Reduction by hydrostatic pressure

A sterile douche water is introduced in to

the vaginal canal to distend it This tends to stretch the vaginal vault

allowing opening of the cervical ring andpermitting replacement of the uterus

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ANOTHER METHODS OSullivan hydrostatic method

New technique

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OSullivan hydrostatic method

Materials needed: An assistant

Long tube(2m) with a large nozzle

Water reservoir/Warm Saline(2-5L)

Put patient in trendelenburg position Place the nozzle of the tube in the posterior

fornix

An assistant start the douche with fullpressure(at least 2m high)

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Fluid escape is prevented by blocking theintroitus by using the labia& operators hand

The fluid distend the vagina, relieves themild cervical constriction & result incorrection or replacement of the inverteduterus

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New technique This is described by Ogueh & Ayida Citing difficulty in maintaining an adequate

water seal to

generate the pressure required, they suggest

attaching the IV tubing to silicone cup used in vacuum

extraction. By

placing the cup in the vagina, an excellentseal is created.

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After repositioning: Discontinue uterine relaxant/general

anaesthesia Start infusion of oxytocin or ergot alkaloids

Continue fluid and blood replacement

Bimanual uterine compression and massageare maintained until the uterus is wellcontracted and hemorrhage is ceased

Remove placenta if retained following

replacement of the inverted uterus andoxytocics given with uterus contracted

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Careful manual exploration to rule out thepossibility of genital

tract trauma

Antibiotics- broad spectrum

Adequate analgesics

Oxytocics/ergot are continued for at least24hrs.

Monitor closely after replacement to avoid re-inversion

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Chronic uterine inversionIn this surgical replacement/intervention

Involve 2 approaches:

Abdominal

Vaginal

Abdominal

Huntingtons procedure

Haultainsprocedure

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Vaginal

Spinellismethod Kustnersmethod

Hysterectomy: if present late with ischaemicchanges of the uterus or non-viable uterine

tissues, removal of the uterus is performedfollowing replacement of normal anatomy

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Huntington procedure Locate the cup of the uterus formed by the

inversion

Dilate the constricting cervical ring digitally

Place clamps in the cup of the inversion

below the cervical ring and gentle upwardtraction is applied

Repeated clamping and traction continueuntil the inversion is corrected.

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Haultain procedure Under laparotomy,incision is made in the

posterior portion of the inversion ring,toincrease the size of the ring , allowrepositioning of the uterus and posteriorincision is repaired.

Spinellismethod Ant. Colpotomy is done & incision of the

cervix extending into the fundus is made

before manually correcting the incision

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ustnersmethod Post. Colpotomy is made & incison of the

cervix extending into the fundus is madebefore manually correcting the incision

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PreventionMany cases of acute uterine inversion result from

mismanagement of the third stage of labour inwomen who are already at risk. Hence thefollowing maneuvers are to be avoided:

Excessive traction on the umbilical cord

Avoid overdosage of Oxytocin Advice for institutional delivery

Avoid applying forceps if the uterus is relaxed

Excessive fundal pressure

Excessive intra-abdominal pressure Excessively vigorous manual removal of placenta