NEENU JACOB

INTRODUCTION

It is a rare but potentially life threatening
situation in which ,the uterine position is
changed from its normal situation


DEFINITION OF INVERSION OF UTERUS

Uterine inversion is a condition where the
uterus becomes turned inside out, with the
fundus prolapsing through the cervix.


Types of inversion

It has been classified on the basis of its duration
and degrees
a, Acute inversion :Occurs immediately after
delivery and before the cervix constricts (most
common >95%) occurs within 24 hours
b, Subacute inversion: Occurs after the cervix
constricts after 24 hours but before 4 weeks
c,Chronic inversion: Inversion noted 4 weeks after
delivery; rare incidence 1:2000 deliveries


Management of uterine inversion involves
two important components:

Immediate treatment of Shock
Replacement/Repositioning of the uterus

Acute and subacute inversion
Hypotension and hypovolaemia require
aggressive fluid and blood replacement.

Steps may include:

Get help. This should include the most
experienced anaesthetic help available
Secure further intravenous access with large
bore cannulae and commence fluids.
Resuscitation is usually started with
crystalloid such as 5% dextrose in normal
saline is started

Send blood for cross matching and start a
transfusion in time
Analgesics
Use warm sterile towel to apply compression
while preparing for the procedure
Insert a urinary catheter

REPOSITIONING

Manual reduction

It 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 with
other hand placed on the abdomen . After
replacement ,the hand should remain inside the
uterus until the uterus becomes contracted by
parentral oxytocin. The placenta is to be removed
manually only after the uterus becomes
contracted.


Use of tocolytics: to allow uterine relaxation.
For example:
Nitroglycerin (0.25-0.5 mg) intravenously
over 2 minutes Or terbutaline 0.1-0.25 mg
slowly intravenously Or magnesium sulphate
4-6 g intravenously over 20 minutes
Use of general anaesthesia: halothane


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 and
permitting replacement of the uterus


ANOTHER METHODS

OSullivan hydrostatic method
New technique


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 full
pressure(at least 2m high)
Fluid escape is prevented by blocking the
introitus by using the labia& operators hand
The fluid distend the vagina, relieves the
mild cervical constriction & result in
correction or replacement of the inverted
uterus

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 excellent
seal is created.


After repositioning:

Discontinue uterine relaxant/general
anaesthesia
Start infusion of oxytocin or ergot alkaloids
Continue fluid and blood replacement
Bimanual uterine compression and massage
are maintained until the uterus is well
contracted and hemorrhage is ceased
Remove placenta if retained following
replacement of the inverted uterus and
oxytocics given with uterus contracted

Careful manual exploration to rule out the
possibility of genital
tract trauma
Antibiotics- broad spectrum
Adequate analgesics
Oxytocics/ergot are continued for at least
24hrs.
Monitor closely after replacement to avoid re-
inversion


Chronic uterine inversion
In this surgical replacement/intervention
Involve 2 approaches:
Abdominal
Vaginal

Abdominal

Huntingtons procedure
Haultains procedure


Vaginal

Spinellis method
Kustners method
Hysterectomy: if present late with ischaemic
changes of the uterus or non-viable uterine
tissues, removal of the uterus is performed
following replacement of normal anatomy

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 upward
traction is applied
Repeated clamping and traction continue
until the inversion is corrected.

Haultain procedure

Under laparotomy,incision is made in the
posterior portion of the inversion ring,to
increase the size of the ring , allow
repositioning of the uterus and posterior
incision is repaired.

Spinellis method
Ant. Colpotomy is done & incision of the
cervix extending into the fundus is made
before manually correcting the incision


Kustners method

Post. Colpotomy is made & incison of the
cervix extending into the fundus is made
before manually correcting the incision


Prevention
Many cases of acute uterine inversion result from
mismanagement of the third stage of labour in
women who are already at risk. Hence the
following 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