Title

Inversion of uterus
A turning of the uterus inside out, usually
following childbirth.
Uterine inversion is a potentially fatal
childbirth complication with a maternal
survival rate of about 85%.
It occurs when the placenta fails to detach
from the uterus as it exits, pulls on the inside
surface, and turns the organ inside out.
It is very rare.

Incidence
1 in 2500 birth ( Brar et al 1989)
1 in 1853 in india ( Das, 1940)
Approximately : 1: 20,000 deliveries.

Classification of inversion
1. First degree:
there is dimpling of the fundus which still
remains above the level of internal os.
2. Second degree:
the fundus passes through the cervix
but lies inside the vagina.
3. Third degree (complete) :
the endometrium with or
without the attached placenta is visible outside
the vulva. The cervix and part of the vagina may
also be involved in the process.

Classification : according to timing

of the prolapse
1. Acute : prolapse occurs immediately after
delivery, with the placenta till attached.
2. Sub acute and chronic: it occurs after the
first 24 hrs.

Causes
Fundal pressure
Congenital weakness
Excess cord traction during the 3rd stage of
labor
Precipitate delivery
Uterine weakness
short umbilical cord
It is more common in multiple gestation than
in singleton pregnancies.

Types
ONE: Complete. Visible outside the cervix.
TWO: Incomplete. Visible only at the
cervix.[

Diagnosis

Investigations
If not clinically very obvious, ultrasound
can be used to identify the inversion

Management

The important principles are:

Treatment should follow a logical progression.
Hypotension and hypovolaemia require aggressive fluid and blood replacement. [15]Steps
may include:
Calling help. This should include the most experienced anaesthetic help available.
Securing further intravenous access with large-bore cannulae and commencing
fluids. Resuscitation is usually started with crystalloid, such as normal saline or
Hartmann's solution, although some people prefer colloids from the outset.
Inserting a urinary catheter.
Immediate uterine repositioning is essential for acute puerperal inversion. Measures
may include:
Preparing theatres for a possible laparotomy.
Administering 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.

Attempt prompt repositioning of the uterus. This is best done manually and
quickly, as delay can render repositioning progressively more difficult.
Reposition the uterus (with the placenta if still attached) by slowly and steadily
pushing upwards.
If this fails then a general anaesthetic is usually required.[16] The uterus may
then be returned by placing a fist on the fundus and gradually pushing it back
manually into the pelvis through the dilated cervix.
Maintain bimanual uterine compression and massage until the uterus is well
contracted and bleeding has stopped.
If this is unsuccessful, a surgical approach is required. Laparotomy for
surgical repositioning is more usual (find and apply traction to the round
ligaments) but a vaginal or even laparoscopic approach can be used.[17][18]
General anaesthetic or uterine relaxant is then stopped and replaced with
oxytocin, ergometrine or prostaglandins.
Start antibiotics and continue the stimulant for at least 24 hours. Monitor
closely after repositioning, in order to avoid re-inversion.

Complications
Complications include endomyometritis,
and damage to intestines or uterine
appendages.

 Prognosis
The condition carries a good prognosis if
managed correctly.

 Thank you