Displacement of the

uterus

Ms. Sneha Sehrawat

AIIMS Rishikesh
1. The uterus has central position in the
pelvic
2. The ternal os is at the level of the ischial
spine
3. It is ante verted & ante flexed
4. Anteverted ;angle between axis of the
cervic and vertical axis of female .
5. Ante flexed ;angle between
6. Axis of the uterine body and
7. Axis of the cervix
Retroversion of the uterus ;
it mean that the axis of the cervix become
behind the vertical axis of femal body .
Retoflexion;
axis of the uterine body become behind the ais
of female body .
 DEGREE
First ;axis of the cervix is behind the vertical
axis of female but the fundus is above the
promontory .

Second ;the fundus is below the promontory

but still above the external os .

Third ; the fundus is

below the external os
 Causes of RVF ;
 Acquired during L&D;
1-Bearing down
2- Forceps delivery
3-breach extraction before fully dilatation

 During puerperium ;
No kegle’s ex
No sim’s position
 heavy uterus; fibroid , subinvolution
 Lax ligament ; pregnancy
 Adhesion ; inflammation
 symptoms
Pain
1. Low backache
2. Dysmenorrheal
3. Dysparunia
4. Dyschasia
5. Mid cyclic pain
6. Menstrual disturbance ;polymenorrhea
7. Leucorrhea
 Signs
1. Cervix is displaced
2. Fundus in dougl’s pouch
3. Absent of the uterus interiorly

4. Acute anterior angulation of the vagina

5. The cervix positioned well behind the pubic symphysis

6. A soft, smooth, nontender mass filling the cul-de-sac

 investigation
 PV Examination -----fied or mobile uterus

 Hystrography---- position of the uterus

 Double pessary test

 complication
1. Kinking of the uterine vessels----------
congestion of utters-- dysmenorrhea ,abortion
menorrhagia
2. Congestion of the ovary
polymenorrhra , anovulation ,mid cyclic pain
3. Infertility
anovulation ,cervix away from seminal pool
 Uterine prolapse
 Prolapse of tube & ovaries
 Management
 Prophylactic
1. During labor ,avoid bearing down , breach
extraction before full dilatation of the cervix
2. During puerperium , sleeping in semi’s
position empty of bladder , Hodge pessary
Management
Possible therapies for retroversion or incarceration include the
following:

Bladder drainage by indwelling catheter

Patient positioning exercises (eg, intermittent knee-chest or all-fours

positioning, sleeping prone)

Manipulation of the uterus into its usual anatomic position, with or

without tocolysis or anesthesia

Colonoscopic manipulation of the uterine fundus under anesthesia

Surgical exploration and replacement (almost never indicated)

Specialized and rarely attempted techniques of replacement (eg,
employment of a mercury-filled Voorhees bag in the vagina,
amniocentesis with manipulation)
 Prolapse of the Uterus

 Prolapse of the uterus refers to the downward

displacement of the vagina and uterus .The word
prolapse is derived from the latin procidere which
means with effect to fall.

 The uterus is held in position by adequate ligaments

Besides, it has the support of the muscular structures
of vagina and all other local tissues and muscles. Due
to the laxity of support by muscles, tissue and
ligaments, the uterus sags downwards .
 Types of uterine prolapse;
1. True uterine prolapse
2. False uterine prolapse
DEGREE
 First degree ;external os lies behind
ischial spine but inside the introitus
 Second degree ; external os lies outeside
the introitus but the fundus is inside the
introitus
 Third degree,fundus lies outside the
introitus (procedentia )
 Vaginal prolapse
 Cystocoele ; bulge of bladder into anterior vaginal
wall
 Urethrocoele ; bulge of post wall of urethra into
vaginal wall
 Rectocoele ; bulge of anterior wall of rectum into
post vaginal wall
 Prolapse of post vaginal wall; bulge of lower
posterior vaginal wall of into lumen of vagina
 Hernia of Dougl’s pouch ; bulge of loop of intestine
into upper part of post vaginal wall
 Vault prolapse ; bulge of the scare of TAH
 causes
 Congenital
1. Congenital prolapse ---at birth
2. Virginal prolapse -----before marriage

 Acquired
1. Labor 1-Bearing down
2- Forceps delivery
3-breach extraction before fully dilatation
4- large head without episiotomy
5-traction on cord
6-prolonged labour, an interference in the
delivery by inexpert people,
 During puerperium ;
No kegle’s ex
No sim’s position
lack of exercise and bodily weakness
lack of proper rest and diet in post-
natal periods, repeated deliveries and
manual work.
 heavy uterus; fibroid , sub involution
 Lax ligament ; pregnancy
 Menopausal atrophy ----decrease of
estrogen
 Increase in intra abdominal pressure;
1. Abdominal mass
2. Ascitis
3. Chronic cough
4. Chronic constipation
 Heavy uterus
1. tumors of the uterus,
2. Pregnancy
3. Subinvolution
 symptoms
 She feels a sense of fullness in the region of
the bladder and rectum .
 dragging discomfort in the lower abdomen,
low backache, heavy menses and milk vaginal
discharge
 .increase in the frequency of urination and the
patient feels difficulty in total emptying of the
bladder. burning sensation due to infection.
sexual
 The woman may experience difficulty in
passing stools and complete evacuation of
bowels .
 These symptoms become more pronounced
before and during menstruation .
 The condition may also result in difficulty in
normal sexual intercourse and sometimes
sterility .
 Complications
 Cystocoele ;
1. Cystitis
2. Pyelonephrinits
3. Kinking of the tube
 Uterine prolapse
1. Keratinisation of the
2. Decubital ulcer
3. Kinking of the tube
 prevention
good antenatal care in pregnancy,
proper management and timely intervention during
delivery,
1. Empty of bladder &rectum
2. Avoid bearing down
3. Avoid piston technique in placental delivery
good postnatal care
1. with proper rest, correct diet and appropriate
exercise so as to strengthen the pelvic
musculature .
2. sleeping in semi’s position empty of bladder ,
Hodge pessary, avoid early ambulation
 Uterine inversion
Uterine inversion may occur immediately postpartum
or, much less frequently, during the puerperium .

Inversions are usually described as acute (<30 d after

delivery) or chronic (>30 d after delivery) .
 Degree
 In first-degree inversion, the inverted wall
extends to but not through the cervix .
 In second-degree inversion, the inverted wall
protrudes through the cervix but remains
within the vagina .
 In third-degree inversion, the inverted fundus
extends outside the vagina. In fourth degree or
total inversion, both the vagina and uterus are
inverted .
 Possible etiology
 Reported associations for uterine inversion include the
following:
 Idiopathic
 Excessive cord traction or a short umbilical cord
 Credé (fundal) pressure
 Placenta accreta or increta or percreta
 Fundal implantation of the placenta
 Chronic endometritis
 Fetal macrosomia
 Trials of vaginal birth following cesarean delivery
 Myometrial weakness
 Precipitate labor
 drugs, including magnesium sulfate

 S&S
 The classic observations include
 postpartum hemorrhage,
 the sudden appearance of a vaginal mass, and
 varying degrees of cardiovascular collapse—all usually
occurring in the immediate puerperium .
 The postpartum hemorrhage is usually the most striking
of the symptoms and initially commands the attention of
the clinician .
 In other cases, the sudden and disconcerting protrusion
of a large, dark red, polypoid mass through the vagina
either accompanying or following the placenta is noted.
The characteristic appearance of the inverted uterus
either retained within the vagina or protruding externally
is both surprising and startling and usually immediately
establishes the correct diagnosis
 Management
 Following uterine inversion, prompt treatment
of hemorrhage and shock is vital in limiting
maternal morbidity and the risk of mortality.
 Hypotension and hypovolemia require
aggressive fluid resuscitation. The general
principles of treatment follow the (STAR)
protocol
 Shock
1. Initiate fluid resuscitation with 2 large-bore intravenous
lines. Promptly administer 1 or more liters of an isotonic
salt solution such as lactated Ringer parenterally.
2. Submit specimens to the laboratory for possible transfusion
and for determination of baseline values of hemoglobin
(Hgb), hematocrit (Hct), and coagulation factors.
3. Insert a Foley catheter.
4. Immediately summon an anesthesiologist.
5. Treat aggressively
6. Order appropriate surgical equipment and assistants to ready
the operating room for a possible laparotomy.
7. Administer tocolytics to promote uterine relaxation. These
may include nitroglycerin , or magnesium sulfate at 4-6 g
IV over 20 minutes.
 Attempt prompt uterine replacement.
First, proceed with a trial of simple
manual replacement. If this is
unsuccessful, promptly perform a
laparotomy for a surgical
replacement At laparotomy, general
anesthesia employing a uterine
relaxing agent is best,
 It is important that the part of the uterus
that came out last (the part closest to the
cervix) goes in first.
 Figure P-52
 Manual replacement of the inverted
uterus

 Repair
 Suture birth canal lacerations and any surgical
incisions in cervix or vagina .
 Perform uterine massage (after replacement).
 Administer uterotonics. These may include
methyl ergonovine maleate (Methergine 0.2
 Surgical techniques
 If 2 or more attempts at manual replacement
are unsuccessful, surgery is indicated. An
abdominal approach for uterine replacement is
favored. A vaginal technique has also been
described but has few adherents.
 In the vaginal procedure, the bladder is
dissected from the cervix, and the anterior lip
of the cervix and the anterior wall of the uterus
are incised to the extent necessary to permit
replacement .
 POST-PROCEDURE CARE
 Once the inversion is corrected, infuse oxytocin 20
units in 500 mL IV fluids (normal saline or
Ringer’s lactate) at 10 drops per minute:
 - If haemorrhage is suspected, increase the
infusion rate to 60 drops per minute;
 - If the uterus does not contract after oxytocin,
give ergometrine 0.2 mg or prostaglandins (Table
S-8).
 Give a single dose of prophylactic antibiotics after
correcting the inverted uterus:
 - ampicillin 2 g IV PLUS metronidazole 500 mg
IV;
 - OR cefazolin 1 g IV PLUS metronidazole 500 mg
IV.