Diagnosis and Management of Uterine Inversion

Uterine inversion is an obstetric emergency. It is a rare but potentially life-threatening complication of the third stage of labor. The cardinal signs and symptoms of acute inversion are hemorrhage and shock. When it occurs, prompt recognition and treatment reduce morbidity and mortality.

HISTORICAL PERSPECTIVES

A historical review by Das (1940) states: “In the Ayurvedic literature, the Hindu system of medicine (2500–600 BC), there are passages which suggest the condition of inversion of the uterus was known to the Hindus.” Hippocrates (460–370 BC) is credited as the first to recognize the inverted uterus. Das suggests, however, that it was Soranus who clearly defined uterine inversion and attributed its cause to traction on the umbilical cord. Subsequently, Aretius (second century AD), Aetius, and Paulus Aegineta (AD 625–699) were acquainted with uterine inversion. Arvicenna, an Arabian physician (AD 980–1037), gave the first clear description of the differential diagnosis between inversion of the uterus and prolapse. Since Ambroise Paré (sixteenth century), inversion of the uterus has been recognized as a pathologic entity (Das, 1940).

CLASSIFICATION

A number of classification systems for uterine inversion exist. Most are related to duration or severity of inversion. The following is an example of one system of classification by duration:

• Acute inversion. An inversion diagnosed within 24 hours of delivery; cervical contraction may or may not be present.

• Subacute inversion. An interval between delivery and diagnosis of greater than 24 hours but less than 4 weeks; cervical contraction is always present.

• Chronic inversion. The presence of inversion for 4 weeks or more.

A classification by severity is as follows:

• First degree. Incomplete inversion in which the corpus extends to the cervix but not beyond the cervical ring.

• Second degree. Protrusion through the cervical ring but not to the perineum.

• Third degree. Complete inversion in which the inverted fundus extends to the perineum.

• Total. Inversion of the vagina.

From 1977 to 1986, the Los Angeles County University of Southern California (LAC/USC) Medical Center (Brar and associates, 1989) reported 139,771 births and 56 patients with uterine inversion, for an incidence of 1 in 2495 deliveries. Second-degree inversion occurred in 41 women (73.2 percent), and third-degree inversion in 15 (26.8 percent); none had first-degree or total inversion. Fifty-four patients (96.4 percent) had acute uterine inversion; two had subacute inversion requiring readmission 4–6 days following delivery. An earlier study by Platt and Druzin (1981) reported 68 percent second-degree inversions, 21 percent third-degree inversions, and 11 percent first-degree inversions.

INCIDENCE

The reported incidence of puerperal inversion of the uterus varies widely, but recent series indicate an incidence of approximately 1 in 2000 (range 1/500 to 1/20,000; Watson and associates, 1980). In Bunke and Hofmeister’s survey (1965) of Milwaukee hospitals between 1940 and 1962, puerperal inversion occurred in 1/4000 and 1/47,000 for an overall incidence of 1/20,000.

Many authors attribute a significant number of uterine inversions to mismanagement of the third stage of labor by excessive cord traction or fundal pressure, or both (Jones, 1913, 1914; Gordon, 1936). Jones suggests that traction on a placenta adherent to the fundus with its relatively weakened underlying musculature or pressure on the fundus by the hand of an attendant could produce a dimpled fundus to be gripped by the remaining uterine musculature and expelled through the cervix like a foreign body. In contrast, the Crede maneuver was not routinely used at the University of Colorado and they strongly discouraged vigorous cord traction. Oxytocin and methylergonovine were delayed until after placental separation. When this form of third-stage management was used, the authors rejected the association of uterine inversion and mismanagement (Watson and associates, 1980).

In 1925, McCullagh suggested a link between prolonged or precipitous labor and uterine inversion, although no association was confirmed by others (Watson and associates, 1980). After a number of authors (Das, 1940; Gordon, 1936; McCullagh, 1925; Henderson and Alles, 1948) noted the prevalence of primigravidas in large studies, some suggested that inversion is related to the number of primiparas in each patient population rather than to cause-and-effect relationship. In Watson and coworkers’ series (1980), 7 of 18 patients (39 percent) in the treatment group and 8 of 18 (44 percent) in the control group were primiparas. In Brar and colleagues’ study (1989) 32/56 patients (57 percent) were primiparas compared to 37 percent primiparas for the institution as a whole for the same time period. These authors and others (Shah-Hosseini and Errard, 1989; Rachagan and coworkers, 1988) also identified another significant factor; that fundal implantation of the placenta is more common in primiparas. In Brar’s study, fundal implantation of the placenta occurred in 52 percent of patients. Delivery of a macrosomic fetus was also associated with uterine inversion (Brar, 1989).

Brar also concluded that the use of oxytocin with or without magnesium sulfate placed women at higher risk for inversion; however, magnesium sulfate when used alone did not appear to be a risk factor. In contrast, Platt and Druzin (1981) found an association between the use of magnesium sulfate and uterine inversion and concluded that this was independent of the concomitant use of oxytocin. In their series, 7 of 15 (46 percent) primigravid women and two multi-gravid women received magnesium sulfate for the treatment of preeclampsia. Six of these nine women also received oxytocin. Three other patients received only oxytocin. Thus, 9 of 28 women with uterine inversion received magnesium sulfate and 9 of 28 received oxytocin, while 6 women received both drugs. The authors did not state the overall use of oxytocin or magnesium sulfate in their population.

In one woman, puerperal uterine inversion occurred in subsequent pregnancies. Steffen (1957) identified a patient who sustained a uterine inversion and spontaneous rupture of the uterus in her first pregnancy and a uterine inversion in her second. Heyl and colleagues (1984) reported a case of recurrent uterine inversion following the successful reduction of a uterine inversion occurring at the time of delivery. In this patient, a complete uterine inversion was recognized and manually reduced immediately after delivery. Fifteen minutes later, the inversion recurred and was again reduced. Two hours later, the uterus was again inverted. The inversion was corrected under general anesthesia, and 15-methyl prostaglandin F_2α; and uterine packing were used to prevent a recurrence of the inversion. Although uterine inversion may occur in a woman of any parity, it appears that primiparous women with a fundal implantation of the placenta are most likely to encounter this complication of the third stage of labor.

DIAGNOSIS

While the most common presenting sign of uterine inversion is hemorrhage (94 percent) (Watson, 1980; Jones, 1913; McCullagh, 1925; Bell, 1953; and their associates), shock is the most common complication of uterine inversion (40 percent) (Watson, 1980). In the past, shock out of proportion to blood loss was noted as one of the cardinal signs of uterine inversion (Das, 1940; Bunke and Hofmeister, 1965; McCullagh, 1925), but this has not been substantiated in more recent series (Platt, 1981; Watson, 1980; Kitchin, 1975; and their colleagues). The appearance of shock out of proportion to the amount of blood loss is more readily explained by an underestimation of blood loss than as the result of a neurologic response to the inverted uterus. Prompt recognition and treatment may prevent or minimize the consequences of the shock.

While uterine inversion generally presents with extensive postpartum hemorrhage, it may present predominantly as a pelvic mass, particularly if the fundus is located in the vagina (Fig. 13-1

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