Uterus

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© Springer Nature Singapore Pte Ltd. 2020
A. Sharma (ed.)Labour Room Emergencieshttps://doi.org/10.1007/978-981-10-4953-8_39



39. Inversion Uterus



Pratima Mittal1   and Jyotsna Suri1


(1)
Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, Delhi, India

 



 

Pratima Mittal


39.1 Introduction


Inversion of the puerperal uterus, which is the passage of the uterine fundus through the endometrial cavity and the cervix, is the turning of the uterus inside out (Fig. 39.1). It is a rare but catastrophic complication of the third stage of labor, which is associated with a very high maternal morbidity and mortality, and hence it is very important for all obstetricians to be familiar with the emergency management of this condition. The incidence of uterine inversion has been variably reported from 1 in 1200–57,000 deliveries [1]. A retrospective review over a 24-year period estimated an incidence of 1 in 3737 after vaginal delivery and 1 in 1860 after cesarean section [2]. After the institution of active management of the third stage of labor in 1988, the incidence of inversion following vaginal delivery has fallen 4.4-fold [2].

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Fig. 39.1

A case of acute third-degree puerperal inversion of the uterus


39.2 Classification


Inversion of the uterus can be categorized into four degrees, according to the extent of inversion of the fundus [3] (Fig. 39.2):



  • First degree: the fundus dips into the uterine cavity; also known as incomplete inversion.



  • Second degree: the fundus traverses the uterine cavity through the cervix; also known as complete inversion.



  • Third degree: the fundus protrudes up to or beyond the introitus; also called the prolapsed inversion.



  • Fourth degree: the uterus and vagina invert completely and come out of the introitus; referred to as total inversion. This condition is most often seen in the non-puerperal state.


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Fig. 39.2

Degrees of uterine inversion


It has been observed that most of the cases (90%) present as second- or third-degree acute inversion to the emergency room [1].


The classification according to timing since delivery is as follows [4]:



  • Acute inversion—occurs within 24 h of delivery and before contraction of the cervical ring



  • Subacute inversion—presents from 24 h to 4 weeks after delivery and after contraction of the cervical ring



  • Chronic inversion—presents after 4 weeks of delivery


Acute presentation is the most common, whereas chronic inversion is the rarest, making it a diagnostic dilemma [4].


39.3 Risk Factors and Pathogenesis


The pathogenesis of inversion of the puerperal uterus is not clearly known. However the factors which have been associated with this condition are as follows [5, 6].


39.3.1 Factors Related to Labor Management


Mismanaged third stage of labor has been considered historically as a very important pathogenetic mechanism in the causation of inversion uterus. However a recently published RCT has shown inconsistent results between third stage management and inversion of the uterus [7]. The practices which have been associated with inversion of uterus are:



  • Excessive cord traction especially on a fundal placenta



  • Fundal pressure (Credé’s maneuver) during the third stage of labor



  • Rapid labor and delivery



  • Use of tocolytic-relaxed uterus and lower segment


39.3.2 Placental Factors [5, 6]






  • Fundal attachment of placenta



  • Retained placenta



  • Placenta accreta (especially if fundal)



  • Short cord


39.3.3 Maternal Factors






  • Anomalies of uterus



  • Uterine fibroids



  • Nulliparity


39.3.4 Fetal factors


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Mar 28, 2021 | Posted by in OBSTETRICS | Comments Off on Uterus

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