Acute uterine inversion: a review of 40 cases

Uterine inversion in retained placenta, that's why a good management of third stage of labor matters: A case report

Uterine inversion is characterized by the folding of the fundus into the uterine cavity. While infrequent, it ranks among the most serious complications of childbirth, posing a significant risk of mortality primarily due to hemorrhage and shock. Retained placenta after vaginal delivery is diagnosed when placenta does not spontaneously deliver within 18-60 min. Manual placenta can be considered first if retained placenta occurs. A 29-year-old woman with parity status P2A0 came to maternal emergency referred from the first health care provider with severe post-partum hemorrhage after delivering her second living 3100 g baby 2 h before admission. The midwife reported that the placenta was hard to have. There was a resistance felt inside when she tried to do umbilical cord traction. The manual placenta was not done. After several trials, the placenta finally came out, followed by fundus of uterine. Acute hemorrhage occurred, causing a decrease of hemoglobin level to 7.8 g/dl. At maternal emergency, the placenta delivered spontaneously yet the fundus still inverted. Fast reposition of uterine done by doctor on duty to stop the hemorrhage. Following successful repositioning and 4 days of observation, the patient was discharged from the hospital with no signs of hemorrhage and favorable results on abdominal ultrasonography.

Sonographic confirmation of placental detachment during placental delivery for uterine inversion prevention

AIM

To evaluate the usefulness of transabdominal sonographic confirmation of placental detachment in preventing uterine inversion.

METHODS

This was 14-year retrospective cohort study that included women who had transvaginal deliveries in our hospital. We introduced routine transabdominal ultrasonography during placental delivery to prevent uterine inversion. Followed by the confirmation of placental detachment by ultrasonography, we started placental delivery procedure. The frequency of uterine inversion during placental delivery was compared before and after the ultrasonography was introduced. Moreover, the duration of the third stage of labor and bleeding volume during labor were compared between the ultrasonography performing group (USG group) and the non-performing group (non-USG groups).

RESULTS

Five thousand and eighty-one women, including 1724 and 3357 women who delivered before and after the ultrasonography was introduced, respectively. The frequency of uterine inversion after the introduction of the ultrasonography system was significantly reduced compared to that before the introduction (0.03% vs. 0.23%, p = 0.03). Even after the introduction of ultrasonography, the actual rate of performing ultrasonography remained 54.1% due to various restrictions. The mean duration of the third stage of labor in the USG group was slightly longer than that in the non-USG group (8.4 ± 5.0 vs. 6.8 ± 3.6, p < 0.01). The mean bleeding volume during labor in the USG group was higher compared with the non-USG group (457 ± 329 vs. 418 ± 285, p < 0.01).

CONCLUSIONS

Transabdominal sonographic confirmation of placental detachment may be useful in preventing uterine inversion.

Bleeding, Hemorrhagic Shock, and the Global Blood Supply

Hemorrhage is responsible for at least 40% of deaths after trauma and 27% of maternal deaths worldwide. Patients with hemorrhagic shock require attentive critical care and transfusion of blood products. Access to a safe and affordable blood supply is critical to providing safe surgical care. Traumatic injury, obstetric hemorrhage, and upper gastrointestinal bleed are the main causes of severe bleeding requiring transfusion. This article discusses the presentation and management of these causes across the world and provides a brief overview of the current challenges in maintaining a global blood supply.

Acute uterine inversion - A complication revisited; a case series and review of literature

Objectives

The objective of this case series is to discuss the various presentations of acute uterine inversion and to discuss how these varied presentations can cause a diagnostic confusion. Differences in acute uterine inversion following a vaginal delivery and a cesarean section are also discussed along with the management of acute uterine inversion, emphasizing the need for a rapid diagnosis and management.

Case presentation

Three such cases of acute uterine inversion - two after vaginal delivery (one second-degree inversion and one third degree inversion) and one during cesarean section have been discussed along with their management.

Conclusions

Uterine inversion is a potentially life-threatening complication which can be prevented by active and careful management of third stage of labor and avoiding cord traction prior to development of the signs of placental separation. Early stages of uterine inversion may be confused with a prolapsed fibroid or a cervical polyp. Prompt management can avert maternal mortality and morbidity.

Unusual and delayed presentation of chronic uterine inversion in a young woman as a result of negligence by an untrained birth attendant: a case report

BACKGROUND

Uterine inversion is a rare but known complication following parturition and may prove fatal due to neurogenic shock or postpartum hemorrhage if not corrected immediately. The incidence is variable, occurring in 1 in 2000 to 1 in 50,000 deliveries, as reported in the past. Nowadays, the incidence is declining due to better antenatal care and increasing institutional deliveries. However, in a developing country such as India, due to cultural and financial reasons, most of the deliveries are still being conducted by untrained birth attendants ("dais") who have sparse knowledge of oxytocic drugs. Hence, proper education and training should be imparted to the traditional birth attendants and local village health practitioners about the management of labor, placental delivery, timely diagnosis, and proper management of uterine inversion to avoid this grave complication. We report this case because only a limited number of such cases have been reported so far with delayed presentation of chronic uterine inversion 8 months after delivery as a result of the negligence of an untrained birth attendant.

CASE PRESENTATION

We report a case of a patient with chronic uterine inversion presenting 8 months after childbirth as a result of ignorance at the time of delivery. A 22-year-old P1L1 (Para 1 Live 1) Asian woman of Punjabi ethnicity presented to our institute with a progressively increasing painless vaginal mass along with blood-stained vaginal discharge for the last 6 months and progressive dyspareunia (pain during intercourse) for the last 5 months that had worsened with time. She had experienced a full-term normal vaginal delivery at home 8 months earlier with the assistance of an untrained birth attendant (dai). Her history revealed that she had an unduly prolonged second stage of labor and was given aggressive fundal pressure due to inadequate bearing-down efforts and had collapsed after delivery but was managed conservatively by an untrained birth attendant. A provisional diagnosis of chronic uterine inversion was made on the basis of vaginal findings of a globular mass protruding from the cervix and approaching the vagina with thinning of the cervix around the mass, forming a tight constriction ring, in addition to ultrasound findings. The patient's condition was corrected surgically using Haultain's approach. She had a satisfactory outcome and was discharged symptom-free.

CONCLUSION

Awareness of this complication with timely diagnosis and prompt management can significantly minimize maternal morbidity and mortality, especially in a low- and middle-income country such as India, where 70-80% of deliveries still occur in a rural setting with untrained birth attendants.

Risks and consequences of puerperal uterine inversion in the United States, 2004 through 2013

BACKGROUND

Puerperal uterine inversion is a rare, potentially life-threatening obstetrical emergency. The current literature consists of small case series and a single nationwide study from Europe with only 15 cases.

OBJECTIVE

We aimed to define the incidence, temporal trends, and outcomes in women with uterine inversion using a nationally representative US cohort.

STUDY DESIGN

We used the Nationwide Inpatient Sample, a 20% sample of US hospital admissions, to identify all deliveries from 2004 through 2013. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify cases of uterine inversion and associated adverse outcomes (maternal death, blood transfusion, maternal shock, need for surgical correction, and length of hospital stay). The incidence of uterine inversion overall and for each year of the study period was calculated with 95% confidence intervals. The case fatality and incidence of other adverse outcomes among women with a uterine inversion were also estimated.

RESULTS

Among 8,294,279 deliveries in 2004 through 2013, there were 2427 cases of puerperal uterine inversion, corresponding to an incidence of 2.9 per 10,000 deliveries (95% confidence interval, 2.8-3.0). There was 1 maternal death in our cohort (4.1 per 10,000 events). No change in the incidence of uterine inversion over the study period was detected. Among women with a uterine inversion, 37.7% (95% confidence interval, 35.8-39.6%) had an associated postpartum hemorrhage, 22.4% (95% confidence interval, 20.7-24.0%) received a blood transfusion, and 6.0% (95% confidence interval, 5.1-7.0%) required surgical management. Only 2.8% (95% confidence interval, 2.1-3.5%) underwent a hysterectomy. The median length of hospital stay was 3 days.

CONCLUSION

This study provides the largest population-based results on puerperal uterine inversion to date and highlights the high likelihood of adverse maternal outcomes associated with the condition. The results inform the optimization of clinical management, by preparing for possible postpartum hemorrhage, need for blood products, and surgical management in the rare event of uterine inversion.

Acute complete uterine inversion after controlled cord traction of placenta following vaginal delivery: a case report

Early recognition and active management of the third stage of labor will reduce the risks associated with uterine inversion. All staff members in the maternal unit should be updated with Green‐Top guidelines No. 52 and be appropriately trained in the PROMPT course to provide a standardized approach in obstetric emergencies.

Color Doppler examination for the diagnosis of subacute puerperal uterine inversion

PURPOSE

Obstetric uterine inversion is a rare and life-threatening complication. Diagnosis is often difficult to establish, particularly in recurrent or chronic cases.

METHOD

We performed color Doppler examination in addition to B-mode sonography in a case of subacute recurrent uterine inversion.

RESULTS

Identification of the vessels providing uterine blood supply helped to clarify the distorted anatomy; furthermore, information about tissue viability was gained.

CONCLUSION

We propose to perform color Doppler examination in all cases with suspected uterine inversion or vaginal masses of unknown origin.

Upside-Down and Inside-Out Signs in Uterine Inversion

Uterine inversion is a rare condition that is accompanied by massive hemorrhaging and shock, resulting in a maternal emergency. The diagnosis of uterine inversion is often difficult due to massive postpartum hemorrhaging. Ultrasonography is useful for the diagnosis in such conditions, but we do not often encounter typical ultrasonographic images in uterine inversion because it occurs rarely. In the present case report of uterine inversion, we demonstrate the typical ultrasonographic findings of uterine inversion.

Uterine inversion after an unskilled delivery - still a concern for maternal mortality: A case report and discussion of the related medico-legal issues

Uterine inversion is a life-threatening medical emergency, which can result in fatal shock and sudden unexpected death during and after delivery. Most cases of uterine inversion occur due to mismanagement of the third stage of labour. We report a case of sudden death occurring post full-term vaginal delivery conducted by a traditional birth attendant (TBA) popularly known as dai. Autopsy revealed signs of haemorrhage and shock due to an inverted uterus. This emergency medical condition, though frequently fatal, can be treated if prompt action is taken by a trained and skilled obstetrician, preventing morbidity and mortality. We discuss the incidence, aetiology, symptomatology, complications and the management of uterine inversion. We also review the capability and eligibility of TBAs in handling such obstetrical emergencies, along with their culpability, if any, in such cases of negligence as per the applicable statutes.

Cardiac arrest following acute puerperal uterine inversion

Although uterine inversion is a potentially life-threatening complication of childbirth, there are only six case reports of cardiac arrest due to acute inversion to date. We report a successful outcome in a patient with sickle cell disease who had a witnessed cardiac arrest due to acute puerperal uterine inversion. Revival from cardiac arrest and resuscitation was followed by manual repositioning of the uterus. She gradually recovered from the acute kidney injury that developed as sequelae of the cardiac arrest and subsequent circulatory shock. Awareness of this rare complication and timely intervention is the key to a successful outcome in these patients.

Managing Major Postpartum Haemorrhage following Acute Uterine Inversion with Rusch Balloon Catheter

Acute postpartum uterine inversion is a relatively rare complication. The uterus inverts and the uterine fundus prolapses to or through the dilated cervix. It is associated with major postpartum haemorrhage with or without shock. Shock is sometimes out of proportion to the haemorrhage. Minimal maternal morbidity and mortality can be achieved when uterine inversion is promptly and aggressively managed. We present this report of three cases of acute uterine inversion complicated with major postpartum haemorrhage and managed with Rusch balloon. The paper highlights the importance of early recognition and the safety of the use of intrauterine balloon to manage major postpartum haemorrhage in these cases.

Acute uterine inversion in a rural African woman: a rare consequence of child birth

A case study of Ms. TE a 38-year-old Para7(+0) with seven living children is presented. Ms. TE had no antenatal care and was rushed to hospital with features of acute incomplete uterine inversion, 90 min after a spontaneous vaginal birth at home. The birth was supported by the second wife of her husband who had no experience in birth attendance. Her third stage of labour was not managed actively. Successful repositioning of the uterus was achieved under anaesthesia in the hospital. Uninformed mismanagement of third stage of labour was probably the reason for the condition of Ms. TE. Though acute uterine inversion is rare, accessible primary health care services are necessary for safe motherhood and for supporting women to birth safely.

Complete uterine inversion during caesarean section: A case report

Inversion of the uterus through the uterine lower segment incision during a caesarean section is an extremely rare obstetric incident. It consists, though, an emergency complication that is potentially life-threatening, especially in cases of prolonged inversion, because haemodynamic instability and shock may occur. Prompt diagnosis and immediate uterine reversion are the key actions in the management of this serious complication.

Postpartum hemorrhage: a recurring pregnancy complication

Postpartum hemorrhage (PPH) is a potentially life-threatening complication of both vaginal and cesarean deliveries. Although many variables increase the chance for bleeding, a PPH in a previous pregnancy is one of the greatest risk factors for recurrent PPH. A physiologic explanation for this association is not known, but recurrent risk factors such as a retained placenta or underlying medical disorders may account for the majority of recurrent PPH cases. To reduce maternal morbidity and mortality, prevention of PPH in these patients is critical. Steps to minimize hemorrhagic complications include the identification of high-risk patients through a complete history, vigilant management of the third stage of labor, and having uterotonic medications readily available in the delivery room. Patients with inherited coagulopathies require individualized treatment, and their risks for bleeding extend beyond the first 24 hours after delivery. Further studies are needed to determine whether the administration of prophylactic measures such as prostaglandins decrease the PPH occurrence in high-risk patients.

Puerperal uterine inversion: A report of four cases

Acute puerperal uterine inversion is a life-threatening and unpredictable obstetric emergency. If overlooked, it could lead to a maternal death. Although the precise cause is unknown, it is postulated to be caused by the mismanagement of the third stage of labor with premature traction of the umbilical cord and fundal pressure before placental separation. At the Ipoh General Hospital in Malaysia there were 31 394 deliveries and four acute uterine inversions occurring from 1 January 2002 to 30 June 2005. The four patients were between 25 and 36 years of age and their parities were between two and three. When manual repositioning of the uterus failed, successful correction was accomplished by the O'Sullivan's hydrostatic method. One case had to undergo subtotal hysterectomy after repositioning because of massive hemorrhage secondary to placenta accreta. Early diagnosis, immediate treatment of shock, and replacement are essential.

Acute tocolysis

PURPOSE OF REVIEW

Emergency uterine relaxation may decrease the morbidity and mortality of the mother and her fetus. Obstetricians need to be aware of the indications, pharmacological methods, efficacy and complications of acute tocolysis.

RECENT FINDINGS

A variety of pharmacological agents are used to suppress uterine contractions. Newer agents like cyclo-oxygenase-2 inhibitors (Celecoxib) and oxytocin antagonists (atosiban) have been introduced into clinical practice with the hope of reducing the complications of betasympathomimetic drugs. Calcium-channel blockers are used but there are recent case reports of acute pulmonary oedema with the use of these agents. Most of the trials on tocolytics have been for suppression of preterm labour. Nitroglycerin has been used successfully as an acute tocolytic during Caesarean sections and manual removal of placenta. A recent randomized trial has suggested that atosiban may be an option for acute intrapartum tocolysis. This article will review the recent literature on the use of pharmacological agents used to suppress uterine contractions in emergency obstetric situations.

SUMMARY

Acute tocolysis may be indicated in antepartum, intrapartum and postpartum periods for a variety of indications. It may help reduce maternal and fetal morbidity and mortality. The ideal tocolytic is yet to be developed. Research is needed to develop a drug which has a greater uterospecificity with no effect on other organs with a rapid onset and a short duration of action.

Delayed uterine re-inversion: a unique symptom complex

A case of late recurrence of uterine inversion is presented. Symptoms included constipation and urinary retention without uterine bleeding. Symptoms resolved 3 months after the replacement of the uterus. It is hypothesized that the symptoms were related to stretch injury to the pelvic parasympathetic nerves. Timely intervention may prevent long-term sequelae.