Tuesday, 11 May 2010

Uterine inversion in pregnancy

Clinical features

Severe lower abdominal pain in third stage



Haemorrhage


shock out of proportion to bleeding


Uterine fundus not palpable



Mass in the vagina




Management

two important aspects
(A) resuscitation
(B)repositioning of uterus


Help-Call for help(Obstetrician/Anaesthetist/Senior midwives)



Replacement of uterus should go hand in Hand with resuscitation measures


ABC-Airway,Breathing(Remember to give oxygen),Circulation



two wide bore (14/16 G) & Fluid replacement(crystalloid & colliods)


Bloods for FBC,coagulation studies and cross matching (4-6 units)

"Take bloods & label correctly"




The earlier the correction of inversion the more likely the success.


Analgesia should be given


The earlier the reposition of uterus the more likely the success.




Techniques for repositioning uterus

(I)Manual replacement(The Jhonsons Manoeuvre)-Using the fist to push the fundus through the cervix.

(II)Hydrostatic repositioning (O'Sullivan's technique)-
(a) patient is placed in the trendlenberg position
(b)one end of the long tube(2m) with a large nozzle is placed in the posterior fornix
(c) warm saline is infused
(d) leak is prevented by approximating the labia with the hand or a vacuum cup can also be used.

(III)Medical approach
(a)Magnesium sulphate 2-4 g infused over 5 minutes
(b)ritodrine 0.15 mg IV bouls
(c)terbutaline 0.25 mg slow IV bolus
(d) volatile agent as a part of general anaesthesia





(IV) Surgery

(a)Huntingdon's procedure-Allis forceps is used to grasp the dimple of the inverted uterus and then gentle traction is applied.Further application of forceps on the advancing fundus helps in the correction of uterine inversion.

(b)Haultin's technique-posterior aspect of cervical ring is incised to help the Huntingdon's procedure.



Oxytocics should be administered after the correction of uterine inversion.


Non Surgical approach is successful in the majority of the cases.












An excellent presentation on uterine inversion