MRCOG FACTS: 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)

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.

"Take bloods & label correctly"

Fluid replacement (colloids & crystalloids)

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

An excellent presentation on uterine inversion