Acute inversion of the uterus

Abstract

Key content:• Acute uterine inversion is a rare and unpredictable obstetric emergency.• Mortality and morbidity are reduced by early recognition and management. • Shock and uterine replacement must be addressed simultaneously.• The importance of teamwork cannot be overemphasised.• There is a need for skills and drills training because of the rarity of acute inversion. Learning objectives:• To understand the pathophysiology.• To understand and to be able to evaluate critically the general management principles. Ethical issues:• Management of uterine inversion is guided by a relatively small evidence base, resulting in treatment modalities being used without proper evaluation.

Reduction of subacute uterine inversion by Haultain’s method: A case report

“…Unfortunately, this attempt was unsuccessful. The Haultain [2,4,5] procedure was then performed where the cervical ring was opened posteriorly at the 6 o' clock position using a 6 cm vertical incision and reversion was achieved. An oxytocin infusion was started and the posterior aspect of the uterus was repaired (Fig.…”

“…[2,3] Tocolytics may be administered to make the procedure easier but it was not given because of the risk of worsening the shock. Uterotonics are administered after successful reduction to prevent re-inversion and antibiotics are used to prevent endometritis.…”

“…The hydrostatic method recommended by the World Health Organization, which was described by O'Sullivan in 1945, was not attempted in this case as 24 hours had already elapsed since the inversion -the method was therefore unlikely to be successful and would increase the risk of infection. [2][3][4][5] The hydrostatic method is performed in an operating theatre with the woman in the lithotomy position; sterile water or normal saline is rapidly instilled into the vagina using a fluid-giving set with a tight seal at the introitus using hands or preferably a silastic ventouse cup. The fundus is pushed into the natural position as fluid fills and distends the vagina.…”

“…Spontaneous inversion has been reported in about 50% of the cases. [2,3] Case reportA 26-year-old patient, who had had two previous normal vaginal deliveries and one miscarriage presented with a day's history of a vaginal mass after an attempted removal of a retained placenta following a miscarriage that was managed at a local hospital. The mass was associated with vaginal bleeding and lower abdominal pain.…”

“…A manoeuvre to correct the inversion by placing a cupped hand into the vagina and applying upward pressure, also known as Johnson's manoeuvre, was attempted in casualty to no avail. [2,3] She was taken to theatre and the procedure was attempted again under anaesthesia without success. We proceeded to do a laparotomy and attempted the Huntington manoeuvre [2,4,5] during which the round ligaments are identified and upward traction is applied on them, while a cupped hand in the vagina pushes the inverted uterus upwards.…”