A 27-year-old black African primigravida with an uneventful antenatal course was admitted in active labour at term. Six hours following admission, the cervix was fully dilated. The second stage of labour lasted 45 minutes and a 3200-g male infant was born without apparent complications. Five units of oxytocin were given intravenously with delivery of the anterior shoulder, and the complete placenta delivered spontaneously 15 minutes later without any need for cord traction. The postpartum period was uneventful until day 4 when the woman complained of acute pelvic pain associated with the desire to pass urine. Increased vaginal bleeding was noted at the same time. Vaginal examination revealed complete uterine inversion. The woman was taken immediately to the operating theatre, where an initial attempt at manual replacement under epidural analgesia was unsuccessful because of a constricted cervix. Terbutaline was administrated intravenously but a further effort at replacement failed and it was decided that a surgical reduction should be undertaken. Laparotomy revealed a complete uterine inversion, with bladder and ovaries pulled down through the inverted uterus. A Silastic® cup (Silc-cup; Menox AB, Gothenburg, Sweden) was easily inserted into the inverted uterus (Figure 1A), a vacuum was created and a gentle traction achieved reduction of the inversion (Figure 1B). Digital examination demonstrated an empty uterine cavity and an intact cervix. Twenty units of oxytocin were then administrated intravenously by slow infusion over 12 hours and broad-spectrum antibiotics were prescribed. The woman was discharged well 4 days later.
Puerperal uterine inversion is an uncommon and potentially life-threatening event occurring in approximately 1 in 5000 deliveries.1 It is classified as acute if the inversion has occurred without cervical contraction, subacute if cervical contraction is present and chronic if more than 4 weeks have elapsed since inversion and cervical contraction.2 Caesarean section, a sudden increase in abdominal pressure, use of magnesium sulphate and rare connective tissue disorders have all been described as possible causes of uterine inversion. Manoeuvres such as excessive cord traction, Crede fundal pressure, or a combination of both, might produce dimpling of the fundus and the cascade of events leading to uterine inversion.3–5 Successful treatment depends on prompt recognition and correction of the inversion and of the postpartum haemorrhage which accompanies 65 to 94% of cases.6
Uterine inversion has been classified as incomplete if no part of the corpus inverts passes through the cervix, complete if there is inversion beyond the cervix and prolapsed if the inverted uterus extends beyond the introitus.7 Reduction can be accomplished via conservative (nonsurgical) or surgical approaches. Johnson8 was the first to describe manual replacement of an inverted uterus. O’Sullivan9 proposed another conservative nonsurgical technique which involves the use of hydrostatic pressure. More recently, Ogueh and Ayida10 described a new technique of hydrostatic replacement with the use of a Silastic ventouse cup inserted into the vagina. When these attempts are unsuccessful, surgical correction becomes necessary. Huntington11 described an abdominal approach in which, at laparotomy, Allis clamps are used to apply traction to the round ligaments in order to reduce the inversion.
If the Huntington procedure fails, the Haultain12 procedure can be attempted, in which a longitudinal hysterotomy is made in the posterior portion of the lower uterine wall through the cervical ring, to release the constricting pressure and facilitate reduction. This can also be performed vaginally, as described by Spinelli.13
Our suggested approach has the advantage of avoiding having to incise the uterus and allows better traction on the fundus of the uterus than pulling on the round ligaments, which have a tendency to tear. The Silastic cup has the advantage of being soft, thus allowing easy placement, through the constriction ring, on the fundus. We suggest it should be used instead of more traumatic alternatives.