This commentary refers to the article by Rajagopalan and Sujatha on page 1100.
Acute uterine inversion is a recognised but fortunately rare obstetric emergency, usually presenting with vaginal bleeding and shock. The extent of the shock is usually out of proportion to the amount of blood loss because of vagal stimulation as a consequence of stretching of the peritoneum.
In this issue, we have published a case report on the replacement of an acute uterine inversion with the aid of a laparoscope.1 There were some controversial decisions in the clinical management of this woman. In the first instance, the diagnosis is usually made on clinical grounds, and it is debatable whether a pelvic ultrasound examination was necessary for the diagnosis, especially as it might have caused some delay in attempting correction. Any delay in management is undesirable in the presence of acute maternal shock. Second, the authors attempted to correct the uterine inversion with manual replacement following administration of a tocolytic and then subsequently under a general anaesthetic using halothane to further relax the uterus. When all these measures failed, conventional teaching would advocate the use of hydrostatic reduction to reduce the inversion,2 but this was not employed in this case. Third, the introduction of a pneumoperitoneum for laparoscopy may further impair the haemodynamic state. It may also further worsen the inversion, thereby making it more difficult to correct. Fourth, the authors were unable to correct the inversion by grasping and pulling part of the uterus or its adnexae laparoscopically, and this might have resulted in tears and further bleeding (indeed, some bleeding from traction on the round ligament is visible on the video). From the video clip provided by the authors, it is not entirely clear whether the laparoscopic manoeuvres aided the reduction significantly or whether it was mainly the cephalad pressure from the hand in the vagina that actually resulted in the correction of the inversion.
On the other hand, it is possible that the laparoscopic visualisation of the pelvic organs helped the obstetrician to decide where to apply pressure with the hand in the vagina in order to reduce the inversion more successfully. It is also possible that counter pressure with a blunt-tipped probe in the caudal direction as suggested by the authors may have aided the reduction. In this particular case, the pneumoperitoneum created during laparoscopy did not seem to have affected the woman’s haemodynamic circulation in any significant manner.
We have decided to publish this case report for several reasons. First, by publishing a few controversial manuscripts we hope to generate debate among the readership, and we would value your views through letters submitted to the journal. Second, an edited video clip of this case can be assessed at www.blackwell-synergy.com. Most of us are unlikely to have seen the pelvis during acute uterine inversion and its appearance as it is being corrected. This video clip will serve as a potential educational resource for the readership to understand the altered pelvic anatomy in a uterine inversion.