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Introduction

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References
  6. Supporting Information

Acute inversion of the uterus is a rare but potentially fatal obstetric emergency in the third stage of labour. Although the exact causes of this life-threatening emergency are unclear, active management of the third stage of labour is recommended to avert maternal morbidity and mortality. The reported incidence of uterine inversion varies considerably in the literature, with reports ranging from approximately 1 in 550 to 1 in several thousands deliveries.1–4 Maternal mortality has been reported to be as high as 15%.1–3 We describe a case of third-degree acute inversion of uterus managed successfully under laparoscopic guidance. To the best of our knowledge, this is the first report of the use of laparoscopy in reducing an acute uterine inversion.

Case report

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References
  6. Supporting Information

A 23-year-old primigravida presented at full-term gestation for induction of labour. She had no antecedent medical illnesses. After 3 hours in labour and a right mediolateral episiotomy, she gave birth to a healthy boy. The placenta was delivered without difficulty with minimal controlled cord traction. At this stage, there was sudden massive vaginal bleeding together with the appearance of a large fleshy mass at the introitus. Attempts by the attending obstetrician to reduce the uterus manually were unsuccessful. Inj Terbutaline 0.25 mg was administered. At this time, the woman was pale, with a heart rate of 150 beats/minute, a thready pulse, prolonged capillary refill time, and an unrecordable arterial pressure. A central line was inserted, fluids and colloids infused simultaneously, and once her arterial pressure rose to 90/60 mmHg, she was transferred to the operating theatre. While these measures were being instituted, an urgent bedside ultrasound examination was carried out simultaneously and an inversion of the uterus was confirmed. Attempts at manipulation under general anaesthesia using halothane failed to reduce the inversion, and instead, just displaced the entire inverted uterus cephalad. A decision was then taken to proceed with a surgical correction.

In the semilithotomy position, after establishment of pneumoperitoneum by a veress needle inserted in the left hypochondrium, a 10-mm trocar was inserted in the supraumbilical area well above the fundus of the uterus and insufflation pressures maintained at 12 mmHg. Her blood pressure was maintained throughout, and the head-down position did not further worsen the haemodynamic status. An additional 5-mm trocar was inserted into the left pararectus border at the midclavicular line. With the left hand in the vagina maintaining pressure and an instrument providing countertraction laparoscopically, an attempt was made to reduce the inversion by cephalad traction on the round ligaments using a 5-mm laparoscopic Allis forceps initially and subsequently for better grip and traction, a 5-mm ring forceps and a 5-mm claw forceps successively. The grip on the round ligament was insufficient to achieve enough traction for reduction, and any further forced traction would have resulted in tears on the round ligaments. An additional 10-mm trocar was inserted in the left flank, and using a 10-mm round-tipped rod made of Teflon, counter pressure was maintained on the superior aspect of the inverted uterus while pressure was applied from the vagina. The shaft of the Teflon rod maintained constant downward and caudal pressure on one aspect of the apex of the inverted uterus while the hand in the vagina maintained a constant cephalad counterpressure. With this manoeuvre, the process of reversal of the inversion was initiated, and using downward, sweeping movements of the Teflon rod, complete reduction was achieved. A check of the uterus and adnexa showed no compromised vascularity. The entire procedure from the time of insertion of the first trocar to completion of reduction took less than 15 minutes (Figure 1A–D). The episiotomy wound was sutured, and hysteroscopy was performed to ascertain that all the uterine blood clots were evacuated. No further bleeding was noted. Her post-transfusion haemoglobin measured in the recovery room was 8 g/dl. Her subsequent recovery was uneventful. Two years to date, she has had no symptoms except for episodes of a white discharge. Subsequent ultrasound examinations have shown a normal uterus, and she is presently 10 weeks pregnant.

image

Figure 1. (A) Laparoscopic appearance of the inverted uterus. (B) A 5-mm forceps being used to press down on the top of the inverted uterus. (C) Partial reduction achieved; further reduction was completed using a 10-mm blunt-tipped Teflon rod to press down on the top of the inverted uterus. (D) Complete reduction achieved.

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Discussion

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References
  6. Supporting Information

The exact aetiology of an uterine inversion remains unclear, with the most likely cause being strong traction on the umbilical cord, particularly when the placenta is in a fundal location during the third stage of labour.1 Other factors might include excessive fundal pressure; relaxed uterus, lower uterine segment and cervix; placenta accreta, particularly involving the uterine fundus; short umbilical cord; congenital weakness or anomalies of the uterus; and antepartum use of magnesium sulphate or oxytocin.1–4 Primiparity and rapid emptying of the uterus after prolonged distention have also been suggested as possible predisposing factors.1

Diagnosis of uterine inversion is usually based on clinical signs and symptoms. When there is complete inversion, the diagnosis is most easily made by palpating the inverted fundus at the cervical os or vaginal introitus. In incomplete inversion, palpating the fundal wall in the lower uterine segment and cervix might be required for diagnosis. Profuse bleeding, absence of uterine fundus, or an obvious defect of the fundus on abdominal examination, as well as evidence of shock with severe hypotension will further provide the clinician with diagnostic clues.1–4

The diagnosis of uterine inversion is essentially clinical; occasionally, when time permits, sonography may show a hyperechoic mass in the vagina.

Treatment of uterine inversion consists of manual manipulation of the uterus and the use of pharmacologic agents to assist in uterine relaxation for achieving correction. Further agents are then given to cause uterine contraction to prevent reinversion and to decrease blood loss. If these methods fail, surgical intervention might be necessary.

Manual correction of inversion through the vagina, known as the Johnson manoeuvre, consists of pushing the inverted fundus through the cervical ring with pressure directed toward the umbilicus. It is generally suggested that removal of the placenta before correction will result in increased blood loss and worsening haemodynamics.2–5 The chances of immediate reduction is reported to be between 22 and 43%.6

To facilitate replacement of the uterus, myometrial relaxation is achieved by tocolytics such as magnesium sulphate or terbutaline. While terbutaline takes less than 2 minutes to take effect, magnesium sulphate takes about 10 minutes to be effective.5,6 These medications help relax the uterus and the cervical contraction ring. Reports on the use of low-dose intravenous glyceryl trinitrate for uterine relaxation cite benefits such as quicker onset of uterine relaxation and rapid dissipation of the effect. In the event that correction is not established with tocolytic agents, general anaesthesia with halothane may be induced to provide uterine relaxation. This approach may be particularly useful when the woman is haemodynamically unstable because halothane anaesthesia has fewer potential adverse effects on haemodynamics.5,6

Hydrostatic reduction, originally described by O’Sullivan in 1945, uses the pressure of warm fluid infused into the vagina to achieve reduction; modifications of this technique to retain the infused fluid within the vagina until reduction is successful have been reported.1

When all attempts at manual reduction of the inversion are unsuccessful, surgical correction may be necessary. The two most commonly used procedures are the Huntington and Haultain procedures. The Huntington procedure requires a laparotomy to locate the cup of the uterus formed by the inversion. Clamps are placed in the cup of the inversion below the cervical ring and gentle upward traction is applied. Repeated clamping and traction continues until the inversion is corrected. In the Haultain procedure, an incision is made in the posterior portion of the inversion ring, again through the abdomen, to increase the size of the ring and allow repositioning of the uterus.1–4 Occasionally, as a life-saving measure, emergency peripartum or obstetric hysterectomy is needed to achieve control of haemorrhage.7

The most obvious advantages of a laparotomy include ease and familiarity of the procedure and easy access for conversion to hysterectomy, if needed. Disadvantages include the relatively large incision, postoperative pain and the possibility of an incisional hernia.

One needs to consider the possible adverse effects of a pneumoperitoneum-induced intra-abdominal hypertension in a haemodynamically unstable woman. Published reports suggest that laparoscopy is the preferred method of treatment of ectopic pregnancies even in the presence of massive haemoperitoneum.8–10 Appropriate preoperative and intraoperative measures to achieve haemodynamic stability prior to either open or laparoscopic surgery is mandatory.

There are no reports of the use of laparoscopy in acute inversion of the uterus; the nonavailability of skilled expertise in an emergency situation could be a possible explanation. The role of laparoscopy in the scenario of shock is yet to be clearly defined, although there are increasing reports of the benefits of laparoscopy, with most surgeons having laparoscopic expertise preferring to have an initial laparoscopic evaluation and convert to an open procedure if needed.8,10 The benefits of laparoscopy would include smaller incision, lesser pain, and early recovery; however, the need for skilled expertise and infrastructure in an emergency is obvious. With laparoscopy pervading into all specialties and more procedures being added on to the repertoire of the laparoscopic surgeon, this method may offer an attractive alternative in helping achieve reduction of uterine inversion. Using any blunt-tipped instrument such as a closed-tip 10-mm suction cannula would help in maintaining downward pressure on the top of the inverted uterus while a hand in the vagina would give the counterpressure. We used a round-tipped rod fabricated from Teflon for the manipulation and are confident that the 10-mm closed-tip suction cannula would serve the purpose perfectly. For an experienced laparoscopic surgeon, the time taken for insertion of the first trocar would be less than a minute, and the whole procedure as described above may not take more than 15–20 minutes to achieve complete reduction. As is evident from our case, there were no ill effects of the pneumoperitoneum on the haemodynamic status of the woman; however, in the presence of haemodynamic instability, conversion to laparotomy would be appropriate. In a difficult and tense situation, the laparoscope can guide the manipulation by the obstetrician’s hand in the vagina (to achieve reduction of the uterine inversion) and could possibly reduce the overall time during which the woman is in shock. The role of laparoscopy in acute uterine inversion will, however, need evaluation.

References

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References
  6. Supporting Information
  • 1
    Hostetler DR, Bosworth MF. Uterine inversion: a life-threatening obstetric emergency. J Am Board Fam Pract 2000;13:1203.
  • 2
    Calder AA. Emergencies in operative obstetrics. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14:4355.
  • 3
    Thomson AJ, Greer IA. Non-hemorrhagic obstetric shock. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14:1941.
  • 4
    Milenkovic M, Kahn J. Inversion of the uterus: a serious complication at childbirth. Acta Obstet Gynecol Scand 2005;84:956.
  • 5
    Abouleish E, Ali V, Joumaa B, Lopez M, Gupta D. Anaesthetic management of acute peurperal uterine inversion. Br J Anaesth 1995;75:4867.
  • 6
    Beringer RM, Patteril M. Puerperal uterine inversion and shock. Br J Anaesth 2004;92:43941.
  • 7
    Sumera T, Mahmood A, Samina A. Indication and maternal outcome of emergency peripartum hysterectomy. Pak J Med Sci 2003;19:1826.
  • 8
    Takeda A, Manabe S, Mitsui T, Nakamura H. Management of patients with ectopic pregnancy with massive hemoperitoneum by laparoscopic surgery with intraoperative autologous blood transfusion. J Minim Invasive Gynecol 2006;13:438.
  • 9
    Sowter MC, Frappell J. The role of laparoscopy in the management of ectopic pregnancy. Rev Gynaecol Pract 2002;2:7382.
  • 10
    Sagiv R, Debby A, Sadan O, Malinger G, Glezerman M, Golan A. Laparoscopic surgery for extrauterine pregnancy in hemodynamically unstable patients. J Am Assoc Gynecol Laparosc 2001;8:52932.

Supporting Information

  1. Top of page
  2. Introduction
  3. Case report
  4. Discussion
  5. References
  6. Supporting Information

Video Clip S1. Laparoscopic view of a uterine inversion being corrected.

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BJO_1052_sm_movie.wmv27054KSupporting info item

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