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Sir,

I read with interest the case report by Vijayaraghavan and Sujatha,1 and the accompanying commentary by Chien,2 and have the following comments to make. First, it should be emphasised that acute postpartum uterine inversion is a life-threatening emergency. I have personally been involved with a case of maternal death because of haemorrhagic shock following a uterine inversion. In the case report by Vijayaraghavan and Sujatha, the inversion resulted in massive vaginal bleeding and signs of shock. I believe there is no place for attempted laparoscopic reduction in that situation. If reduction of the inverted uterus fails with the vaginal approach, and an abdominal approach is necessary, a laparotomy rather than laparoscopy should be attempted. Laparotomy would allow faster entry to the abdomen, and faster reduction of the uterus, and a higher chance of success.

I once assisted at an attempted laparoscopic reduction of a chronic uterine inversion. As the patient was completely stable, and not bleeding, the laparoscopic approach was a reasonable option. However, a laparotomy and posterior hysterotomy (Haultain’s procedure) were eventually required to achieve the reduction.

Finally, I question Chien’s statement that the degree of shock in uterine inversion is usually out of proportion to the amount of blood loss. Case reports and case series do not convincingly show this.3 The suggested mechanism of this non-haemorrhagic shock is through excessive stretching of the pelvic peritoneum and adnexal structures while the uterus is inverted. However, it should be remembered that at the time of an inversion, the uterus has just expelled a baby, and has suddenly shrunk down to a much smaller size than just before delivery. Surely, there is much greater stretching of the pelvic peritoneum and adnexae in late pregnancy than immediately after delivery, even if the uterus has become inverted.

Postpartum haemorrhage is the critical issue in acute inversion of the uterus.

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