FRCA Notes

Uterine Inversion

This ultimately rather rare condition is included as it is a cause of major obstetric haemorrhage and has been a cause of maternal mortality in previous CEMACH (now MBBRACE) reports.

  • Uterine inversion is a rare (1 in 10,000) obstetric emergency characterised by the uterus inverting ± prolapsing through the cervix or vaginal vault
  • It usually occurs during vaginal delivery, although has been reported during LSCS
  • It usually presents acutely, although can do so 24hrs post-delivery or sub-acutely many days post-delivery

  • Typical features include:
    • Vaginal mass
    • Haemorrhage, usually 1 - 2L
    • Shock disproportionate to blood loss e.g. due to parasympathetic activation from traction on the uterine ligaments

Non-modifiable Modifiable
Short umbilical cord Excessive umbilical cord traction
Fundal placental site Inappropriate fundal pressure
Abnormality of placentation Uterine atony
Uterine anatomical abnormalities


Immediate

  • Immediate replacement of the uterus by our obstetric colleagues
    • Immediate manual replacement is successful in 20 - 40% of cases; delayed replacement reduces the success rate
    • May require uterine relaxation i.e. tocolytics e.g. IV terbutaline 0.25mg | 4g IV Magnesium | 100μg GTN
    • So-called "hydrostatic repositioning" using a Trendelenburg position and warm saline infused into the uterine cavity

  • Treatment of shock and/or major obstetric haemorrhage
    • Wide-bore access
    • Bloods inc. FBC, U&E, clotting, group and cross-match, VBG and TEG/ROTEM
    • Vasopressors etc.

Subsequent

  • If immediate, manual replacement of the uterus fails, will require attempted replacement under GA
  • If manual replacement under GA fails, surgical intervention is required i.e. laparotomy
  • Uterotonics should be administered post-replacement to prevent recurrence of inversion
  • Antibiotic prophylaxis is required due to high incidence of endometritis