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Uterine Inversion
Monika Thakur; Angesh Thakur.

Author Information and Affiliations

Last Update: November 28, 2022.

Continuing Education Activity

Uterine inversion is one of the most serious complications of childbirth. It refers

to the collapse of the fundus into the uterine cavity. Although it is rare, it carries a
high risk of mortality due to hemorrhage and shock. This activity describes the
pathophysiology, etiology, presentation, and management of uterine inversion
and highlights the interprofessional team's role in caring for patients with this
condition.

Objectives:

Review the etiology of uterine inversion.

Describe the presentation of a patient with uterine inversion.

Explain the treatment and management options available for uterine

inversion.

Summarize the need for a well-integrated, interprofessional team approach

to improve care for patients with uterine inversion.

Access free multiple choice questions on this topic.

Introduction

Uterine inversion is one of the most serious complications of childbirth. Uterine

inversion refers to the collapse of the fundus into the uterine cavity. Although it
does not often occur, it carries a high risk of mortality due to hemorrhage and
shock.[1]

Etiology

Excessive umbilical cord traction with a fundal attachment of the placenta and
fundal pressure in the setting of a relaxed uterus are the 2 most common
proposed aetiologies for uterine inversion.

Other possible risk factors for uterine inversion include rapid labor, invasive
placentation, manual removal of placenta, short umbilical cord, use of uterine-
relaxing agents, uterine overdistension, fetal macrosomia, nulliparity, placenta
previa, connective tissue disorders (Marfan syndrome and Ehlers-Danlos
syndrome), and history of uterine inversion in the previous pregnancy. However,
in most cases, no risk factors are identified, thus making this condition
unpredictable.[2][3][4]
Degrees of Uterine Inversion

Incomplete: Fundus inverts but does not herniate through the level of the
internal os

Complete: The internal lining of the fundus crosses through the cervical os
with no palpable fundus abdominally

Prolapsed: Entire uterus prolapsing through the cervix with the fundus
passing out of the introitus

Classification

Acute: Twenty-four hours or less after delivery

Subacute Longer than 24 hours postpartum)

Chronic: Longer than 1 month postpartum[1][5]

Epidemiology

A uterine inversion is a rare event, complicating about 1 in 2000 to 1 in 23,000

deliveries. Ironically, most are seen with “low-risk” deliveries. The incidence is 3-
times higher in India as compared to the United States. The incidence of uterine
inversion has decreased 4-fold after the introduction of active management
during the third stage.

Pathophysiology

Three possible events explain the pathophysiology of acute uterine inversion:

1. A portion of the uterine wall prolapses through the dilated cervix or indents
forward

2. Relaxation of part of the uterine wall

3. Simultaneous downward traction on the fundus leading to the uterine

inversion

History and Physical

Uterine inversion is a clinical diagnosis and should be suspected when the fundus
is not palpable abdominally. The sudden onset of brisk vaginal bleeding leads to
hemodynamic instability in the mother. Traditionally, the shock has been
considered disproportionate to blood loss, which is possibly mediated by
parasympathetic stimulation caused by the stretching of tissues. However, careful
evaluation of the need for blood transfusion should be made because blood loss is
massive and is greatly underestimated. The other symptoms are mainly severe
lower abdominal pain with a strong bearing down sensation, though
most women may not be able to complain due to severe shock. It may occur
before or after placental detachment.[1][6]

Evaluation
The diagnosis is often made clinically with a bimanual examination, during
which the uterine fundus is palpated in the lower uterine segment or within the
vagina. If a clinical examination is equivocal, then an ultrasound can be used to
confirm the diagnosis.[7][1][8]

Treatment / Management

Once the diagnosis of uterine inversion is made, immediate intervention to

control hemorrhage and restore hemodynamic stability in the mother is
required because a delay will lead to an increase in the mortality rate
appreciably. The following actions should be taken urgently and simultaneously:

Call for help and call for an anesthesiologist immediately.

Hemodynamic stability is achieved by a large-bore cannula, and crystalloid

and blood are given to combat hypovolemia.

The recent uterine inversion with the placenta already separated from it
may often be replaced by manually pushing up on the fundus with the palm
and fingers in the direction of the long axis of the vagina. A delay will
render replacement more difficult and also increase the risk of hemorrhage.

If the placenta is still attached, it is usually not removed until fluids

are given, and uterine-relaxing anesthetics, for example, a halogenated
inhalation agent, have been administered. Other tocolytic agents such as
magnesium sulfate or beta-mimetic and nitroglycerine have been used
successfully for uterine relaxation and repositioning. Any portion of the
inverted uterus prolapsed beyond the vagina is replaced within the vagina.

After the placenta is removed, steady pressure with the fist is applied to the
inverted fundus in an attempt to push it up into the dilated cervix.
Alternatively, two fingers can be extended rigidly to push the center of the
fundus upward. Undue force is not applied to avoid perforation of the
uterus with the fingertips. This is followed by the administration of
uterotonic agents, which help uterine contraction, thereby preventing
recurrence of the inversion.

An appropriate antibiotic is administered to prevent infection.

Other options include hydrostatic reduction and surgical correction if manual

repositioning is unsuccessful due to a dense constriction ring.

Hydrostatic reduction: If manual reduction alone is not successful, simple

hydrostatic pressure may be of great assistance in pushing the fundus back to its
normal anatomical position. Warmed sterile saline is infused into the vagina.
The clinician’s hand or a silicone ventouse cup is used as a fluid retainer to
generate intravaginal hydrostatic pressure and resultant correction of the
inversion. The bag of fluid should be elevated about 100 to 150 cm above the
vagina to guarantee sufficient pressure for insufflation. It is also effective at
preventing blood loss and inhibiting the uterus from inverting again. The possible
complications associated with the procedure include infection, failure of the
procedure, and saline embolus.
Surgical options include Huntington and Haultain procedures, laparoscopic-
assisted repositioning, and cervical incisions with manual uterine repositioning.
The Huntington procedure involves laparotomy by gradually pulling on the
round ligaments to restore the uterus to its proper position. In case the cervical
ring is very tight, repositioning may be more easily achieved by incising the ring
posteriorly with a vertical incision along with manual pushing of the fundus. As
with manual repositioning, after replacing the fundus, the anesthetic agent used
to relax the myometrium is stopped, and uterotonic therapy is administered
immediately, followed by repair of uterine incision. If these procedures are
performed, then pregnancies in the future will require a cesarean delivery.

If the placenta is not separated from the uterus, then a hysterectomy may be
necessary.

Differential Diagnosis

The conditions that cause a lump in the vagina and lead to postpartum collapse
need to be excluded. These include:

Severe atony of the uterus

Uterovaginal prolapse

Fibroid polyp

Neurogenic collapse

Postpartum collapse

Retained placenta without inversion

Coagulopathy

Prognosis

Acute cases can lead to hemorrhagic shock, but prompt management usually
mitigates long-term sequelae. It is unknown whether the condition affects future
pregnancy prospects, but case reports exist of uncomplicated pregnancies.

Complications

Complications associated with uterine inversion can be due to the condition

(primary) or its management (secondary).

The condition's complications primarily revolve around hemorrhage and its

associated risks, including multi-organ damage, shock, Sheehan syndrome,
hysterectomy). Without treatment, the condition can result in significant,
persistent blood loss and tissue necrosis.

Complications accompanying treatment relate to general anesthesia and blood

transfusions.

Deterrence and Patient Education

Women who have experienced uterine inversion need to be counseled that they
run the risk of recurrence in subsequent pregnancies.

Enhancing Healthcare Team Outcomes

Uterine inversion is a true obstetric emergency that requires immediate

treatment if the patient's life is to be saved. The condition is best managed by an
interprofessional team, including ICU nurses. The patient needs immediate
resuscitation, patent airway, blood transfusion, and either manual or surgical
management.

The outcomes for most patients are guarded.[9][10]

Review Questions

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Comment on this article.

References

1. Wendel MP, Shnaekel KL, Magann EF. Uterine Inversion: A Review of a Life-
Threatening Obstetrical Emergency. Obstet Gynecol Surv. 2018 Jul;73(7):411-
417. [PubMed: 30062382]
2. Free L, Ruhotina M, Napoe GS, Beffa L, Wohlrab K. Uterine Inversion
Presenting as Pelvic Organ Prolapse in a Patient with Leiomyosarcoma. J
Minim Invasive Gynecol. 2019 Nov-Dec;26(7):1217-1218. [PubMed: 30926367]
3. Vieira GTB, Santos GHND, Silva Júnior JBN, Sevinhago R, Vieira MIB, Souza
ACS. Non-puerperal uterine inversion associated with myomatosis. Rev Assoc
Med Bras (1992). 2019 Feb;65(2):130-135. [PubMed: 30892434]
4. Girish B, Davis AA. Chronic uterine inversion with malignancy mimicking
carcinoma cervix. BMJ Case Rep. 2019 Feb 01;12(2) [PMC free article:
PMC6366801] [PubMed: 30709891]
5. Eddaoudi C, Grohs MA, Filali A. [Uterine inversion: about a case]. Pan Afr Med
J. 2018;29:99. [PMC free article: PMC5987136] [PubMed: 29875980]
6. Mishra S. Chronic Uterine Inversion Following Mid-Trimester Abortion. J
Obstet Gynaecol India. 2018 Aug;68(4):320-322. [PMC free article: PMC6046678]
[PubMed: 30065549]
7. Zohav E, Anteby EY, Grin L. U-turn of uterine arteries: a novel sign
pathognomonic of uterine inversion. J Ultrasound. 2020 Mar;23(1):77-79. [PMC
free article: PMC7010891] [PubMed: 30284197]
8. Della Corte L, Giampaolino P, Fabozzi A, Di Spiezio Sardo A, Bifulco G. An
exceptional uterine inversion in a virgo patient affected by submucosal
leiomyoma: Case report and review of the literature. J Obstet Gynaecol Res.
2019 Feb;45(2):466-472. [PubMed: 30187623]
9. Coad SL, Dahlgren LS, Hutcheon JA. Risks and consequences of puerperal
uterine inversion in the United States, 2004 through 2013. Am J Obstet
Gynecol. 2017 Sep;217(3):377.e1-377.e6. [PubMed: 28522320]
10. Oladapo OT, Akinola OI, Fawole AO, Adeyemi AS, Adegbola O, Loto OM,
Fabamwo AO, Alao MO, Sotunsa JO., Nigerian AMTSL Group. Active
management of third stage of labor: evidence versus practice. Acta Obstet
Gynecol Scand. 2009;88(11):1252-60. [PubMed: 19824866]
Disclosure: Monika Thakur declares no relevant financial relationships with ineligible
companies.

Disclosure: Angesh Thakur declares no relevant financial relationships with ineligible

companies.

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