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Puerperal uterine inversion

Puerperal uterine inversion
Literature review current through: Jan 2024.
This topic last updated: Jul 20, 2023.

INTRODUCTION — Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. Although a rare complication of vaginal or cesarean birth, it is a life-threatening obstetric emergency because, if not promptly recognized and treated, uterine inversion can lead to severe hemorrhage and shock, resulting in maternal death.

This topic will discuss the clinical features, diagnosis, and management of puerperal uterine inversion. Spontaneous inversion of the nonpuerperal uterus accounts for approximately 5 percent of all uterine inversions and will not be addressed here [1]. It is almost always associated with a polypoid uterine tumor, usually a leiomyoma, but other tumors (eg, teratoma, sarcoma) have also been implicated [2-5]. (See "Uterine fibroids (leiomyomas): Prolapsed fibroids", section on 'Complications'.)

CLASSIFICATION — Uterine inversions are classified by the extent of inversion and time of occurrence.

Extent of inversion (figure 1) [6-9]:

1st degree (incomplete inversion) – Fundus within the endometrial cavity

2nd degree (complete inversion) – Fundus protrudes through the cervical os

3rd degree (prolapsed inversion) – Fundus protrudes to or beyond the introitus

4th degree (total inversion) – Both the uterus and vagina are inverted

In a review of 358 cases of puerperal uterine inversion, approximately 90 percent were 2nd degree or more [10].

Time of occurrence [11]:

Acute – Within 24 hours of delivery

Subacute – More than 24 hours but less than four weeks postpartum

Chronic – ≥1 month postpartum

In a review of 229 cases of puerperal uterine inversion, 83.4 percent were acute, 13.9 percent were chronic, and 2.6 percent were subacute [1].

INCIDENCE — Incidence ranges from 1 in 3500 to 20,000 deliveries [7,12,13]. This wide range may be related to differences in definition of inversion, patient populations, case ascertainment, routine obstetric procedures, and postpartum care. The incidence in the United States was 1 in 3500 deliveries between 2004 and 2013 and appeared to be stable; more recent data are not available [7].

PATHOGENESIS — The pathogenesis of uterine inversion is incompletely understood. It has been attributed to use of excessive cord traction and fundal pressure (Credé maneuver) during the third stage of labor, especially in the setting of uterine atony with fundal placental implantation [8]. However, evidence is inconsistent, and a causal relationship between management of the third stage and puerperal uterine inversion is unproven [14]. It is likely that other factors play a role since spontaneous inversions occur and inversion is rare even though cord traction and the Credé maneuver are commonly performed.

Hemorrhage may occur because the invaginated fundus may not contract normally and the inverted endometrium is stretched, which exacerbates bleeding from any areas of placental separation.

RISK FACTORS — In the largest series of puerperal uterine inversion, which included 2427 cases, statistically significant risk factors were abnormal placentation such as retained and/or abnormally adherent placenta (153 cases, adjusted OR 13.6, 95% CI 11.5-16.1), prolonged labor (32 cases, adjusted OR 1.58, 95% CI 1.12-2.25), and preeclampsia with severe features (102 cases, adjusted OR 2.43, 95% CI 1.98-2.98) [7]. The association with preeclampsia was unexpected and unexplained. Multifetal pregnancy appeared to be protective (<10 cases, adjusted OR 0.17, 95% CI 0.07-0.37), but this finding may have been related to the small number of cases.

CLINICAL FEATURES

Patient presentation — Puerperal uterine inversion can follow vaginal or cesarean birth; the latter includes inversion through the hysterotomy incision [12,15]. The clinical presentation depends on the extent and time of occurrence of the inversion. Signs and symptoms include one or more of the following:

Mild to severe vaginal bleeding

Mild to severe lower abdominal pain

A smooth, round mass protruding from the cervix or vagina

Urinary retention

The most common presentation is 2nd degree/complete uterine inversion (fundus protrudes through the cervical os) accompanied by severe postpartum hemorrhage, often leading to hypovolemic shock. Shock out of proportion to blood loss has also been described and attributed to increased vagal tone from stretching of the pelvic parasympathetic nerves (neurogenic shock), but this is controversial and may just reflect underestimation of blood loss [16]. On vaginal examination, the inverted fundus fills the vagina. Providers may initially misdiagnose this finding as a protruding fibroid; however, on transabdominal palpation, the uterine fundus is absent from its expected periumbilical position.

With 3rd degree (fundus to or beyond the introitus) and 4th degree (uterus and vagina inverted) cases, the protruding uterus is grossly evident on inspection of the perineum.

First-degree/incomplete uterine inversion is associated with more subtle findings [7,10]. Blood loss may be minimal. Examination through the dilated cervix may reveal a mass (ie, fundus) in the uterine cavity. On abdominal examination, a cup-like defect (fundal notch) may be palpated in the area of the normally globular fundus. In the absence of heavy bleeding or careful examination of the fundus, these patients may not be identified for days or weeks. In such cases, the uterus may become edematous and infected and surgical intervention is likely to be required to replace the uterus because of normal postpartum cervical constriction.

Imaging — Ultrasound examination of uterine inversion shows the absence of the normal uterine fundal contour and a homogeneous globular mass (ie, inverted fundus) within the uterus [17,18].

DIAGNOSIS — The diagnosis of acute uterine inversion should be suspected in postpartum patients with hypotension out of proportion to estimated blood loss and/or when the provider is unable to palpate a normally positioned fundus on abdominal examination. Vaginal bleeding potentially resulting in shock and lower abdominal pain are supportive findings.

The diagnosis is confirmed when the fundus is seen protruding through the cervix or vaginal opening or when transcervical examination finds the fundus inside the uterine cavity and transabdominal examination finds a cup-like defect in the area of the normally globular fundus. (See 'Patient presentation' above.)

Radiographic imaging (eg, ultrasound, magnetic resonance) is rarely necessary, but has been used to confirm inversion when the diagnosis was uncertain and the patient was hemodynamically stable [17]. Importantly, in patients with significant vaginal bleeding, treatment should not be delayed for radiologic confirmation.

Differential diagnosis — The most common disorder in differential diagnosis is a prolapsed fibroid. Physical and ultrasonographic examination of the fundus help to distinguish the two disorders: the fundus is usually normal in contour and position with a prolapsed fibroid, whereas with uterine inversion the fundus is absent from its normal position or markedly abnormal (eg, cupped and smaller than expected). (See "Uterine fibroids (leiomyomas): Prolapsed fibroids".)

MANAGEMENT — The management of puerperal uterine inversion is based on clinical experience described in case reports and small retrospective case series, as well as good clinical judgment. No randomized trials have been performed.

Goals

Replace the uterine fundus to its correct position

Manage postpartum hemorrhage and shock, if present

Prevent recurrent inversion

Initial interventions — Interventions for the management of acute uterine inversion should begin promptly and simultaneously. A delay in diagnosis or prompt initiation of treatment increases the risk of maternal morbidity and mortality. We suggest:

Discontinue uterotonic drugs since uterine relaxation is needed to replace the uterine fundus.

Call for immediate assistance, including anesthesiology staff, additional obstetric staff (and where appropriate, more experienced obstetric staff), and operating room personnel. The patient may require transfer from a labor room to an operating room if manual replacement of the uterus is unsuccessful.

Establish adequate intravenous access and aggressive fluid/blood product resuscitation. We suggest placing two large bore intravenous lines (eg, at least one intravenous catheter should be 16-gauge) and infusing crystalloid to support blood pressure. Draw blood for baseline laboratory tests, including a complete blood count and coagulation studies (fibrinogen concentration, prothrombin time, activated partial thromboplastin time). Blood products are administered, as needed, to treat hypovolemia and prevent cardiovascular collapse, and reverse coagulopathy, if present. Activate your institutional massive transfusion protocol, as needed. (See "Overview of postpartum hemorrhage".)

Do not remove the placenta. (See 'Management of the placenta' below.)

Immediately attempt to manually replace the inverted uterus to its normal position. This is best accomplished by placing a hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus (Johnson maneuver) (figure 2). Prompt intervention is critical since the lower uterine segment and cervix will contract over time and create a constriction ring, thereby making manual replacement progressively more difficult.

If a constriction ring is palpable, apply pressure to the part of the fundus nearest the ring to ease it through from bottom to top. This avoids attempting to push a wider diameter of the fundal mass through the ring, which is likely to fail.

Attempts at manual replacement may be accompanied by severe bleeding [19].

Immediate uterine replacement is unsuccessful was one-third of cases in one series [20].

Hemodynamically unstable patients – After an initial unsuccessful manual attempt at replacement, proceeding directly to laparotomy is reasonable when the patient is hemodynamically unstable.

Hemodynamically stable patients – After an initial unsuccessful manual attempt at replacement in a hemodynamically stable patient, administer uterine relaxants then reattempt manual replacement.

Nitroglycerin (glyceryl trinitrate) is an excellent uterine relaxant [21]; we suggest 50 micrograms administered intravenously, followed by up to four additional doses of 50 micrograms, as needed to achieve adequate uterine relaxation for replacement. Nitroglycerin has an extremely short half-life [22], which could be advantageous in patients with severe hemorrhage and hemodynamic instability.

Terbutaline (0.25 milligrams intravenously or subcutaneously) or magnesium sulfate (4 to 6 grams intravenously over 15 to 20 minutes) are other options for uterine relaxation. Magnesium sulfate has a slow onset of action, both drugs have relatively mild effects on the myometrium, but both are acceptable if other agents are not available or if the practitioner is unfamiliar with their use.

Inhalational anesthetic agents, such as sevoflurane, desflurane, and isoflurane, are also excellent uterine relaxants and may allow uterine replacement without surgical intervention [23]. Halothane and enflurane are also effective, but these drugs are not used in adults in the United States because of concerns about serious side effects (eg, halothane-related hepatotoxicity), but may be used in some countries with limited resources because of their low cost. The use of all of these drugs requires controlling the maternal airway (intubation). Therefore, inhalational anesthetic agents are best administered in the operating room as an initial step before proceeding to laparotomy for correction of an otherwise refractory uterine inversion. (See 'Preferred secondary interventions' below.)

Preferred secondary interventions — If the above measures to replace the uterus fail, then the patient should be taken promptly to the operating room to attempt surgical correction of the inversion.

At laparotomy, in place of the uterus, a constriction ring containing a dimple or cup or slit is often observed, and the adnexa (fallopian tubes, round ligaments, and possibly one or both ovaries) are typically pulled into this hole.

We prefer to start with the Huntington procedure because it is less invasive than incision of the constriction ring.

Huntington procedure

Locate the cup formed by the inversion

Place a clamp, such as an Allis or Babcock clamp, on each round ligament entering the cup, approximately 2 cm deep in the cup. Clamp the myometrium if the round ligaments cannot be identified.

Gently pull on the clamps to exert upward traction on the inverted fundus (figure 3) [19,24].

Repeatedly clamp in 2 cm increments along the ligament and exert traction until the inversion is corrected. This procedure is similar to the hand-over-hand movements used when pulling up an anchor line.

If available, a second operator can place a hand in the vagina and apply upward pressure on the fundus to facilitate the procedure, or they can pull one of the clamps while the first operator pulls the other clamp.

Haultain procedure

Make an incision (approximately 1.5 inches in length) in the posterior surface of the uterus to transect the constriction ring and thus increase the size of the previously constricted area (figure 4) [25,26]. Surgical release of the constriction ring should allow manual reduction of the uterine inversion. We prefer a posterior incision to an anterior incision (Ocejo incision) to reduce the risk of accidental cystotomy.

Manual reduction can be performed through the vagina or by placing a finger abdominally through the myometrial incision to below the fundus and then exerting pressure on the fundus to reduce the inversion. Alternatively, the inversion can be corrected using the Huntington procedure, as described above.

The incision is repaired when the uterus has been returned to a normal position.

Other options — Further investigation of safety and efficacy of these other options are needed before they can be recommended.

Hydrostatic reduction of acute uterine inversion is an option if initial nonsurgical interventions have failed and surgical intervention is not possible [27-29].

The patient is placed in reversed Trendelenburg lithotomy position.

A bag of warmed fluid is hung at least one meter above the patient and allowed to flow by gravity or with light pressure through tubing connected to a silastic ventouse cup in the vagina; the seal between the perimeter of the cup and the vagina prevents significant leakage.

The resulting intravaginal hydrostatic pressure may force the inverted fundus back to its normal position (figure 5). Two to 5 liters of fluid may be needed.

A few cases of successful laparoscopic-assisted reduction of acute and chronic uterine inversion have been reported [30-32].

A case report described inserting a vacuum cup into the inverted uterus at laparotomy, creating negative pressure, and then applying gentle traction to reduce the inversion [33].

Procedures to avoid — Vaginal surgical approaches are no longer performed and are potentially dangerous.

Management of the placenta — The author’s preference is to not remove the placenta until the uterus has been replaced. Removing the placenta before replacing the uterus increases blood loss, which may be severe [13,34]. Leaving the placenta in situ rarely interferes with the operator's ability to restore the uterus to its normal position, provided that the patient has appropriate anesthesia. After the uterus has been replaced, the most conservative approach is to await spontaneous separation of the placenta, reserving manual extraction for usual obstetric indications (eg, hemorrhage, prolonged third stage).

Alternatively, the clinician may attempt manual removal, provided that the patient has appropriate anesthesia and is hemodynamically stable. It should be performed in an operating room so that surgical intervention can be undertaken if complications occur.

Place a hand into the vagina, through the cervix, and into the uterine cavity.

Develop a cleavage plane between the placenta and uterine wall. The operator's hand should eventually be positioned under and cephalad to the placenta so that it can be extracted within their cupped hand, rather than by pulling on a portion of the tissue, which might break off during the extraction.

If placental extraction cannot be accomplished easily, or if bleeding increases, a repeat attempt can be supplemented with sponge-stick or suction curettage.

If the placenta remains attached, the possibility of placenta accreta spectrum should be considered. Risk factors, diagnosis, and treatment of placenta accreta are discussed separately. (See "Placenta accreta spectrum: Clinical features, diagnosis, and potential consequences".)

Management after correction of inversion

Hold the uterus in place – After the uterus has been replaced, the fundus should be held in place and then monitored until the surgeon is sure that the uterus is firm and its position is stable. The fundus can be held in place with the clinician's hand(s) placed internally, externally, or both.

Administer uterotonic drugs – Atony is common after restoration of the normal uterine position. Once placental removal has been successfully accomplished, uterotonic agents are administered to induce myometrial contraction and maintain uterine involution, thereby impeding reinversion and reducing the risk of hemorrhage.

An oxytocin infusion (20 to 40 units in 1 liter of crystalloid infused at 150 to 200 mL per hour) is titrated to keep the uterus contracted. Other options, which can be administered with or without concomitant oxytocin, include:

Carboprost tromethamine (15-methyl prostaglandin F2 alpha) 250 mcg intramuscularly, may be repeated every 15 to 90 minutes for a maximum of eight doses (total cumulative dose 2 mg).

Misoprostol 800 to 1000 micrograms vaginally. Rectal administration is also acceptable, especially if there is heavy vaginal bleeding.

Dinoprostone 20 mg (one suppository) vaginally or rectally.

Methylergonovine 200 mcg intramuscularly every two to six hours for a maximum of four doses.

Reactive airway disease is a contraindication to the use of prostaglandin F analogues and methylergonovine. Poorly controlled hypertension is also a contraindication to use of methylergonovine.

Antibiotic prophylaxis – We favor administration of a single dose of a first-generation cephalosporin (eg, cefazolin) for endometritis prophylaxis, provided that the patient does not have a penicillin allergy. In patients with true penicillin allergy, we would use a single dose of clindamycin and gentamicin to cover Gram-positive, Gram-negative and anaerobic bacteria. Studies have reported inconsistent data on the efficacy of antibiotic prophylaxis in this setting [35-37]. Infection, which may be severe, has been described in nonacute uterine inversion [38-40].

Reinversion — The treatment of reinversion is similar to that for the initial inversion. In a single case report, an abdominal cerclage was placed to prevent reinversion in a patient with chronic recurrent inversion [41]. In other case reports, an intrauterine balloon [42] or uterine compression sutures were placed to treat postpartum hemorrhage and prevent recurrent uterine inversion [43-45].

As an example, the Matsubara-Yano compression suture consists of two longitudinal sutures and two transverse sutures: the longitudinal compression sutures extend from the lower uterine segment to the fundus and penetrate the fundal edge; the transverse compression sutures are placed perpendicular to and across the longitudinal sutures to prevent them from sliding off or migrating to the middle of the uterine fundus (figure 6) [45]. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device" and "Postpartum hemorrhage: Management approaches requiring laparotomy", section on 'Atony'.)

OUTCOME — In a series of 2427 cases of puerperal uterine inversion in the United States, the types and frequencies of complications were [7]:

Postpartum hemorrhage (37.7 percent)

Blood transfusion (22.4 percent)

Need for laparotomy (6.0 percent)

Hysterectomy (2.8 percent)

Hypotension (2.1 percent)

Shock (1.3 percent)

Death (one patient)

RECURRENCE IN FUTURE PREGNANCY — The risk of recurrence of uterine inversion in a future pregnancy is not well-defined. In a series of 40 cases of acute postpartum uterine inversion, there were no recurrences in 26 subsequent deliveries [12].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Delivery".)

SUMMARY AND RECOMMENDATIONS

General principles

Clinical significance – Uterine inversion is a rare complication of vaginal birth, and an obstetric emergency. If not promptly recognized and treated, it can lead to severe hemorrhage and shock, resulting in maternal death. (See 'Patient presentation' above.)

Classification – Uterine inversions are classified in terms of the extent and timing of the inversion. Most inversions are acute and complete. (See 'Classification' above.)

Etiology – Uterine inversion has been attributed to excessive cord traction and fundal pressure (Credé maneuver) during the third stage of labor, especially in the setting of a uterine atony and fundal implantation of the placenta. (See 'Pathogenesis' above.)

Diagnosis – The diagnosis should be suspected in postpartum patients with hypotension out of proportion to estimated blood loss and/or when the provider is unable to palpate a normally positioned fundus on abdominal examination. Vaginal bleeding potentially resulting in shock and lower abdominal pain are supportive findings. The diagnosis is confirmed when the fundus is seen protruding through the cervix or vaginal opening or when transcervical examination finds the fundus inside the uterine cavity and transabdominal examination finds a cup-like defect in the area of the normally globular fundus. (See 'Diagnosis' above.)

Treatment

Algorithm (algorithm 1).

Initial interventions – Initial interventions for management of uterine inversion should be applied rapidly: summon help, discontinue uterotonic drugs, administer crystalloid aggressively and blood products (as needed), and attempt to manually reposition the uterus by pushing the fundus cephalad along the long axis of the vagina. (See 'Initial interventions' above.)

Management of the placenta – If the placenta is attached to an inverted uterus, we suggest leaving it in place rather than extracting it before replacing the uterus (Grade 2C). Placental extraction may increase hemorrhage. (See 'Management of the placenta' above.)

Refractory cases

-Uterine relaxant – If the initial attempt at manual uterine replacement is unsuccessful and the patient is hemodynamically stable, we administer a uterine relaxant and reattempt reduction of the inversion. We suggest nitroglycerin over other uterine relaxants (Grade 2C). It is highly effective and has a short duration of action. However, if the patient is hemodynamically unstable after an initial attempt at replacement, it is reasonable to proceed directly to laparotomy. (See 'Management' above and 'Initial interventions' above.)

-Surgery – Surgical intervention is required if manual replacement remains unsuccessful after administering a uterine relaxant. We suggest the Huntington rather than the Haultain procedure (Grade 2C), given the former does not require incising the uterus. (See 'Preferred secondary interventions' above.)

Post-uterine replacement management – A uterotonic agent is administered after uterine replacement to induce myometrial contraction, maintain uterine involution, and prevent reinversion. We use oxytocin because of its rapid action, short half-life, familiarity to personnel on labor and delivery units, and relative lack of side effects in virtually all patients. However, any standard uterotonic drug is acceptable, provided there are no medical contraindications to its use, such as hypertension (methylergonovine) or reactive airway disease (carboprost). In the absence of any medical contraindications, we suggest, in order of preference, oxytocin, carboprost (Hemabate), or misoprostol (Cytotec), and we employ methylergonovine and/or dinoprostone as second-line agents. (See 'Management after correction of inversion' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges John T Repke, MD, who contributed to an earlier version of this topic review.

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