Uterine inversion is a rare complication of the postpartum or postpartum period, in which there is a partial or complete uterine inversion by the mucous membrane outward. The causes of the condition most often lie in the improper management of childbirth and an attempt to forcibly separate the placenta, spontaneous inversion rarely occurs. It is manifested by bleeding and the appearance of the uterus in the vagina, the vestibule or outside the genital slit. Eversion is diagnosed during the examination of the maternity hospital. Treatment consists in emergency reduction of the uterus, anti-shock measures and prevention of infectious complications.
N85.5 Uterine inversion
Uterine inversion in obstetric practice is very rare. According to statistics, this complication is observed in 1 case per 45,000 births. But in countries with a low level of medical care, a shortage of qualified midwives, the frequency of inversion increases to 1 case per 8,000 births. This is due to a violation of the technique of conducting the third period of labor. The relationship of the inversion with the age of the woman in labor, the number of births has not been established. But with high parity, multiple fertility, polyhydramnios, the risk of hypotension increases, which is one of the provoking factors.
Spontaneous eversion is rare. For the formation of pathology, it is necessary that the woman’s cervix is opened, hypotension is observed. The producing factor is the pressure directly on the uterine body or an increase in intra-abdominal pressure. The reason for the increased risk of atony and eversion is uterine fibroids, surgeries, Marfan syndrome and aggressive rodostimulation.
- Using the Krede–Lazarevich method. In the 3rd period of labor, a technique simulating contractions can be used to separate the afterbirth. First, gentle stroking is performed, and then the bottom of the uterus is grasped by hand, squeezed and pushed a little in the direction of the womb. If the uterine body is not massaged beforehand, this becomes the cause of eversion.
- Application of the Genter method. Imitation of labor forces occurs in the subsequent period with an undelivered placenta. A midwife or gynecologist presses with her fists through the abdominal wall to the bottom of the uterus in the direction of the pubic articulation. Gradually, the birth of the afterbirth occurs or the mechanisms that determine the causes of the inversion are triggered.
- Pulling the umbilical cord. Dense increment of the placenta in the area of the uterine fundus after prolonged labor or with multiple pregnancies can cause hypotension. The tension of the umbilical cord does not lead to the separation of the afterbirth, but causes an uterine inversion. This condition increases the risk of severe bleeding.
- The birth of fibroids. A node with a submucosal arrangement on the leg, with an increase in size, can shift to the isthmus and cause contractions, opening of the cervix, which simulates labor activity. But the separation of fibroids from the wall of the organ is impossible, and its birth can lead to the involvement of the uterine fundus and the formation of eversion.
Normally, the follow-up period lasts no more than half an hour. The delay of the afterbirth in the uterus for more than 30 minutes reduces its ability to contract, leads to hypotension. After 20-25 minutes, attempts may be made to accelerate the separation of the child’s place with the help of external methods of Genter, Krede-Lazarevich or for the end of the umbilical cord. With a tight attachment of the placenta and the developed uterine atony, these methods do not give the desired result and lead to a displacement of the uterine floor in the direction of the vagina or a complete inversion of the mucous layer outside of the birth canal. Sometimes this process is accompanied by vaginal prolapse.
The inverted uterus pulls the appendages and ovaries, which leads to irritation of the nerve bundles, peritoneum and the development of pain shock. A woman’s skin turns pale, blood pressure decreases, but at the same time the heart does not accelerate the rhythm, bradycardia is characteristic. The cause of incessant bleeding is hypotension of the myometrium and gaping vessels. This aggravates the picture of shock, leads to depletion of the coagulation system. If the inversion is not corrected, an infection joins after 6-8 hours, and necrosis develops even later.
The type of uterine inversion is determined by the degree of displacement of its bottom relative to other anatomical structures: the cervix and vagina. This affects the amount of care needed, the clinical symptoms and the severity of the condition of the woman in labor. The following types of uterine inversion are distinguished:
- Partial. In the third period of labor, the bottom of the uterus shifts to the neck, a curvature is formed, facing the concave part into the abdominal cavity, and the convex part to the neck. Sometimes the bottom passes into the open neck.
- Full. In childbirth, the uterine floor extends beyond the neck into the vagina, gradually turns inside out according to the type of glove. In the advanced stage, the mucous layer of the uterus is turned outward behind the genital slit, dragging the vagina with it.
Signs of eversion appear in the subsequent or early postpartum period. The separation of the placenta may be delayed for up to half an hour. If the techniques of afterbirth extraction have reached the goal, the eversion may begin with increased bleeding. The woman feels warm flowing blood on the perineum and buttocks, a sharp pain in the abdomen, which does not subside. Then there are signs of shock. Very dizzy, there is a general weakness, which is a consequence of a sharp decrease in blood pressure. There is a chill, a small muscle tremor.
Due to irritation of the peritoneum, there is no reflex tachycardia, the heart slows down the rhythm. The skin rapidly turns pale, cold sticky sweat appears. Lips become dry, tormented by intense thirst. Nausea and vomiting may occur, which are poor prognostic signs. Breathing becomes faster. With a severe degree of shock, the skin becomes bluish. The woman in labor breathes often, but superficially.
The uterine inversion must be corrected no later than 2-6 hours after delivery. In the absence of medical care, severe life-threatening complications occur. If the woman has not separated the afterbirth, massive bleeding is observed. It leads to a violation in the coagulation system and is the cause of DIC syndrome, which goes through several phases. First, the blood coagulation system is activated, hypercoagulation develops. During this phase, there is a high risk of blood clots. Blood clotting factors are consumed very quickly, consumption coagulopathy occurs, which turns into hypocoagulation and increased bleeding. The result is hemorrhagic shock, agony and death.
Childbirth outside a medical institution, which is complicated by uterine inversion, may be accompanied by infection with Clostridium tetani and the development of tetanus. In women who have not had a reduction of the uterus after eversion, infectious complications quickly arise that lead to myometritis, necrosis or gangrene. The occurrence of these pathologies requires extirpation of the uterus.
The diagnosis of eversion is carried out according to a typical clinical picture. After childbirth, a soft round tumor-like formation of red color is detected in the vagina. With a complete inversion, the uterus appears outside the genital slit. If the afterbirth is not separated after the inversion, this facilitates diagnosis. At the bottom of the uterus, a placenta with an attached umbilical cord is visually noticeable.
With partial inversion, a two-handed examination helps to establish a diagnosis in childbirth. Palpation through the anterior wall of the abdomen determines a funnel-shaped depression in place of the genitals. Manipulation is painful, gives a woman unpleasant sensations. The condition of a woman after childbirth with an eversion can be severe, so other diagnostic methods are not used. Laboratory tests, pulse counting and blood pressure measurement are necessary to assess the severity of the condition and determine the level of necessary care.
Treatment is carried out urgently in the maternity hospital by an obstetrician-gynecologist. It is necessary to have an assistant and two midwives, as well as an anesthesiologist for narcotic anesthesia and resuscitation. The purpose of eversion therapy is organ reposition and elimination of shock symptoms. Prevention of infectious complications is also carried out.
If a woman was intravenously injected with uterotonics during childbirth, the infusion is immediately stopped in order to prevent the uterus from contracting before its reduction. The nurse provides venous access, colloidal and crystalloid solutions are prescribed to correct the water-salt balance, reduce the effects of blood loss. The following groups of drugs are used:
- Narcotic analgesics. Manipulations to correct the uterine inversion and the subsequent separation of the placenta are necessary for high-quality and rapid anesthesia. They are used intramuscularly after childbirth for 1-3 days with severe pain syndrome.
- Antibiotics. They are prescribed for the prevention of infectious complications and the development of endometritis. Cephalosporins of the 2-3 generation are used in combination with metronidazole, which suppresses the anaerobic microflora. The duration of treatment is up to 5 days.
- Blood preparations. After massive blood loss, with the development of DIC syndrome, freshly frozen plasma, platelet mass or individual components of the coagulation system are used to replenish clotting factors. Whole blood is not used in DIC syndrome.
The inversion correction is performed under general anesthesia after reducing the signs of shock. First, the possibility of separating the placenta is checked. If it is tightly attached, a reduction is carried out and only after that a manual separation. Otherwise, bleeding occurs, which cannot be stopped due to hypotension. To facilitate manipulation, dissection of the posterior lip of the neck is performed. The inversion is corrected by carefully inserting the body of the organ in the opposite direction or using the Johnson method, in which the uterus is first shifted into the abdominal cavity and then turned out.
If the inversion is unsuccessful, a laparotomy is performed. During the operation, the Johnson reposition technique is combined and supplemented with the Huntington procedure. If the uterine inversion is accompanied by a cervical spasm, manipulation becomes impossible. It is replaced by the Holtaine operation, in which the Huntington procedure is supplemented by a cut of the contractile ring on the neck.
After correction of the inversion, a hot water bottle with ice is placed on the lower abdomen, uterotonics are prescribed (an intravenous oxytocin solution to improve uterine contractility, reduce the risk of bleeding). Some doctors apply compression sutures and insert a vaginal balloon to prevent repeated inversion after childbirth.
After uterine inversion, a woman must undergo restorative treatment. Anemia, which developed after complicated childbirth, is corrected with the help of iron preparations. Enzyme preparations are used to prevent the development of adhesions in the pelvis. Lifting weights of more than 3 kg for a month is limited. In order to eliminate straining and increased intra-abdominal pressure, nutrition is adjusted, with a tendency to constipation, laxatives are used. Effective contraception is mandatory for 2 years to avoid a new pregnancy.
Prognosis and prevention
The prognosis for uterine inversion depends on the speed of medical care and the degree of shock, may threaten the life of the mother. But in most cases, everything ends favorably. Prevention consists in the rational management of childbirth. It is necessary to avoid aggressive stimulation, the appointment of large dosages of uterotonics, so as not to cause anomalies of labor activity. With a lingering afterbirth in the uterine cavity, it is recommended to use manual separation of the placenta under anesthesia as a safer method of delivery.