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1. INVERSION OF UTERUS
Sunil Kumar Daha

2. • Extremely rare
• Life threatening complication in third stage in
which the uterus is turned inside out partially
or completely
INVERSION OF UTERUS

3. VARIETIES
1. First degree: Dimpling of the fundus, which still
remains above the level of internal os.
2. Second degree (partial):
passes through cervix but lies inside the vagina.

4. 3. Third degree (complete):
• Endometrium with or without the attached placenta is
visible outside the vulva.
• The cervix and part of the vagina may also be involved in
the process.

5. ETIOLOGY
 May be spontaneous or induced
1. Spontaneous - 40% of the time
• Due to rise in intra-abdominal pressure
Eg: coughing, sneezing or bearing down effort
• caused by localized atony at the placental site over the fundus
• May be associated with
fundal attachment of placenta
short cord
placenta accreta

6. PLACENTA ACCRETA
 Placenta attaches strongly to
the myometrium, but does not
penetrate it
PLACENTA INCRETA
 Occurs when the placenta
penetrates the myometrium
PLACENTA PERCRETA
 The worst form of the
condition is when the placenta
penetrates the entire
myometrium to uterine serosa

7. 2. Iatrogenic:
• Due to mismanagement of 3rd stage of labor
• Occurs when attempts to deliver the placenta
by cord traction with the uterus relaxed
• Fundal pressure while the uterus is relaxed

8. RISK FACTORS
1. Prolonged labor
2. Fetal macrosomia
3. Uterine malformation
4. Short umbilical cord
5. Manual removal of placenta
6. Collagen vascular disease like Ehler’s Danlos
Syndrome
7. Uterine over enlargement

9. DANGERS
1. Shock : Extremely profound mainly of neurogenic origin
due to
tension on the nerves due to stretching of the
infundibulopelvic ligament
pressure on the ovaries as they are dragged with the
fundus through the cervical ring and
peritoneal irritation.

10. 2. Hemorrhage: Especially after detachment of
placenta
3. Pulmonary embolism
4. If left uncared for, it may lead to
• infection
• uterine sloughing
• a chronic one.

11. DIAGNOSIS
Symptoms: Acute lower abdominal pain with bearing
down sensation
Signs:
• Varying degree of shock is a constant feature
• Abdominal examination
(a) Cupping or dimpling of the fundal surface
(b) Bimanual examination
(c) Sonography

12. PROGNOSIS
• The prognosis is extremely gloomy.
• Even if the patient survives, infection, sloughing of the uterus
and chronic inversion with ill health may occur.

13. PREVENTION
• Do not employ any method to expel the placenta out when
the uterus is relaxed
• Pulling the cord simultaneous with fundal pressure should be
avoided
• Manual removal should be done in a manner

14. MANAGEMENT

15. Before the shock develops
 urgent manual replacement
 Principal steps:
• To replace that part first which is inverted last with the placenta
attached to the uterus by steady firm pressure exerted by the
fingers
• To apply counter support by the other hand placed on the
abdomen
• After replacement, the hand should remain inside the uterus
until the uterus becomes contracted by parenteral oxytocin or
PGF2α.

16. • The placenta is to be removed manually only after the
uterus becomes contracted.
a) The placenta may however be removed prior to
replacement to reduce the bulk which facilitates
replacement
b) If partially separated to minimize the blood loss
• Usual treatment of shock including blood transfusion
should be arranged simultaneously

18. After the shock develops
 Principal Steps:
• The treatment of shock should be instituted with an urgent
normal saline drip and blood transfusion
• To push the uterus inside the vagina if possible and pack the
vagina with antiseptic roller gauze
• Foot end of the bed is raised
• Replacement of the uterus either manually or hydrostatic
method (O’Sullivan’s) under general anesthesia is to be
done along with resuscitative measures.

19. HYDROSTATIC METHOD
Procedure:
• 5L of warm sterile fluid is run into the posterior fornix using a
douche nozzle
• Vaginal orifice is blocked by operator’s palm supplemented by
labial opposition around the palm by an assistant
Douche
nozzle

20. ALTERNATIVE HYDROSTATIC METHOD
• Attaching the IV tubing to silicon cup used in vacuum
extraction
• By placing the cup in the vagina, an excellent seal is
created

21. Subacute stage
• To improve the general condition by blood transfusion
• Antibiotics are given to control sepsis
• Reposition of the uterus either manually or by hydrostatic
method may be tried
• If fails, reposition may be done by abdominal operation
(Haultain’s operation)

22. Haultain’s operation
Make an incision in the lower uterine segment to bisect
the inversion ring,  increase its size  replacement
of the fundus

23. POST PROCEDURE CARE
• Once the inversion is corrected, infuse Oxytocin 20
units in 500 ml IV fluids (NS or Ringer’s Lactate) at 10
drops/min
• If the uterus does not contract after Oxytocin,
Ergometrine 0.2mg or Prostaglandins can be given
• Give Prophylactic antibiotics  1 dose only each
Ampicillin 2g IV + Metronidazole 500mg IV, or,
Cefazolin 1 g IV + Metronidazole 500mg IV

24. • Konar.H, DC Dutta’s Textbook of obstetrics 8th edition, Jaypee publication
• Cunningham ,Bloom, Spong, Dashe, Hoffan, Casey, Sheffield, Williams obstetrics, 24th edition , Mc
Graw Hill education
• Manual of Obstetrics, 3rd Edition
REFERENCES

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