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Uterine inversion obgyn gynae emergeny (1) (1).pptx

uterine inversion

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INVERSION OF UTERUS
• Extremely rare • Life threatening complication in third stage in which the uterus is turned inside out partially or completely INVERSION OF UTERUS
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.
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.
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
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
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
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
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.
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.
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
PROGNOSIS • The prognosis is extremely gloomy. • Even if the patient survives, infection, sloughing of the uterus and chronic inversion with ill health may occur.
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
MANAGEMENT
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.
• 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
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.
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
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
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)
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
• Konar.H, DC Dutta’s Textbook of obstetrics 8th edition, Jaypee publication • Cunningham ,Bloom, Spong, Dashe, Hoffan, Casey, Sheffield, Williams obstetrics, 24th edition , M Graw Hill education • Manual of Obstetrics, 3rd Edition REFERENCES
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