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Uterine Inversion

Pathophysiology
1. Serious complication of vaginal delivery
Epidemiology
1. Incidence: 1 per 25,000 deliveries
2. More commonly affects multiparous patients
3. Iatrogenic cause most often
Signs
1. Placenta appears at introitus attached to mass
2. Shock
  1. Bradycardia associated with vagal response
3. Excessive hemorrhage
Grading
1. First Degree: Incomplete inversion
2. Third Degree: Complete inversion to perineum
Management
1. Treat shock and blood loss
  1. Immediate Intravenous Access
  2. Intravenous Fluid replacement
2. Call for consultation
  1. Obstetrics
  2. Anesthesia (consider Halothane)
3. Give uterine relaxants (Tocolytics)
  1. Terbutaline 0.25 mg SC
  2. Nitroglycerin
    1. Intravenous: 50 to 200 mcg IV
    2. Sublingual (200 mcg per spray): 2 sprays sublingual
4. Immediate Manual Replacement (Johnson Maneuver)
  1. Replace uterus in non-inverted position
    1. Replace last part out first (last out, first in)
  2. Administer Terbutaline or Nitroglycerin as above
  3. Consider General Anesthesia
  4. Repeat trial of Manual Replacement
  5. Surgical Replacement
5. Post-Replacement Uterine Hemorrhage management Options
  1. Pitocin IV 40 u/L at 100-250 cc/h
  2. Hemabate 0.25mg IM Myometrium q15 minutes (max: 2 mg)
  3. Methergine 0.2 mg IM or PO q6-8h
6. Consider exploratory laparotomy if needed
References
1. Hicks (2000) Am Board Fam Pract 13:374

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 6/1/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.