Trauma, uterine inversion & uterine rupture Flashcards
What is uterine inversion?
the folding of the fundus into the uterine cavity in varying degrees
What is the pathophysiology and usual cause of uterine inversion?
- uterine atony
- soft dilated cervix
- fundal pressure or cord traction
- usually due to mismanagement of third stage beginning before uterus has contracted firmly and placental separation has occured
What are the three classifications of uterine inversion?
1st degree/incomplete: fundus protrudes through cervical os
2nd degree/complete: fundus descends into the vaginal introitus
3rd degree/prolapsed: extends beyond the vulva
What are some factors associated with a higher risk of uterine inversion?
- short umbilical cord
- multiparity
- abnormally adherant placenta
- fundal implantation
- VBAC
- fetal macrosomia
- antenatal use of MgSO4
- precipitate labour
- sudden increase in abdominal pressure (e.g. coughing)
What are the signs/symptoms of uterine inversion?
- severe abdominal pain
- shock
- haemorrhage
- unable to palpate fundus
- if palpable fundus may feel indented, globular or irregular
- pelvic examination reveals mass in vagina
- uterus visible at vulva
What is the procedure for manual replacement of an inverted uterus?
- call for assistance (CODE)
- tocolytics if needed (turbutaline or GTN) prior to replacement
- do not attempt to remove placenta
- immediately attempt manual replacement- sterile gloves, grasp uterus with palm and gently push back through cervix towards umbilicus, supporting with opposite hand on abdomen
- give oxytocic and keep hand in uterus until firm contraction is felt
- reinversion may occur
What are the 2 main priorities of management of uterine inversion?
- immediate replacement of uterus
- simultaneous maternal resuscitation
What are the main priorities of maternal resuscitation in managment of inverted uterus?
- call for assistance (CODE)
- lower bed to flat
- commence monitoring immediately (BP, P, RR, SO2)
- assess for signs of shock (cool, clammy, pale, tachycardic, hypotension)
- administer oxygen
- 2x 16G IV cannulae
- take blood (FBR, group & hold, crossmatch at least 4 units blood, coagulation profile)
- Fluid bolus, preferably with pressure infusion device e.g. normal saline, hartmann’s , gelafusine
- IDC, monitor output
- strong analgesia
- administer oxytocic if uterus successfully replaced and placenta born
- may need to transfer to theatre for manual removal of placenta
- administer prophylactic antibiotics ( cephazolin and metronidazole)
- otherwise resucitate and transfer to theatre
What other techniques may be used if first attempt at manual replacement is unsuccessful?
- O’sullivan technique - hydrostatic pressure, warm saline rapidly instilled into the vagina, distends cavity and forces fundus back up, several litres may be required
- surgical correction PV or via laparotomy
What is chronic inversion?
- inversion as late as 14/52 postpartum
- unusual, not well understood
- symptoms include PV bleeding, back pain, pelvic pressure, malaise, low grade fever
- diagnosed on USS
What are the main causes of trauma in pregnancy?
- car accidents
- domestic violence
- falls
What are the major risks associated with trauma in pregnancy?
- preterm labour
- placental abruption
- fetal-maternal haemorrhage
- pregnancy loss
- rupture of uterus/bladder
- acute shock
What is the correct way to wear a seatbelt in pregnancy?
- one strap as low as possible under the abdomen, other between breasts
Why are pregnant women particularly at risk for falls?
- changes in center of gravity
- changes in gait
- visual changes, can’t see feet
What are the priorities when managing trauma in pregnancy?
- diagnosis of damage (Xray, CT)
- resuscitation (continuous monitoring of maternal vital signs and fetus)
- IV access and fluid replacement
- take bloods (FBC, crossmatch, group & save, LFTs, coagulation studies, platelets, FDPS for DIC risk and Kleihauer)
- position woman left lateral
- administer oxygen (O2 sats to >90%)
- cathetre
- reassurance and followup CTG/USS
- postmortem or perimortem CS (up to 20 minutes)
