Uterine Inversion

Question 1

Classification of uterine Inversion

Answer 1

Protusion of the uterus into the endometrial cavity and potentially through the vaginal orifice.

First degree: corpus or wall of uterus extends into the
cervix
Second degree: corpus of uterus passes through the
cervical ring but does not reach the perineum
Third degree: fundus of uterus extends to the perineum
Fourth degree: uterus and vagina invert past the
perineum

Question 2

RFx for uterine inversion

Answer 2

Maternal
- Connective tissue disorders (marfan’s, Ehlers-Danlos)
- Pre-eclampsia
- Uterine tumours or structural abnormalities
- Placenta Accreta

Foetal
- Multiple pregnancy
- Macrosomia

Labour
- Prolonged labour
- Atony
- Excessive cord traction
- MROP
- Use of uterotonic agents before placental separation

Question 3

CFx of uterine inversion

Answer 3

• Severe lower abdominal pain
• Profound bradycardia and hypotension due to vagal stimulation
• Vaginal bleeding

Question 4

Management of uterine inversion

Answer 4

Replacement of uterus
- Stop uterotonics
- Manual replacement with hand
- May require tocolytic agents (GTN, terbutaline, MgSO4)
- Surgical intervention with a laparotomy

Management of initial shock
- May require atropine for bradycardia
- Vasopressors for SVR

Management of PPH
- Uterotonics when the uterus is replaced
- Fluid resus
- Blood products
- TXA

Management of pain
- Alfentanyl
- Volatiles (help uterine relaxation)
- Epidural top-up