Inversión uterina puerperal

Introduction

Uterine inversion is a rare obstetric emergency that occurs during the third stage of labor

Objective

To describe the clinical, diagnostic and therapeutic characteristics and outcomes in patients with uterine inversion.

Material and methods

We performed a retrospective study of six patients with uterine inversion during the puerperium in the Hospital de Leon (Spain) in 2005.

Results

All inversions occurred in primiparous women with epidural anesthesia and instrumental delivery at term. Oxytocin was used in 83% during dilatation; the average duration of which was 6.5 hours. Diagnosis was mainly clinical except in one grade II inversion, which required ultrasonography and was resolved surgically. The remaining cases were resolved through manual reduction (83%). After the episode, hemoglobin levels were reduced by an average of 2.7 g/dl from prepartum levels, and only two patients required blood transfusion.

Conclusions

Factors predisposing to uterine inversion were hypotonic uterus, fundal implantation of the placenta, and placenta accreta. Sixty percent of all cases were caused by precipitous maneuvers including traction on the cord or improper fundal pressure. Diagnosis is essentially clinical. Although uncommon, uterine inversion will result in severe hemorrhage and shock if left unrecognized, leading to maternal death. Once a diagnosis is made, immediate measures must be taken to stabilize the mother. Manual manipulation should be attempted immediately to reverse the inversion. Tocolytics, such as ritrodine, magnesium sulphate and terbutaline, or halogenated anesthetics may be administered to relax the uterus and aid its reversal. Intravenous nitroglycerin is an alternative to tocolytics. Failure of reversion or recurrence requires surgical treatment.