inversion of the uterus.pptx
- 1. INVERSION OF THE UTERUS
- 2. INVERSION OF THE UTERUS • It is an extremely rare but a life-threatening complication in third stage in which the uterus is turned inside out partially or completely. • The incidence is about 1 in 20,000 deliveries.
- 3. VARIETIES • First degree—There is dimpling of the fundus, which still remains above the level of internal os. • Second degree—The fundus passes through the cervix but lies inside the vagina. • Third degree (complete)—The 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.
- 6. ETIOLOGY The inversion may be spontaneous or more commonly induced. Spontaneous (40%): • This is brought about by localized atony on the placental site over the fundus associated with sharp rise of intraabdominal pressure as in coughing, sneezing or bearing down effort. • Fundal attachment of the placenta (75%) • short cord • placenta accreta • weakness of uterine wall at the placental site are often associated.
- 7. • Iatrogenic: This is due to the mismanagement of third stage of labor. • Pulling the cord when the uterus is atonic especially when combined with fundal pressure • Fundal pressure while the uterus is relaxed • Faulty technique in manual removal.
- 8. Common risk factors are uterine over enlargement prolonged labor fetal macrosomia, Uterine malformations morbid adherent placenta short umbilical cord tocolysis manual removal of placenta.
- 9. DANGERS: (1) Shock is extremely profound mainly of neurogenic origin (2) Hemorrhage, especially after detachment of placenta (3) Pulmonary embolism (4) If left uncared for, it may lead to— (a) Infection (b) uterine sloughing (c) a chronic one.
- 10. DIAGNOSIS: Symptoms: Acute lower abdominal pain with bearing down sensation. Signs: (1) Varying degree of shock is a constant feature (2) Abdominal examination— (a) Cupping or dimpling of the fundal surface (b) Bimanual examination not only helps to confirm the diagnosis but also the degree. In complete variety, a pear-shaped mass protrudes outside the vulva with the broad end pointing downward and looking reddish purple in color (c) Sonography
- 11. 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, as it should be
- 12. MANAGEMENT: • Call for extra help • Before the shock develops- urgent manual replacement even without anesthesia
- 13. Principal steps: • The patient is under general anesthesia. (1) To replace that part first, which is inverted last. (2) To apply counter support by the other hand placed on the abdomen. (3) After replacement, the hand should remain inside the uterus until the uterus becomes contracted by parenteral oxytocin or PGF2α.
- 14. (4) The placenta is to be removed manually only after the uterus becomes contracted. The placenta may however be removed prior to replacement— (a) to reduce the bulk which facilitates replacement (b) if partially separated to minimize the blood loss (5) Usual treatment of shock including blood transfusion should be arranged simultaneously.
- 15. After the shock develops Principal Steps: (1) The treatment of shock should be instituted with an urgent NS infusion and blood transfusion . (2) The inverted fundus lies on the palm of the hand with the fingers placed near the uterocervical junction. When pressure is exerted on the fundus, it gradually returns into the vagina. The vagina is packed with antiseptic roller gauze. (3) Foot end of the bed is raised
- 16. • (4) Replacement of the uterus using hydrostatic method (O’Sullivan’s) under general anesthesia
- 17. • The inverted uterus is replaced into the vagina. • Warm sterile fluid (up to 5 liters) is gradually instilled into the vagina through a douche nozzle. • The vaginal orifice is blocked by operator’s palms supplemented by labial apposition around the palm by an assistant. • Alternatively, a silicon cup (vacuum extraction cup) is placed into the vagina. • The douche can be placed at a height of about 3 feet above the uterus. • The water distends the vagina and the consequent increased intravaginal pressure leads to replacement of the uterus.
- 18. Sub acute stage: (1) To improve the general condition by blood transfusion (2) Antibiotics are given to control sepsis (3) Reposition of the uterus either manually or by hydrostatic method may be tried (4) If fails, reposition may be done by abdominal operation