Inversion Of Uterus

Sort and Sweet...as well as good explanation and easy language which are understands all

1. UTERINE INVERSION Joshi Abhishek F.Y.P.B.B.SC.Nursing Govt College of Nursing Jamnagar

2. OBJECTIVES To learn about uterine inversion To learn how to diagnose uterine inversion To Learn what are are the causes of uterine inversion To learn What are the Treatment of Uterine Inversion Steps to manage uterine inversion

3. Content Introduction Of Topic Definition Classification of Inversion of Uterus Degrees Causes Pathophysiology Sign & Symptoms Diagnosis Management Prevention

4. Introduction This is Rare.But Potentially Life Threatening Complication of the Third Stage Of Lobour. It Occurs in Approximately 1 in 20,000 Deliveries The Obstetric Inversion is almost always an Acute One & Usually Complete.

5. DEFINITION ‘‘ When Uterus Turns Inside Out , It Is Called Uterine Inversion.” ‘‘Inversion of Uterus means Uterus is Turned Inside Out Partially OR Completely. Uterine inversion is the folding of the fundus into the uterine cavity in varying degrees.

6. CLASSIFICATION Inversion Of Uterus is Classified in Mainly 3 Types : According Types According Degrees According the Timing of Event

7. A. Types 1) Incomplete Inversion : When fundus of uterus has turned inside out, like toe of socks, but inverted fundus has not descended through Cx… 2) Complete Inversion : When the inverted fundus has passed completely through Cx to lie within the vagina or lie often outside the Vaginal Wall.

8. B. Degrees First degree : The uterus is partially turned out Second degree : The fundus has passed through the cervix but not outside the vagina Third degree : The fundus is prolapsed outside the vagina Fourth degree : The uterus, cervix and vagina are completely turned inside out and are visible

9. Universally…. First Degree : Incomplete Inversion Second Degree : Complete inversion in the vagina Third Degree : Complete inversion outside the Vagina

10. 1 st Degree - Inverted fundus up to cervix 2 nd Degree - Body of uterus protrudes through cervix into vagina 3 rd Degree - Prolapse of inverted uterus outside vulva

11. C. According to Timing of Event Acute : It occurs within 24 hrs of delivery. Sub-acute : It presents between 24 hrs & 4 wks of delivery. Chronic : It presents beyond 4 wks of delivery or in non pregnant stage.

12. CAUSES Excessive cord traction (esp. with an unseparated placenta) Excessive fundal pressure (esp. when uterus is poorly contracted Atonic) Placenta accreta Congenital predisposition Fundal implantation of placenta Either Spontaneous OR Iatrogenic causes.

13. Conti… Spontaneous (40%) : Abnormal short umbilical cord or functionally shortened by being wrapped around the fetal body. Sudden rise in intra abdominal pressure due to maternal coughing or vomiting. Morbid adherence of fundally implanted placenta Connective tissue disorder such as Marphan’s syndrome.

14. Conti… Latrogenic: Due to mismanagement of third stage of labor… Pulling the cord when the uterus is atonic while combined with fundal pressure Crede’s Expression while the uterus is relaxed Faulty technique in manual removal of placenta While separating retained placenta from the wall, a portion may remain attached and as the placenta is withdrawn, the fundus is also withdrawn.

15. PATHOPHYSIOLOGY a portion of uterine wall prolapses through the dilated cervix or indents forward relaxation of part of the uterine wall simultaneous downward traction on the fundus leading to inversion of the uterus.

16. Sign & Symptoms Hemorrhage (94%) Severe abdominal pain in 3 rd stage Hypotension with Bradycardia: shock out of proportion to the blood loss (neurogenic due to increased vagal tone) Uterine fundus not palpable abdominally Mass in the vagina on vaginal examination. Sudden cardiovascular collapse Lump in the vagina Abdominal tenderness Absence of uterine fundus on abdominal palpation

17. Conti… Shock Shock is initially out of proportion with the amount of blood loss. Woman becomes sweaty with bradycardia, profound hypotension and rarely cardiac arrest . In short time there is marked hemorrhage and Hypovolemic shock.

18. DIAGNOSIS The diagnosis of uterine inversion is based upon clinical findings: Bleeding, which may be severe and result in Hemorrhagic Shock Palpation of the prolapsed uterine fundus : Lower uterine segment = INCOMPLETE Vagina = COMPLETE By Intra Uterine Manual Examination

19. DIFFRENTIAL DIAGNOSIS Inversion of uterus Uterine rupture. Prolapse of uterine tumor (submucous fibroid). Large endometrial polyp. Passage of succenturiate lobe of placenta.

20. Dr Shashwat Jani. 9909944160 22 Management

21. Uterine Inversion Remove placenta Oxytocic infusion (40 units/500mls NS) Antibiotics observe O’Sullivan hydrostatic method -dependent part replace into vagina -5L or more physiological solution deposited onto posterior fornix -assistant create water tight seal Manual reduction -apply pressure to dependent part of uterus -simultaneous pressing with other hand on other part which inverted last GA/ stabilize patient UTERUS REPLACED Immediate replacement Resuscitate, IV access, fluids/ bolus replacement NO YES

22. Conti… Teamwork = resuscitation + uterine repositioning simultaneously postpartum hemorrhage drill. The quickest way to treat neurogenic shock - to replace the uterus.

23. Mx of Acute Inversion of Uterus Delay in treatment increases the mortality, So number of steps are taken immediately and simultaneously. Before shock develops : When one is on the spot when the inversion happens TRY IMMEDIATE MANUAL REPLACEMENT , even without anesthesia if not easily available. Principle : “ The part of the uterus which has come down last , should go back first. “

24. Procedure If the diagnosis is made immediately after the inversion has occurred, then that same degree of relaxation of myometrium and cervix (which is required for the inversion to occur) will allow uterine replacement easily … 1. The gloved hand is lubricated with suitable antiseptic cream and placed inside the vagina. 2. The uterine fundus with or without the attached placenta, is cupped in the palm of the hand. The fingers and thumb of the hand are extended to identify margins of the cervix.

25. The whole uterus is lifted upwards towards and beyond umbilicus 4. Additional pressure is exerted with the fingertips systematically and sequentially to push and squeeze the uterine wall back through the cervix. 29 Dr Shashwat Jani. 9909944160

26. 5 . Sustained pressure for 3-5 mins to achieve complete replacement 6 . Apply counter support by the other hand placed on the abdomen 7. Once the fundus has been replaced keep the hand in the uterus while rapid infusion of oxytocin is given to contract the uterus. Initially, bimanual compression aids in control of further hemorrhage until uterine tone is recovered.

27. 8. When the uterus is felt contracting , the hand is slowly withdrawn. If placenta is attached , it is to be removed only after the uterus becomes contracted. If the placenta is partially attached , it should be peeled out before replacement of uterus.

28. 1) Starting from the edge of placenta , 2) The placenta is separated by a) keeping the back of the hand in contact with the uterine wall. b) with slicing movement of the hand. 33 Dr Shashwat Jani. 9909944160

29. O ’ Sullivan ’ s hydrostatic method Tube passed into the posterior fornix Assistant close vulva around operator ’ s wrist Warm saline run in until pressure gradually restores position of uterus

30. Silicon Vacuum cup

31. Alternatively the tubing can be attached to sialistic vacuum extracter cup which is placed inside introitus and may provide better seal. As the vaginal wall distends, there is increase in intravaginal pressure, the fundus of uterus rises and inversion is corrected Once this is achieved, fluid is allowed to escape slowly from vagina. Dr Shashwat Jani. 9909944160 37

32. Conti… If this technique fails, Haultain's Operation can done. In this following steps are taken: Exteriorize the uterus Cervical ring may be stretched

33. Spinellis’s method Kustner’s method Hysterectomy 41 Vaginal route

34. SPINELLI’S METHOD Anterior Colostomy is done and incision on the constricting cervical ring is given for the replacement of uterus .

35. KUSTNER’S METHOD Posterior Colpotomy is done and incision of the cervix similar to that of spinelli’s method. 43

36. Hysterectomy Failure of conservative surgery Family is completed sepsis Dr Shashwat Jani. 9909944160 44

37. MANEUVERS : TO BE AVOIDED Excessive traction on the umbilical cord Excessive fundal pressure Excessive intra-abdominal pressure Excessively vigorous manual removal of placenta. 45 Dr Shashwat Jani. 9909944160

38. Prevention Do not employ any method to expel the placenta when the uterus is relaxed Patient should not be instructed to change her position. Pulling the cord simultaneously with fundal pressure should be avoided Manual removal of placenta should be done in proper manner. 47 Dr Shashwat Jani. 9909944160

39. Bibliography 1. D.C. DATTA’S ; ‘‘A TEXT BOOK OF OBSTETRICS ’’ SEVENTH EDITION;PUBLISHED BY NEW CENTRAL BOOK AGENCY MEDICAL PUBLISHERS (P) LIMITED;KOLKATA; P.NO.420 TO 421. 2.PV BOOKS; ‘‘ A TEXT BOOK OF MATERNAL HEALTH NURSING’ ’ FIFTH EDITION;EDITED BY R.K.GUPTA;P.NO. TO 500. 3.MYLES; ‘‘A TEXT BOOK FOR MIDWIVES’’ SIXTEENTH EDITION ; INTERNATIONAL EDITION;PUBLISHED BY SAUNDERS ELSEVIER; EDITED BY JAYNE MARSHALL & MAUREEN RAYNOR P NO.- 510 TO 515 4. WEBPAGE; ‘‘ WWW.WIKIPEDIA.COM & WWW.ENCYCLOPEDIA.COM ’’; TOPIC OF UTERINE INVERSION ;TEXT AND PICTURES OF ANAEMIA BY DR.KIRAN SADHU,R.N.R.M PROFESSOR. 5. WEBPAGE; ‘‘ WWW.GOOGLE.COM & WWW.SLIDESHARE.COM”; TOPIC OF UTERINE INVERSION;TEXT AND PICTURES;BY RUCHITA BHATT,R.N.R.M.LECTURER

40. 49 Dr Shashwat Jani. 9909944160.