MANAGEMENT OF ACUTE UTERINE INVERSION BY DR SHASHWAT JANI

MANAGEMENT OF ACUTE UTERINE INVERSION BY DR SHASHWAT JANI

1. Acute Uterine Inversion What to do & What not to do ? Dr. Shashwat Jani. M.S. ( Gynec ). Diploma in Advance Endoscopy ( France ) . Assistant Prof., Smt. N.H.L. Mun . Medical College, Ahmedabad, Gujarat . Mobile : [phone] . E- mail : [email protected]

2. Definition When Uterus Turns Inside Out , It Is Called Uterine Inversion. Uterine inversion is the folding of the fundus into the uterine cavity in varying degrees . 2 Dr Shashwat Jani. 9909944160

3. Incidence Varies between 1 : 2000 to 1 : 35,000 deliveries. 3 Dr Shashwat Jani. 9909944160

4. Incidence Rarely , it Can occur even in the non-pregnant uterus in relation to the expulsion of an intrauterine tumor…!!! 4 Dr Shashwat Jani. 9909944160

5. CLASSIFICATION 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 introitus. 5 Dr Shashwat Jani. 9909944160

6. 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 6 Dr Shashwat Jani. 9909944160

7. Universally… First Degree : Incomplete Inversion Second Degree : Complete inversion in the vagina Third Degree : Complete inversion outside the introitus 7 Dr Shashwat Jani. 9909944160

8. C. In relation to time interval between its diagnosis & time of delivery : 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. 8 Dr Shashwat Jani. 9909944160

9. Causes… For the uterus to be inverted, must be relaxed or local atony of uterus at the site of placental insertion especially fundal . There should be fundal insertion of placenta. Either of above two along with : Spontaneous OR Iatrogenic causes . 9 Dr Shashwat Jani. 9909944160

10. 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. Dr Shashwat Jani. 9909944160 10

11. B. Iatrogenic 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. 11 Dr Shashwat Jani. 9909944160

12. Patho physiology In complete inversions, once the fundus passes through the cervix, the cervical tissues function as a constricting band and edema rapidly forms . The prolapsed mass then progressively enlarges and increasingly obstructs venous and finally arterial flow, contributing to the edema. 12 Dr Shashwat Jani. 9909944160

13. Clinical Presentation Large boggy mass appears at introitus with or without placenta attached Other signs and symptoms are as follows – Severe and sustained hypogastric pain in 3rd stage of labor 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 hypovolumic shock. 13 Dr Shashwat Jani. 9909944160

14. P/A : In incomplete uterine inversion: fundus of uterus may appear to be normal. Only in thin woman it is possible to feel fundal dimple of incomplete inversion. In complete inversion : uterus is not palpable per abdomen. At Vulva, a pear shaped mass is seen protruding outside vulva with broad end pointing downwards, looking reddish purple in color Bimanual Examination - Confirm the diagnosis by detecting inverted body of the uterus and above encircling it, the ring of cervix. 14 Dr Shashwat Jani. 9909944160

15. DIFFERENTIAL DIAGNOSIS Inversion of uterus Uterine rupture. Prolapse of uterine tumor ( submucous fibroid). Large endometrial polyp. Passage of succenturiate lobe of placenta. 15 Dr Shashwat Jani. 9909944160

16. Dr Shashwat Jani. 9909944160 16 Management

17. 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. 17 Dr Shashwat Jani. 9909944160

18. 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. 18 Dr Shashwat Jani. 9909944160

19. 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. “ 19 Dr Shashwat Jani. 9909944160

20. 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. 20

21. 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. 21 Dr Shashwat Jani. 9909944160

22. 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. Dr Shashwat Jani. 9909944160 22

23. 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. Dr Shashwat Jani. 9909944160 23

24. If the patient comes late : Within 1 -2 minutes, from the occurrence of inversion, the cervix and lower segment clamps down inverted part of the uterus. increasing congestion, Edema of the inverted fundus. makes manual replacement without anesthesia difficult. If first attempt at immediate manual replacement of uterus fails, move to the following sequence … 1. Call assistance Anesthesiologist (assistance of nurse and obstetricians SOS) 2. Elevation of the foot of the delivery table may relieve the tension on the viscera and reduce the pain and shock 24 Dr Shashwat Jani. 9909944160

25. 3 . Establish two wide bore i.v . cannulae . Send blood for for grouping and cross match . Rapidly run in 1-2 L of crystalloid. Because though initially shock is neurogenic type, hypovolumia will follow due to hemorrhage. 4. Catheterize . 5. Prophylactic antibiotics are given 6. If pain is a dominant symptom, small doses of i.v . Morphine or Pentazocine with Atropine is given. 7. If the inverted uterus is prolapsed beyond the vagina, it is replaced within the vagina 8. Patient is shifted to OT. 9. Anaesthesia 25 Dr Shashwat Jani. 9909944160

26. General Anesthesia : Shock and with cardiovascular instability . G.A. is preferred. For this one of the fluorinated hydrocarbons are preferred ( Halothne , Sevofurane , Isoflurane ) to aid uterine relaxation. Halothane is associated with rare myocardial irritability/ arrythmia and hepatotoxicity . Therefore other two are preferred . Epidural/ Spinal Anaesthesia : With normal vital signs , spinal anaesthesia can be given or if the patient is already in epidural anaesthesia , then it maybe continued. When anesthetic facilities are not available , replacement will have to be undertaken and combination of i.v . narcotics, combined paracervical and pudendal block and inhalation anesthesia as available and feasible. 26 Dr Shashwat Jani. 9909944160

27. If G.A. does not produce adequate uterine relaxation or if patient is in regional anaesthesia , tocolysis is necessary. If the patient is hypotensive , MgSO4 2 gm i.v . bolus is given to relax cervical contraction ring. If the patient is stable NTG is given… 1 Ampoule of NTG ( 5mg in 1ml solution) is diluted in 100ml NS. This gives concentration of 50 μg /ml. Draw 20ml in syringe 4ml given i.v . (i.e. 200μgm) and repeat it at 2 mins interval SOS in normotensive patient 2ml given i.v . (100μgm) and repeat it at 2 mins interval in hypotensive patient after correcting hypovolumia In all the cases where oxytocin or prostaglandin has been given previously higher doses of NTG is required. Onset of action – 90sec and lasts for 1-2 mins 27 Dr Shashwat Jani. 9909944160

28. Maternal side effect : - Peripheral vasodilatation and reduced venous tone - so Rapid infusion with crystalloid is needed in pts who are hypovolemic Peripheral vasodilatation responds to adrenaline. Uterine relaxation responds to oxytocin . TERBUTALINE CAN BE USED AS TOCOLYTICS AGENT. 11. Manual replacement of uterus. As described before 12. As soon as the uterus is restored to its normal configuration -- The agent used for uterine relaxation is stopped -- Simultaneously oxytocin is started to contract the uterus. 28 Dr Shashwat Jani. 9909944160

29. If there is delay in presentation of the patient i.e. more than 2 hrs or if manual replacement fails then… O’Sullivan’s hydrostatic replacement technique is used: Pre-requisites: Make sure that the uterus and vagina have no lacerations . If there are found, should be sutured. Principle: Install large volume of saline at body temperature (3-5lt) into upper vagina This distends the upper fornices , which serves to pull open the cervical ring This allows replacement of uterine fundus Procedure : Until replacement is effected, a towel soaked with warm hypertonic saline is draped over the inverted uterus to reduce the oedema . 29 Dr Shashwat Jani. 9909944160

30. Use douche and rubber tubing with warm sterile fluid at 3 feet height or 1 litre bags of warm saline with a pressure infuser. Rubber tubing is placed in posterior fornix by one hand which also cups the fundus. The other hand seals the introitus around the wrist so that there is no leakage of fluid. 30 Dr Shashwat Jani. 9909944160

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 31

32. 14. In rare delayed cases, manual replacement with or without hydrostatic technique may be unsuccessful . In such cases, Surgical replacement will have to be done… Procedure: Patient is cleaned and draped in Lloyd Davis position ( frog legged ) with head down ( Trendelenberg ) 32 Dr Shashwat Jani. 9909944160

33. Catheterisation Midline laparotomy done Bowels packed upwards and away from uterus The obstetric surgeon places his/her hands in front and back of the lower segment with the fingertips below the level of inverted fundus. 33 Dr Shashwat Jani. 9909944160

34. With progressive pressure on the finger tips of both hands which flip up simultaneously. The internal dimple is replaced with rising fundus. Uterine perfusion returns. If this technique fails, Huntington’s Operation : In this following steps are taken: Exteriorize the uterus Cervical ring may be stretched 34 Dr Shashwat Jani. 9909944160

35. Locate the cup of the uterus formed by the inversion Dilate the constricting cervical ring digitally Stepwise traction on the funnel of the inverted uterus or the round ligament is given with Allis forceps . Reapplied progressively as fundus emerges.

36. ( A) Obstetric ventouse applied on the inverted uterine fundus. (B) Reduction of the inverted uterus after traction with the ventouse . Instead of allies forceps alternatively vaccum cup can be used in HUNTINGTON PROCEDURE 36

37. HAULTAIN’S PROCEDURE : Incision is made posteriorly through the cervix, relieving cervical constriction to increase the size of the ring and allowing traction on the round ligament for the replacement of uterus with subsequent repair of incision from inside the abdomen. 37

38. Spinellis’s method Kustner’s method Hysterectomy 38 Vaginal route

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

40. KUSTNER’S METHOD Posterior Colpotomy is done and incision of the cervix similar to that of spinelli’s method. 40

41. Hysterectomy Failure of conservative surgery Family is completed sepsis Dr Shashwat Jani. 9909944160 41

42. Post Operative : Whatever method for uterine replacement is used , It should be followed by… 1. Oxytocics to keep uterus is well contracted for 8 – 12hrs. Oxytocin drip 15-methyl PGF 2 α Ιnitially , after correction of inversion, inj. 15-methyl PGF 2α ( carboprost ) given in dose of 0.25mg i.m . or intramyometrially (0.25mg diluted in 5 ml and given at two sites is uterine fundus). Duration of action: 6 hrs 2 . Broad Spectrum Antibiotics given, if it is not given before . 42 Dr Shashwat Jani. 9909944160

43. COMPLICATIONS OF INVERSION OF UTERUS . Postpartum hemorrhage due to uterine atony. Hypovolaemic shock and all its consequence. Vasovagal shock (due to severe pain). Endometritis (sepsis). 43 Dr Shashwat Jani. 9909944160

44. Infection of adnexa. Necrosis of adnexa (ovaries) due to compression of ovaries as they drawn inside. Damage to intestine / septic paralytic ileus. Chronic inversion. 44 44 Dr Shashwat Jani. 9909944160

45. Recurrence of inversion. Increased risk of rupture of uterus in next pregnancy (when surgical procedure done for inversion). Increased risk of C-section in subsequent delivery. Chronic pelvic pain -> if chronic inversion is not treated. 45 Dr Shashwat Jani. 9909944160

46. PREVENTION Many cases of acute uterine inversion result mainly from mismanagement of the third stage of labour in women who are already at risk. 46 Dr Shashwat Jani. 9909944160

47. MANEUVERS : TO BE AVOIDED Excessive traction on the umbilical cord Excessive fundal pressure Excessive intra-abdominal pressure Excessively vigorous manual removal of placenta. 47 Dr Shashwat Jani. 9909944160

48. Recently... Vijayaraghvan et al. 26 reported a case where acute inversion of the uterus was managed under laparoscopic guidance, citing the advantages of laparoscopic surgery as the reason for the procedure. Consideration, however, needs to be given to the woman’s hemodynamic status and the possible effects of pneumoperitoneum. 48 Dr Shashwat Jani. 9909944160

49. 49 Laparoscopic appearance of the inverted uterus. (B) A 5-mm forceps being used to press down on the top of the inverted uterus. (C) Partial reduction achieved; further reduction was completed using a 10-mm blunt-tipped Teflon rod to press down on the top of the inverted uterus. (D) Complete reduction achieved.

50. 50 Dr Shashwat Jani. 9909944160.

51. Thank you