Uterine Inversion – All You Need To Know

Uterine inversion is a potentially fatal maternal condition where the uterus either partially or completely falls outside cervix or even vagina. In simple terms it can be called “Uterus turning inside out”.

What is Uterine Inversion?

Uterine inversion is a life-threatening obstetric emergency which is very rare but can lead to serious ill effects like hypovolemic shock, severe haemorrhage and even death in extreme conditions. The fundus of the uterus is found to pass out of cervix and even vagina causing inversion of the uterus.

How Common is Uterine Inversion?

The Incidence of uterine inversion usually varies and can range from 1 case in 2000 to 1 case in every 50,000 births. In a much broader range, it can occur in about 1 in 3,000 births. The mother’s survival rate is only about 85% and can lead to death.

What are the Grades of inversion?

Uterine inversion has 4 degrees or grades based on its severity. This includes:

• 1st – Incomplete inversion- the top of the uterus (fundus) has collapsed and is still inside the cavity, but if it comes out it does only till cervix and does not exceed cervical external.
• 2^nd – Complete inversion- the uterus protrudes inside-out and comes out through the cervix.
• 3^rd – Prolapsed inversion- the fundus of the uterus comes out of the vagina.
• 4^th – Total inversion- both the uterine fundus and vagina protrude inside-out beyond vaginal introitus (this is mainly seen in cases of cancer rather than childbirth).

What are the Causes of Uterine Inversion?

Major etiological factors leading to uterine inversion include:

• Excessive cord traction in the third stage of labour
• Improper discharge of placenta after child birth
• Forceful expulsion of placenta by doctors using medical aid
• Tension on the umbilical cord
• Prior deliveries.
• Long labour (more than 24 hours).
• Use of the muscle relaxants (like magnesium sulphate) during labour
• Short umbilical cord
• Fetal macrosomia
• Excessive fundal pressure due to fundal implantation of placenta
• Placenta accrete – Invasion of placenta deeply into the uterine walls
• Ligament laxity
• Congenital abnormalities of the uterus

Are There Any Symptoms of Uterine Inversion?

Some of the possible symptoms that can be noticed during Uterine inversion are:

• Protrusion of uterus from the vagina
• Displacement of uterus from its original place
• Excess loss of blood i.e severe haemorrhage or a rapid fall in blood pressure
• Symptoms of hypovolemic shock (lightheadedness, dizziness, coldness, tiredness, shortness of breath)
• Tachycardia – Rapid increase in heart rate.

How is Uterine Inversion Diagnosed?

Quick and reliable diagnosis is important and can prevent maternal death. Signs of uterine inversion are as follows:

• Protrusion of vagina
• Displaced fundus from its place (abdominal area) during abdominal palpitation
• Severe haemorrhage
• Rapid fall in blood pressure (hypotension)
• Signs of shock (blood loss)
• Scans (such as ultrasound or MRI) that may be used in some cases to confirm the diagnosis
• Uterine fundus beyond vaginal introitus
• 3rd degree inversion of uterus
• The Echogenicity of the endometrium shows the shape of the letter C and the echogenicity of the uterus shows the shape of the letter H during ultrasound

Factors that can Increase the Risk of Uterine Inversion

Risk factors that can worsen a maternal condition that are noticed in uterine inversion include:

• Severe bleeding
• Shock
• Trauma

Treatment for Uterine Inversion

Uterine inversion management options include:

• Reposition of maternal fundus back through cervix
• Relaxation of uterus using relaxants that can further help in re-positioning the uterus
• After complete placement of uterus, continuous Intravenous infusion of oxytocin is provided to make the uterus firm and keep it in position, which further controls the bleeding.
• Until uterus is at its place, the doctor may keep applying pressure by using one hand inside the vagina and other over the abdominal area (superficially) to compress the uterus and stop the bleeding.
• The major surgical techniques for uterine inversion management are described below:

1. Huntington – Clamps are placed on the round ligament, near its insertion in the uterus, and traction is applied while the doctor exerts traction on the contralateral way through the vagina. It is the simplest technique and has a lower risk of complications.
2. Haultaim – Preferred when the first technique is a failure. Here in this method, an incision is made in the posterior portion of the ring formed by the cervix in order to increase the size of the ring and thus reposition the uterus.
3. Another surgical technique was given by Spinelli. In this method, the surgeon performs a dissection of the vesicouterine space and makes an incision on the cervix, allowing the uterus to return to its original position.
4. Hydrostatic pressure technique is an alternative method where balloons are generally placed intravaginally and filled by a saline solution to increase the pressure on the uterine fundus resulting in pushing the uterus to its initial position.

• In extreme conditions where there are higher chances of maternal death, the uterus is completely removed by surgery.
• Monitoring of vaginal bleeding and for other symptoms will be done continuously.
• Blood transfusion is made for proper replacement, also supplemented by antibiotics to prevent further complications like infection.
• Until the condition is stabilized the mother is kept under close observation for any other signs of degradation in her condition..
• Post-discharge dietary changes and lifestyle modification plays an essential role which could also be called as part of treatment.

Will You Suffer From Uterine Inversion In Your Next Pregnancy?

Yes, there are higher chances of Uterine inversion in next pregnancy of you have already suffered one. As with any pregnancy complication or other medical problem, the complete medical history has to be provided to the doctor for proper care and management. This will help the practitioner in further reducing the complications associated with the condition.

Things to remember

It is always advisable to keep a track of medical history provide the same to the doctor, and talk to them for proper medical advice and to prevent further risk of uterine inversion in the future.

Conclusion

Uterine inversion is a fatal condition which requires diagnosis in advance and also proper management as quickly as it occurs. Irrespective of the approach, vaginal or surgical, prompt treatment is the best way to deal with uterine inversion to prevent maternal death.