Michael P Wendel1, Kelsey L Shnaekel1, Everett F Magann2. 1. Resident. 2. Professor, Maternal-Fetal Medicine Fellowship Director, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR.
Abstract
IMPORTANCE: Uterine inversion is frequently accompanied by postpartum hemorrhage and hypovolemic shock. Morbidity and mortality occur in as many as 41% of cases. Prompt recognition and management are of utmost importance. OBJECTIVE: The aim of this review is to describe risk factors, clinical and radiographic diagnostic criteria, and management of this rare but potentially life-threatening complication of pregnancy. EVIDENCE ACQUISITION: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. RESULTS: There were 86 articles identified, with 25 being the basis of review. Multiple risk factors for a uterine inversion have been suggested including a morbidly adherent placenta, short umbilical cord, congenital weakness of the uterine wall or cervix, weakening of the uterine wall at the placental implantation site, fundal implantation of the placenta, uterine tumors, uterine atony, sudden uterine emptying, fetal macrosomia, manual removal of the placenta, inappropriate fundal pressure, excessive cord traction, and the use of uterotonic agents prior to placental removal. The diagnosis is almost exclusively clinical, and successful treatment depends on prompt recognition of the uterine inversion. Treatment options include manual and surgical replacement of the inverted uterus. There is no consensus regarding mode of delivery in subsequent pregnancies as reinversion in a subsequent pregnancy is unpredictable. However, if surgical replacement was required in the index pregnancy and involved an incision into the contractile portion of the uterus, cesarean delivery is a reasonable management option similar to that offered for a prior classic cesarean section. CONCLUSIONS: Successful treatment is dependent on prompt recognition. Management should include resuscitation of maternal hypovolemic shock, as well as repositioning of the inverted uterine fundus. RELEVANCE: Uterine inversion is a rare but potentially life-threatening obstetrical emergency.
IMPORTANCE: Uterine inversion is frequently accompanied by postpartum hemorrhage and hypovolemic shock. Morbidity and mortality occur in as many as 41% of cases. Prompt recognition and management are of utmost importance. OBJECTIVE: The aim of this review is to describe risk factors, clinical and radiographic diagnostic criteria, and management of this rare but potentially life-threatening complication of pregnancy. EVIDENCE ACQUISITION: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. RESULTS: There were 86 articles identified, with 25 being the basis of review. Multiple risk factors for a uterine inversion have been suggested including a morbidly adherent placenta, short umbilical cord, congenital weakness of the uterine wall or cervix, weakening of the uterine wall at the placental implantation site, fundal implantation of the placenta, uterine tumors, uterine atony, sudden uterine emptying, fetal macrosomia, manual removal of the placenta, inappropriate fundal pressure, excessive cord traction, and the use of uterotonic agents prior to placental removal. The diagnosis is almost exclusively clinical, and successful treatment depends on prompt recognition of the uterine inversion. Treatment options include manual and surgical replacement of the inverted uterus. There is no consensus regarding mode of delivery in subsequent pregnancies as reinversion in a subsequent pregnancy is unpredictable. However, if surgical replacement was required in the index pregnancy and involved an incision into the contractile portion of the uterus, cesarean delivery is a reasonable management option similar to that offered for a prior classic cesarean section. CONCLUSIONS: Successful treatment is dependent on prompt recognition. Management should include resuscitation of maternal hypovolemic shock, as well as repositioning of the inverted uterine fundus. RELEVANCE: Uterine inversion is a rare but potentially life-threatening obstetrical emergency.