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Acute Uterine Inversion: A Novel Replacement Technique Using The B-Lynch Non-Instrumental Stepwise Reduction Procedure

3049 Int J Fertil Wom Med 52(4) p 143-146 ©2007 MSP International, Inc.

C. B-Lynch (Consultant)
D. Danso (Senior Registrar)
G.D. Thanigaimani (SHO)

Department of Obstetrics and Gynecology
Milton Keynes Hospital NHS Foundation Trust
(Oxford Deanery)
United Kingdom

CASE REPORT

Mrs. N.C., a 24-year-old Caucasian primigravida, presented in November 2004 with an uneventful pregnancy at 41 weeks gestation. She booked at 12 weeks and had an anomaly scan at 20 weeks gestation with no abnormality detected. The configuration of the gravid uterus was described as normal. Her antenatal care was shared with the general practitioner and, because of the normality of her pregnancy throughout, she requested home confinement with adequate midwifery support.
She had an interesting family history in that her mother had pregnancy complications characterized by acute uterine inversion, postpartum hemorrhage and hysterectomy. Mrs. N.C. developed mild anemia in late pregnancy with a hemoglobin recorded at 10.7 compared to her booking hemoglobin, which was 13.2 g/dl.
Her father is diabetic and her mother was said to have had learning difficulties. There was no other relevant medical history.
She was a smoker but drank very little alcohol. She went into spontaneous labor at home at full term and insisted on staying at home for the delivery. After what was described as 48 hours of contracting at home and with ruptured membranes of 10 hours duration, she was eventually persuaded to be transferred to the hospital delivery suite. On arrival she was moderately pyrexial and dehydrated and after fluid replacement and vaginal assessment, labor continued. The clinical assessment at admission on abdominal palpation showed term sized uterus, cephalic presentation, position
left occipito lateral; the fetal heart showed normal characteristics. Vaginal examination
revealed the head was stationed at the ischial spines, the position was the left occipito lateral, clear liquor draining, no caput or molding present. She was advised to have regional anesthesia, which she accepted after persuasion and progressed to full dilatation within 2 hours of admission. She was allowed maternal effort to try and deliver the baby.
After 90 minutes in the second stage of labor the fetal head was stationed at 1cm below the ischial spines. A forceps delivery was successfully carried out after a failed attempt using the ventouse instrument.
The placenta was delivered apparently uneventfully.

While Mrs. N.C. was still in the delivery suite awaiting transfer to the postnatal ward, she began to bleed profusely, about 4 hours after the forceps delivery. She became
shocked with hypotension, blood pressure 90/60, pulse rate 120. She needed 4 units of
blood transfusion, including fluid replacement fresh blood and plasma. Following adequate resuscitation she was transferred to the main operating theater where general anesthesia was administered after taking consent from her partner for Brace suture application, or hysterectomy if this became necessary, particularly where there has been a family history of a similar event for which hysterectomy was performed to save her mother’s life. On abdominal palpation in theater the fundus was not palpable abdominally, and on vaginal examination acute uterine inversion was diagnosed.
The uterine fundus was lying below the cervical constriction ring. The first author was the
consultant on duty who performed this novel technique of non-instrumental stepwise reduction of the acutely inverted uterus by a series of maneuvers as detailed below.
Mrs. N.C. made an uneventful recovery and is currently pregnant with a diagnosis of placenta previa at 30 weeks gestation. She has been counseled and consented for Cesarean section and the probable application of the Brace suture should there be any postpartum hemorrhage.
This second pregnancy has also been uneventful apart from the abnormal position of
the placenta currently.

TECHNIQUE OF NONINSTRUMENTAL STEP-WISE REDUCTION OF ACUTE UTERINE IN-
VERSION AT LAPAROTOMY

Mrs. N.C.s. was catheterized with an indwelling catheter and given broad spectrum antibiotics intravenously. An adequate sized midline laparotomy incision was made with the bowels packed upwards and away from the uterus.

The first author confirmed the classic features of acute uterine inversion, with the first step to place both hands in front and back of the lower segment of the uterus with the fingertips between and below the level of the inverted fundus

Figure 1

Figure 1 A

With progressive pressure using the fingertips of both hands below the fundus the flip up
maneuver spontaneously caused the internal dimple to become replaced progressively,
characterized by the rising uterine fundus

Figure 1b

Figure 1c

Figure 1 D

Uterine perfusion returned with reestablishment of uterine pulse pressure and full recovery of Mrs. N.C’s vital signs. On return of the uterus to its normal position, all vital signs became normal. Uterine contraction was facilitated by bi-manual stimulation to provoke contraction and was maintained with the use of Oxytocin intravenous infusion, 40I/U in 500mls normal saline infusion set.
After satisfactory observations and control of bleeding monitored vaginally, the abdominal incision was closed in the usual way, the patient was returned to the recovery suite for a period in theater followed by transfer to the High Dependency Unit where she made an uneventful recovery and was discharged on the 5th post-operative day. She was seen for follow-up 3 weeks and 6 weeks later with no adverse outcome.

DISCUSSION

Acute postpartum uterine inversion occurs when the uterus is turned inside out. Although
this is a rare condition it nevertheless represents a serious and life threatening complication of the third stage of labor [1,2].
The true incidence is unclear because some milder forms correct themselves spontaneously and are not recognized or reported. Estimates of the incidence of this condition vary:
one suggests less than 1:2,000 [3]; another suggests a 1:5,000 incidence [4]. Uterine inversion may be complete or incomplete depending on whether the fundus has passed
through the cervix [5,6].

In Mrs N.C..s case, the observations were classic for acute uterine inversion. Acute hemorrhage occurred and shock followed. Controlled cord traction is standard practice for the management of the third stage of labor. Mrs. N.C. had received one shot of Syntometrine intramuscular injection (containing 5 I/U Oxytocyin and 5mgs Ergometrine) after the second stage. Forceps delivery was recorded as uneventful and the third stage was apparently complete. Acute uterine inversion was not diagnosed before the administration of Syn-tometrine and this probably facilitated increased uterine fundal tone while incarcerated through the cervical ring. Blood transfusion, mobilizing the resuscitation team and transfer to theater, was timely while Mrs. N.C. was still in the delivery suite. In such circumstances the O.Sullivan technique [6] for fundal reduction was not deemed appropriate. Shock was present, which may also in part be consequent upon neurogenic cause due to the stretching of the peritoneum and in part due to the hemorrhage and anemia. Removal of the placenta without ensuring that the uterus has not become acutely involuted is a special risk, especially in the underdeveloped world where the tradition of birth attendants may encounter this problem. Without the immediate backup emergency team, fatality can occur. In Mrs. N.C..s case, the vaginal vault was inspected and showed no lacerations. The advantage of the Lloyd-Davis position gave access to swab in the vagina by the third assistant and was helpful in confirming adequate hemostasis. This was maintained before the patient was returned to recovery at the high dependency unit.

Other techniques of uterine fundal replacements have been described, such as O.Sullivan [6], Ogueh et al [7], Huntingdon [8], Haultain FWN[9], Spinelli PG [10], Tews et al [11], and more recently Antonelli et al[12].

None of these is atraumatic, nor match this novel technique described here. For example, the O.Sullivan technique uses hydrostatic pressure from the vaginal route. This approach was modified by Ogueh using the vacuum vaginally. Neither would have been suitable or appropriate in Mrs N.C.s circumstances. The Huntingdon, Haultain, Spinelli and Tews use modified surgical techniques to enable displacement of the fundus. The latest published case report by Antonelli [12] uses the ventouse abdominally to achieve reduction of the inverted uterus. This new and totally atraumatic technique has never been previously described. As a non-instrumental approach described here, we firmly believe that this novel approach should be tried first to avoid injury with potential consequences to the inverted uterus and its apparatus while trying to replace
the inverted fundus.

CONCLUSION

This is the first totally conservative technique for reducing the acute uterine inversion of
uterine fundus when laparotomy is indicated.This non-instrumental reduction process is
atraumatic, easy to carry out with prompt cessation of bleeding and return of vital signs
without the need for minor or major surgical incisions. We advocate that this method should be first tried at all times before any other instrumental method is applied at laparotomy.

REFERENCES

1. Hostetler DR, Bosworth MF: Uterine inversion: a life-threatening obstetric
emergency. J Am Board Farm Pract 13:120-123, 2000.
2. Wendel PJ, Cox SM: Emergent obstetric management of uterine inversion. Obstet
Gynaecol Clin N Am 22:261-274, 1995.
3. Watson P, Besch N, Bowes WA: Management of acute and subacute puerperal
inversion of the uterus. Obstet Gynecol 55:12, 1980
4. Dommisse B: Uterine inversion revisited. S Afr Med J 88:849,852-853, 1998.
5. Brar HS, Greenspoon JS, Platt LD, et al: Acute puerperal uterine inversion. J
Reprod Med 34:173-177, 1989.
6. O.Sullivan JV: Acute inversion of the uterus. Br Med J ii:282-283, 1945.
7. Ogueh O, Ayida G: Acute uterine inversion : a new technique of hydrostatic replacement. Br J Obstet Gynaecol 1997;104,951-952.
8. Huntingdon JL: Acute inversion of the uterus. Boston Med Surg J 1921;184:376-
380.
9. Haultain FWN: The treatment of chronic uterine inversion by abdominal hysterotomy
with a successful case. Br. Med J 1901;ii:974.
10. Spinelli PG: Inversione uterine. Riv Ginec Contemp Napoli 1897;17: 567-570.
11. Tews G, Ebner T, Yaman C, et al: Acute puerperal inversion of the uterus .
treatment by a new abdominal uterus pre-serving approach. Acta Obstet Gynecol
Scand 2001;80:1039-1040, 2001.
12. Antonelli E, Irion O, Tolck P, et al: Subacute uterine inversion: description of
a novel replacement technique using the obstetric ventouse. BJOG July 2006 Vol.
113.

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