Uterin Inversion 8243i

Kingdom of Saudi Arabia Ministry of Higher Education King Saud University (Female Health College (SHAQRA

UTERIN INVERSION : Supervised Dr.Tahany alsayed amro

: By Zahra alSaif

: Out line Definition Type Classification Causes Presentation Assessment Diagnosis Investigation Therapeutic management Nursing management Complication .Evaluation . References Some picture describe U.I

: Definition Uterine inversion is a rare complication of vaginal delivery in which the uterus partially or .completely turns inside out Or Uterine inversion: After the delivery of a baby, if the placenta doesn't detach completely from .the uterus, it pulls the top of the uterus out with it when it emerges

:Types .Complete. Visible outside the cervix :1• .Incomplete. Visible only at the cervix :2•

:Classification :Terminology is used to describe the degree of inversion which may be .First degree - the inverted fundus extends to, but not through the cervix• Second degree - the inverted fundus extends through the cervix but remains within• .the vagina .Third degree - the inverted fundus extends outside the vagina• .Total inversion - the vagina and uterus are inverted•

: Causes Short umbilical cord• Excessive traction on the umbilical cord• Excessive fundal pressure• Fundal implantation of the placenta• Retained placenta and abnormal adherence of the placenta5• Chronic endometritis• Vaginal births after previous caesarean section• Rapid or long labours• Previous uterine inversion6•

(Certain drugs such as magnesium sulphate (drugs promoting tocolysis• Unicornuate uterus7•

Presentation :Uterine inversion may present Acutely - within 24 hours of delivery• Subacutely - over 24 hours and up to the 30th postpartum day• Chronic - more than 30 days after delivery9• It presents most often with symptoms of a post-partum haemorrhage. The classic :presentation is of Post-partum haemorrhage10,11• Sudden appearance of a vaginal mass• (Cardiovascular collapse (varying degrees• The sudden appearance of a large dark red mass accompanying the placenta is alarming. Pain is extreme. The diagnosis is usually then immediately obvious and confirmed by inability to feel the fundus. Diagnosing a first degree inversion is much more difficult. Obesity can make diagnosis more difficult. Chronic cases are unusual and difficult to diagnose. They may present with spotting, discharge and low back pain. Ultrasound may be required to confirm the diagnosis. Complete inversion is accompanied by extreme .cardiovascular collapse, more than might be expected from the degree of blood loss alone

. ASSESSMENT . :Clinical manifestations include Excruciating pelvic pain with a sensation of extreme fullness extending .1 .into the vagina Extrusion of the inner uterine lining into the vagina or extending past .2 .the vaginal introitus .Vaginal bleeding and signs of hypovolemia .3

diagnosis Prolapse of a uterine tumour• Gestational trophoblastic disease• Occult genital tract disease• Marked uterine atony• Undiagnosed second twin•

Investigations If not clinically very obvious, ultrasound examination can be used to identify the• .inversion (Magnetic resonance imaging (MRI•

.Radiography• .Sonography•

: Therapeutic Management Treat shock and blood loss○ Immediate Intravenous Access Intravenous Fluid replacement Call for consultation○ Obstetrics (Anesthesia (consider Halothane (Give uterine relaxants (Tocolytics○ Terbutaline 0.25 mg SC Nitroglycerin Intravenous: 50 to 200 mcg IV Sublingual (200 mcg per spray): 2 sprays sublingual (Immediate Manual Replacement (Johnson Maneuver○ Replace uterus in non-inverted position (Replace last part out first (last out, first in ister Terbutaline or Nitroglycerin as above Consider General Anesthesia Repeat trial of Manual Replacement Surgical Replacement Post-Replacement Uterine Hemorrhage management Options○ Pitocin IV 40 u/L at 100-250 cc/h Hemabate 0.25mg IM Myometrium q15 minutes (max: (2 mg Methergine 0.2 mg IM or PO q6-8h Consider exploratory laparotomy if needed○

NURSING MANAGEMENT .Promptly identify & assist with the resolution of uterine inversion . Recognize signs of impending inversion, and immediately notify the .1 .physician and call for assistance Immediate manual replacement of the uterus at the time of inversion .2 will prevent cervical entrapment of the uterus; if reinversion is not performed immediately, rapid and extreme blood loss ma occur, resulting .in hypovolemic shock .Take steps to prevent or limit hypovolemic shock .3 .a. Insert a large gauge intravenous catheter for fluid replacement b. Measure and record maternal vital signs every 5 to 15 minutes to .established a baseline and document change .c. Open an established intravenous line for optimal fluid replacement d. A fibrinogen level should be drawn to determine the risk of blood clot .formation .e. Prepare for anesthesia as needed .f. Prepare to ister a cardiopulmonary resuscitation, if required If manual reinversion is not successful, prepare the client and family for .4 .possible general anesthesia and surgery

Complications .Complications include endomyometritis, damage to intestines or uterine appendages

Evaluation .The condition carries a good prognosis if managed correctly

: References Chen YL, Chen CA, Cheng WF, et al; Submucous myoma induces uterine inversion..1 [Taiwan J Obstet Gynecol. 2006 Jun;45(2):159-61. [abstract Ojwang SB, Rana F, Sayed S, et al; Embryonal rhabdomyosarcoma with uterine.2 [inversion: case report. East Afr Med J. 2006 Mar;83(3):110-3. [abstract Cormio G, Loizzi V, Nardelli C, et al; Non-puerperal uterine inversion due to uterine.3 [sarcoma. Gynecol Obstet Invest. 2006;61(3):171-3. Epub 2006 Jan 26. [abstract Hussain M, Jabeen T, Liaquat N, et al; Acute puerperal uterine inversion. J Coll.4 [Physicians Surg Pak. 2004 Apr;14(4):215-7. [abstract Tsivos D, Malik F, Arambage K, et al; A life threatening uterine inversion and.5 massive post partum hemorrhage caused by placenta accrete during Caesarean [section in a primigravida: a case report. Cases J. 2009 Feb 12;2(1):138. [abstract Tank Parikshit D, Mayadeo Niranjan M, Nandanwar YS; Pregnancy outcome after.6 operative correction of puerperal uterine inversion. Arch Gynecol Obstet. 2004 [Mar;269(3):214-6. Epub 2002 Nov 14. [abstract Sangwan N, Nanda S, Singhal S, et al; Puerperal uterine inversion associated with.7 [unicornuate uterus. Arch Gynecol Obstet. 2009 Feb 6. [abstract Baskett TF; Acute uterine inversion: a review of 40 cases. J Obstet Gynaecol Can..8 [2002 Dec;24(12):953-6. [abstract Livingston SL, Booker C, Kramer P, et al; Chronic uterine inversion at 14 weeks.9 [postpartum. Obstet Gynecol. 2007 Feb;109(2 Pt2):555-7. [abstract Anderson JM, Etches D; Prevention and management of postpartum hemorrhage. Am.10 [Fam Physician. 2007 Mar 15;75(6):875-82. [abstract Klufio CA, Amoa AB, Kariwiga G; Primary postpartum haemorrhage: causes,.11 aetiological risk factors, prevention and management. P N G Med J. 1995 .Jun;38(2):133-49 Pistorius LR, Hartman CR; Sonographic diagnosis of subacute puerperal uterine.12 .inversion. J Obstet Gynaecol. 1998 Sep;18(5):483 Momin AA, Saifi SG, Pethani NR, et al; Sonography of postpartum uterine inversion.13 [from acute to chronic stage. J Clin Ultrasound. 2009 Jan;37(1):53-6. [abstract Beringer RM, Patteril M; Puerperal uterine inversion and shock. Br J Anaesth. 2004.14 [Mar;92(3):439-41. [abstract Abouleish E, Ali V, Joumaa B, et al; Anaesthetic management of acute puerperal.15 [uterine inversion. Br J Anaesth. 1995 Oct;75(4):486-7. [abstract Steigrad S; Re: A new surgical technique for dealing with uterine inversion. Aust N Z.16 .J Obstet Gynaecol. 2005 Dec;45(6):538; author reply 538

: some picture describe uterine inversion C

D