Puerperal uterine inversion
- John T Repke, MD
John T Repke, MD
- ACOG Peer Reviewer
- Professor of Obstetrics and Gynecology
- Penn State College of Medicine
- Milton S. Hershey Medical Center
Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. It is a rare complication of vaginal or cesarean delivery, but when it occurs, it is a life-threatening obstetrical emergency. If not promptly recognized and treated, uterine inversion can lead to severe hemorrhage and shock, resulting in maternal death.
Spontaneous inversion of the non-puerperal uterus accounts for approximately 5 percent of all uterine inversions, and will not be addressed by this topic review . It is almost always associated with presence of a polypoid uterine tumor, usually a leiomyoma, but other tumors (eg, teratoma, sarcoma) have also been implicated [2-5].
Uterine inversions are classified by the extent of inversion and time of occurrence:
●1st degree (incomplete) inversion: the fundus is within the endometrial cavity
- Dali SM, Rajbhandari S, Shrestha S. Puerperal inversion of the uterus in Nepal: case reports and review of literature. J Obstet Gynaecol Res 1997; 23:319.
- Lupovitch A, England ER, Chen R. Non-puerperal uterine inversion in association with uterine sarcoma: case report in a 26-year-old and review of the literature. Gynecol Oncol 2005; 97:938.
- Gomez-Lobo V, Burch W, Khanna PC. Nonpuerperal uterine inversion associated with an immature teratoma of the uterus in an adolescent. Obstet Gynecol 2007; 110:491.
- Occhionero M, Restaino G, Ciuffreda M, et al. Uterine inversion in association with uterine sarcoma: a case report with MRI findings and review of the literature. Gynecol Obstet Invest 2012; 73:260.
- Hu CF, Lin H. Ultrasound diagnosis of complete uterine inversion in a nulliparous woman. Acta Obstet Gynecol Scand 2012; 91:379.
- Pauleta JR, Rodrigues R, Melo MA, Graça LM. Ultrasonographic diagnosis of incomplete uterine inversion. Ultrasound Obstet Gynecol 2010; 36:260.
- Livingston SL, Booker C, Kramer P, Dodson WC. Chronic uterine inversion at 14 weeks postpartum. Obstet Gynecol 2007; 109:555.
- Morini A, Angelini R, Giardini G. [Acute puerperal uterine inversion: a report of 3 cases and an analysis of 358 cases in the literature]. Minerva Ginecol 1994; 46:115.
- Baskett TF. Acute uterine inversion: a review of 40 cases. J Obstet Gynaecol Can 2002; 24:953.
- Witteveen T, van Stralen G, Zwart J, van Roosmalen J. Puerperal uterine inversion in the Netherlands: a nationwide cohort study. Acta Obstet Gynecol Scand 2013; 92:334.
- Lipitz S, Frenkel Y. Puerperal inversion of the uterus. Eur J Obstet Gynecol Reprod Biol 1988; 27:271.
- Deneux-Tharaux C, Sentilhes L, Maillard F, et al. Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR). BMJ 2013; 346:f1541.
- Adesiyun AG. Septic postpartum uterine inversion. Singapore Med J 2007; 48:943.
- Rudloff U, Joels LA, Marshall N. Inversion of the uterus at caesarean section. Arch Gynecol Obstet 2004; 269:224.
- Beringer RM, Patteril M. Puerperal uterine inversion and shock. Br J Anaesth 2004; 92:439.
- Hsieh TT, Lee JD. Sonographic findings in acute puerperal uterine inversion. J Clin Ultrasound 1991; 19:306.
- Momin AA, Saifi SG, Pethani NR, Mitha SH. Sonography of postpartum uterine inversion from acute to chronic stage. J Clin Ultrasound 2009; 37:53.
- Brar HS, Greenspoon JS, Platt LD, Paul RH. Acute puerperal uterine inversion. New approaches to management. J Reprod Med 1989; 34:173.
- Smith GN, Brien JF. Use of nitroglycerin for uterine relaxation. Obstet Gynecol Surv 1998; 53:559.
- Dayan SS, Schwalbe SS. The use of small-dose intravenous nitroglycerin in a case of uterine inversion. Anesth Analg 1996; 82:1091.
- Yoo KY, Lee JC, Yoon MH, et al. The effects of volatile anesthetics on spontaneous contractility of isolated human pregnant uterine muscle: a comparison among sevoflurane, desflurane, isoflurane, and halothane. Anesth Analg 2006; 103:443.
- Vijayaraghavan R, Sujatha Y. Acute postpartum uterine inversion with haemorrhagic shock: laparoscopic reduction: a new method of management? BJOG 2006; 113:1100.
- Sardeshpande NS, Sawant RM, Sardeshpande SN, Sabnis SD. Laparoscopic correction of chronic uterine inversion. J Minim Invasive Gynecol 2009; 16:646.
- Shepherd LJ, Shenassa H, Singh SS. Laparoscopic management of uterine inversion. J Minim Invasive Gynecol 2010; 17:255.
- Antonelli E, Irion O, Tolck P, Morales M. Subacute uterine inversion: description of a novel replacement technique using the obstetric ventouse. BJOG 2006; 113:846.
- Momani AW, Hassan A. Treatment of puerperal uterine inversion by the hydrostatic method; reports of five cases. Eur J Obstet Gynecol Reprod Biol 1989; 32:281.
- Ogueh O, Ayida G. Acute uterine inversion: a new technique of hydrostatic replacement. Br J Obstet Gynaecol 1997; 104:951.
- Tan KH, Luddin NS. Hydrostatic reduction of acute uterine inversion. Int J Gynaecol Obstet 2005; 91:63.
- Kitchin JD 3rd, Thiagarajah S, May HV Jr, Thornton WN Jr. Puerperal inversion of the uterus. Am J Obstet Gynecol 1975; 123:51.
- You WB, Zahn CM. Postpartum hemorrhage: abnormally adherent placenta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol 2006; 49:184.
- O'Connor M. Uterine inversion. J Am Board Fam Pract 2000; 13:385.
- Mahatme S, Badhwar VR, Gandi S. Subacute uterine inversion--an interesting encounter. J Indian Med Assoc 2010; 108:378.
- Watson P, Besch N, Bowes WA Jr. Management of acute and subacute puerperal inversion of the uterus. Obstet Gynecol 1980; 55:12.
- Platt LD, Druzin ML. Acute puerperal inversion of the uterus. Am J Obstet Gynecol 1981; 141:187.
- Garrett-Albaugh S, Stitely ML, Millan L, Hochberg C. Chronic postpartum uterine inversion treated by abdominal replacement and cerclage. W V Med J 2011; 107:43.
- Soleymani Majd H, Pilsniak A, Reginald PW. Recurrent uterine inversion: a novel treatment approach using SOS Bakri balloon. BJOG 2009; 116:999.
- Mondal PC, Ghosh D, Santra D, et al. Role of Hayman technique and its modification in recurrent puerperal uterine inversion. J Obstet Gynaecol Res 2012; 38:438.
- Matsubara S, Yano H, Taneichi A, Suzuki M. Uterine compression suture against impending recurrence of uterine inversion immediately after laparotomy repositioning. J Obstet Gynaecol Res 2009; 35:819.
- Matsubara S, Baba Y. MY (Matsubara-Yano) uterine compression suture to prevent acute recurrence of uterine inversion. Acta Obstet Gynecol Scand 2013; 92:734.
- RISK FACTORS
- CLINICAL FEATURES
- Patient presentation
- Differential diagnosis
- Initial interventions
- Secondary (surgical) interventions
- Other options
- - Hydrostatic reduction
- - Vaginal surgical approaches
- Management of the placenta
- Management after correction of inversion
- RECURRENCE IN FUTURE PREGNANCY
- SUMMARY AND RECOMMENDATIONS