Uterine Inversion: A Review of a Life-Threatening Obstetrical Emergency

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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.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to evaluate published literature regarding puerperal uterine inversion, assess its associated comorbidities and risk factors, define clinical and radiographic diagnostic criteria to assist in prompt recognition and management of this obstetrical emergency, and propose management options for future pregnancies.

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