The uterus is a partially mobile organ fixed in the lower pelvis at the cervix. This anatomic relationship permits the fundus of the uterus to move relatively freely in the sagittal, vertical, oblique, and anteroposterior planes. Hypermobility occurs during the nonpregnant state, but it is more common during gestation and occasionally can result in retroversion/incarceration. Less frequently, following delivery, inversion may occur. Rarely, uterine torsion or prolapse occurs during pregnancy. All of these conditions require prompt diagnosis and treatment. In order to improve both the recognition and management of incarceration, torsion, prolapse, and inversion, this article reviews the incidence, pathophysiology, clinical presentation, and treatment of these symptomatic uterine malpositions.

Introduction UTERINE RETROVERSION & INCARCERATION

During the early part of the 18th century, retroversion of the uterus was identified as an obstetric complication. The term "retroversion," as used in obstetrics, was first coined by William Hunter. In 1754, he reported a case, noting "… after a fright, (a young nullipara) was taken ill, and could not, without great difficulty, go to stool or make water. Over … several days these functions ceased … We placed her upon her knees and elbows, with her head and shoulders as low as possible. Then I … endeavored to replace the uterus, … But… in vain: she became weaker … and died on the Monday following." Recent reports have yet to surpass Hunter's terse clinical description of the presentation, management, and potentially serious complications of uterine incarceration during pregnancy.

In the 19th century, nonpregnant retroversion was identified as an abnormality deemed responsible for a wide range of symptoms. This led to the invention of specialized instruments and the development of techniques to bring the uterus forward and hold it in place. In recent decades, operations for retroversion have fallen into disrepute because of their lack of clinical efficacy and the absence of scientific or experimental support for these once common procedures.

Uterine retroversion is a common and generally asymptomatic state. One out of 5 women has a retroverted uterus, either congenitally or due to an acquired condition. In instances in which pathology is present, conditions associated with retroversion include the following:

Symptoms traditionally attributed to uterine retroversion include the following:

If symptoms occur from retroversion alone in nonpregnant individuals, they are minimal. Pelvic pain and the other symptoms associated with retroversion are principally due to coincidental pathology. Evidence that retroversion alone is responsible for abortion or infertility is lacking. When these conditions are encountered, another etiology must be sought. For these reasons, uterine suspension procedures have nearly disappeared from gynecologic surgery. Uterine suspension is indicated when retroversion is associated with endometriosis or tubal pregnancy or following microsurgical tubal reconstruction procedures for infertility. However, the presence of uterine retroversion alone in an asymptomatic patient is not an indication for a prophylactic uterine suspension.

During pregnancy, uterine retroversion is a normal variant of uterine position. Typically, 10-20% of pregnant women experience retroversion transiently in early gestation. However, if retroversion persists into the mid trimester, it predisposes to uterine entrapment and incarceration. While retroversion is common, symptomatic incarceration is not, although accurate prevalence statistics for this disorder are not known. As with many infrequently occurring obstetric conditions, most instances of retroversion/incarceration are never reported and few data beyond case reports are available for review. The best estimate is that the condition occurs in approximately 1 per 3000 pregnancies. Apparently, retroversion proceeds to incarceration with urinary retention or other acute symptoms in only approximately 2% of women with this condition.

Predisposing factors for symptomatic incarceration include multiparity (89% of cases) combined with a unique combination of pelvic architecture, uterine positioning, and laxity of supporting tissues. A prior history of retroversion/incarceration may be elicited. Women in the latter category should be evaluated frequently in the late-first and early-second trimester to ensure that if the uterus remains retroverted, it does not fully incarcerate.

With incarceration, the acute symptoms may mimic more common obstetric diagnoses or threaten continuation of the pregnancy. In general, the correct diagnosis is established readily after reviewing the patient's clinical history and conducting a pelvic examination. Real-time ultrasound scanning is useful for confirmation.

Pathophysiology

Most pregnancies complicated by retroversion/incarceration involve a normal uterus that simply becomes impacted under the sacral promontory when it enlarges . In the remaining cases, other pathology either alters the normal uterine contour or fixes the uterus, preventing normal motion. When pathology is present, the findings may include (1) m ü llerian abnormalities with a prominent posterior uterine horn, (2) distortion of the uterine contour by adnexal tumor or fundal or posterior leiomyomata, or (3) adhesions from endometriosis or prior pelvic inflammatory disease.

The uterus rotates posteriorly, and the cervix is forced anteriorly as the uterus is wedged progressively more firmly into the hollow of the sacrum. Thus, once the uterus becomes entrapped, the incarceration worsens with time. Normal voiding becomes difficult or impossible, with obliteration of the posterior uterovesical angle restricting funneling of the bladder outlet.

Clinical presentation

The principal symptoms of incarceration include (1) abdominal pain, pelvic pressure, or uterine contractions; (2) tenesmus, rectal pressure, or constipation; (3) paradoxical urinary incontinence or frequency or, more commonly, voiding difficulty or urinary retention (frequently mandating intermittent or continuous catheterization); or (4) vaginal bleeding.

In the evaluation and differential diagnosis of pelvic distress in the late-first or early-second trimester, the clinician should consider the possibility of uterine incarceration. Unfortunately, there is little to distinguish many of the complaints of incarceration from the signs and symptoms associated with normal pregnancy or with other more frequent pregnancy complications, such as threatened abortion or urinary tract infection. In establishing the correct diagnosis, other important exclusions include uterine leiomyomata, m ü llerian anomalies, various adnexal/pelvic tumors, and a heterogenous series of conditions loosely described in the literature as the functional and anatomic malformations of the uterus, which collectively distort the normal uterine contour, mimicking simple retroversion.

Diagnosis

Correct diagnosis of incarceration is established by performing a pelvic examination and reviewing a characteristic history. A common clinical clue is progressive difficulty with voiding associated with pelvic pain and pressure or uterine cramping. Vaginal spotting also may be reported. The clinical examination usually is striking for the following findings:

Management

Possible therapies for retroversion/incarceration include the following:

The best treatment for symptomatic midtrimester incarceration of a normal uterus consists of bladder decompression combined with a program of patient positioning to facilitate spontaneous replacement. Prior to attempting any uterine manipulations, the best plan is to leave an indwelling catheter for 24-48 hours. During this interval, the patient is instructed to perform repositioning exercises (intermittent knee-chest positioning).

If these maneuvers prove unsuccessful, manual uterine replacement with the patient positioned in modified knee-chest position can be attempted. To perform this procedure, the anterior lip of the cervix is grasped with a long Allis or other atraumatic clamp. The patient is placed in the knee-chest position, and pressure is applied to the incarcerated fundus by the surgeon's finger inserted in the vagina or rectum. Gentle but constant traction is applied to the cervix, and the uterus is slowly rotated into the normal position, preferably passing the fundus to one side or the other of the sacral promontory.

These maneuvers usually prove successful and should be neither painful nor difficult. Only mild-to-moderate force is required for the replacement. Excessive force jeopardizes patient compliance, risks a cervical injury from the cervical grasping instrument, or may possibly damage the pregnancy by distorting the uterus or obstructing uterine blood flow.

Uterine replacement via a number of other techniques, including a mercury-filled Voorhees bag placed in the vagina, have also been reported, along with other more complex repositioning methods. However, most of these manipulations are of historical interest only.

In unusual instances, when both bladder drainage with repositioning and a trial of gentle manipulation fail to replace the uterus, uterine and maternal relaxation by the use of anesthesia combined with a tocolytic can be considered. To perform the procedure for uterine replacement under anesthesia, an epidural anesthesia is administered and the anterior lip of the cervix is grasped with a long Allis or other atraumatic clamp. The gravida is positioned in lateral recumbency, and intravenous nitroglycerin (0.15-0.5 mg IV in titrated doses to relaxation) or a parenteral beta-mimetic (eg, terbutaline 0.15-0.25 mg SC) is administered. Cervical traction is combined with digital rectal pressure to the fundus under real-time ultrasound guidance (in the same manner as previously described) to rotate the uterus into the normal anatomic position. Successful replacement is verified by palpation and real-time ultrasound scanning.

Complete uterine relaxation with epidural anesthesia-induced flaccidity of the maternal abdominal wall is the feature most important to success. When replacement is successful, instructing the patient to sleep in the prone position, practice occasional knee-chest positioning, or use a pessary is often recommended to keep the uterus correctly positioned. These manipulations are probably not necessary because reincarceration apparently does not occur during the same pregnancy. No studies have been performed to evaluate either the efficacy or necessity of any of these postreplacement manipulations.

Comments

Uterine retroversion with incarceration is an infrequent but by no means rare obstetrical condition. Clinicians should consider this disorder when presented with a characteristic set of clinical findings and symptoms. In uncomplicated second-trimester incarceration, treatment by patient repositioning or manual uterine replacement is usually easy. The rare instances involving retroversion persisting beyond the second trimester, or cases complicated by pelvic adhesions or permanent distortions in uterine shape, are difficult to manage and require individualization. In most of these instances, cesarean delivery is required. Following any procedures to achieve uterine replacement, administration of Rh immune globulin is indicated in Rh-negative patients who are unsensitized.

Because symptomatic incarceration in its several variants is uncommon, the literature consists mostly of case reports involving small numbers. No systematic studies have been conducted. Based on compiled data, several important clinical features concerning the course of incarceration have been described, and clinicians should know these features.

With modern management techniques, serious maternal injury should not occur because of retroversion/incarceration and fetal losses should be rare. On the other hand, chronic uterine sacculation or pregnancy loss is possible if retroversion or incarceration is not relieved or if it persists into the third trimester. Prompt resolution of acute symptoms should occur after replacement. Spontaneous abortion can occur following manual replacement, but the risk of this, although unknown, is believed to be low.

This paucity of data makes counseling inexact. Patients should be informed that both symptomatic incarceration and its relief carry at least some risk of pregnancy loss. In all cases, a real-time ultrasound examination should precede efforts for uterine repositioning, both to verify the original diagnosis and to confirm that an anatomically normal pregnancy is present. A repeat study after repositioning, verifying an active fetus and normal amniotic fluid, confirms the success of the procedure and reassures the patient and practitioner. Incarceration does not recur within the same gestation, but it may recur in a subsequent pregnancy.

Incidence UTERINE TORSION

Uterine torsion is rare in humans, and the majority of extant papers are case reports. Most reported cases appear in the veterinary literature. The most comprehensive review of this disorder was published by Jensen in 1992, including 212 cases from 1876-1990

The earliest reported age for uterine torsion during pregnancy is in the sixth gestational week and the latest is the 43rd week. Most of the cases of torsion diagnosed at term are noted during the first stage of labor.

Pathophysiology

Uterine torsion is defined as a rotation of more than 45° around the long axis that occurs at the junction between the cervix and the corpus of the uterus. The extent of the torsion is most often 180°, but cases involving twists from 60-720° have also been described. Dextrorotation is the most common finding. Rarely, torsion is of sufficient degree to arrest uterine circulation and result in acute abdominal catastrophe.

The cause of uterine torsion during pregnancy is unclear. Proposed etiologies include the following:

Reported clinical associations include the following:

In approximately 20% of cases, no abnormalities of the uterus or adnexa are demonstrated. Although all the listed predisposing factors are relatively common clinical findings, torsion is rare, to say the least. This suggests that additional factors, such as certain irregular maternal movements, postures, or positions; irregular contractions of the abdominal muscles; functional variations in the size, anatomy, position, and mobility of the bladder and rectum; fetal movements; or possibly even uterine contractions, must also be present with one or more other factors for torsion to occur.

Clinical presentation

Although uterine torsion may be asymptomatic, most patients present with abdominal pain and intestinal or urinary complaints.

Intestinal complaints include nausea, vomiting, diarrhea, abdominal distention, and tenderness. Urinary symptoms include urgency, frequency, nocturia, oliguria, and hematuria. Other symptoms reported occasionally include hypertonic uterine contractions and premature rupture of membranes. Vaginal bleeding and even shock are also possible. At term, obstructed labor occurs in almost all cases.

Diagnosis

The clinical challenge of uterine torsion lies in its elusive diagnosis. The correct diagnosis is rarely established except at surgical exploration. A recent report indicates that MRI has been used successfully to establish a preoperative diagnosis.

Jensen describes 4 pathognomonic clinical findings in cases of uterine torsion, including (1) uterine rotation about the vertical axis with marked venous engorgement and edema of the parametrial tissues (seen at surgery); (2) the round ligament palpably stretching across the abdomen; (3) the uterine artery pulsating anteriorly upon vaginal examination; and (4) the vagina and/or the cervical canal twisting, with the urethra displaced laterally.

To mistake torsion for a nonsurgical entity or another obstetric complication that is managed medically may well prove disastrous to the patient. Unfortunately, the signs and symptoms of acute torsion mimic those of a number of obstetric problems, such as uterine rupture, obstructed labor, or abruptio placentae, and the correct diagnosis normally is not made except at laparotomy.

Management

Treatment of torsion depends on when in pregnancy it occurs. When torsion is discovered at surgery prior to fetal viability, untwisting of the uterus is the principal treatment. Contributing pathology of the uterus or adnexa is removed next, if possible. Whether the pregnancy should be allowed to continue is unclear. Whether any procedures should be performed to fix the uterus in the usual anatomic position is also uncertain. In this unique setting, care must be individualized. In instances in which the fetus is of sufficient maturity to be considered viable, the best treatment is cesarean delivery.

Several cases of torsion have been reported in which the degree of rotation was so severe that the hysterotomy incision at the time of cesarean delivery was performed on the posterior uterine wall. Some surgeons have described these posterior incisions as inadvertent, while others have deliberately performed them. Some posterior entries are performed because the uterus cannot be rotated into the normal position until it is emptied. Too few reports are available to permit an accurate assessment of the long-term sequelae of the posterior approach. It seems reasonable that an effort at rotation to the normal position should precede the performance of a hysterotomy. If detorsion is impossible, a transverse incision is best, curved upward, mimicking the usual anterior procedure. After delivery, prophylactic plication of the round ligaments has been performed with the intent of providing uterine stability, possibly preventing recurrence of torsion in the puerperium.

The stage of pregnancy at the time of the uterine torsion has a bearing on maternal prognosis. No maternal mortality has been reported in cases occurring before 20 weeks. However, the mortality rate is reported to be 17% in the interval from 20-28 weeks, 10% at 29-34 weeks, and 9% at term. Establishing the correct diagnosis of uterine torsion early, before serious complications ensue, remains the challenge.

Conclusions

Uterine torsion is a rare obstetrical complication that must be considered in the differential diagnosis in cases of nonspecific abdominal pain occurring during pregnancy and in instances of dystocia during labor. If uterine torsion is noted, the surgeon should search for a pathologic process responsible for the rotation. At delivery, the type of hysterectomy incision performed is individualized. In general, rotation to the normal uterine position before performing a hysterectomy is prudent. Otherwise, a posterior entry is performed.

Introduction uterine inversion

Partial or complete uterine inversion is an infrequent but potentially life-threatening obstetric complication. The principal risks of inversion, ie, hemorrhage and shock, are minimized by rapid diagnosis and aggressive management. Optimal treatment for inversion employs parenteral tocolytics to permit prompt uterine replacement, followed by uterotonics to maintain normal uterine positioning.

Uterine inversion may occur immediately postpartum or, less frequently, during the puerperium. Inversions are usually described as acute ( < 30 d of delivery) or chronic (>30 d of delivery). A distinction often is made between acute and subacute varieties of puerperal inversion. Acute inversions occur within the first 24 hours postpartum, while inversions occurring more than 24 hours but fewer than 30 days after delivery are termed subacute.

Incidence

Uterine inversion is reported in 1 per 2000-23,000 deliveries. This wide range reflects differences in recording methods and patient populations and, perhaps, variations in routine obstetrical technique. Inversion in individuals who are not pregnant is usually due to a uterine tumor. Very rarely, inversion is idiopathic. So few reports of gynecologic inversion are made that the incidence cannot be accurately estimated.

Pathophysiology

The pathophysiology of puerperal inversion requires that a portion of the uterine wall either indents toward or prolapses through a dilated cervix. Thus, uterine relaxation combined with simultaneous downward traction force on the fundus (or a sudden fundal invagination) must occur to result in prolapse.

Possible etiology

Reported associations with uterine inversion include the following:

The combination of a fundally implanted placenta, flaccidity of the myometrium around the implantation site, and a dilated cervix in some fashion predisposes to puerperal inversion. Undoubtedly, in some cases, mismanagement of the third stage with excessive cord traction and/or the presence of a short cord contributes to inversion. However, this classic explanation is insufficient to explain all occurrences. In some reported cases, inversion has occurred without cord traction at vaginal delivery. Also, the authors have observed spontaneous inversion at cesarean delivery. Because this complication is so infrequent, apparently a number of common factors must act in concert to result in an inversion.

Clinical presentation

The diagnosis of uterine inversion is usually established on clinical grounds when vaginal bleeding, shock, and a vaginal mass are observed in the immediate puerperium. Postpartum hemorrhage is usually the most striking of the symptoms that draw the attention of the clinician. In other cases, the sudden protrusion of a large, dark red, polypoid mass accompanying or following the placenta is observed while the cervix cannot be palpated.

Severity

Terminology for the severity of an inversion is based on the extent of prolapse of the uterine wall in relation to the cervix and how far down the birth canal the resultant mass extends. In the rarest instances of inversion, complete vaginal and uterine inversion occur. In first-degree inversion, the inverted wall extends to but not through the cervix. In second-degree inversion, the inverted wall protrudes through the cervix but remains within the vagina. In third-degree inversion, the inverted fundus extends outside the vagina. In fourth-degree or total inversion, the vagina and uterus are inverted.

Partial acute puerperal inversion also may present less dramatically as the apparent postpartum absence of the uterine fundus. Bleeding is variable with partial inversion, and the acute loss observed may be minimal. The concomitant finding of a characteristic dark red mass within the vagina indicates the correct diagnosis. In some cases, when vaginal bleeding is not severe, the correct diagnosis may remain uncertain until a real-time ultrasound examination is possible or a laparotomy is performed. Chronic inversion presents with a variety of symptoms, including persistent vaginal spotting or discharge, low back pain, and a sensation of pelvic pressure, all with or without a low-grade fever. Establishing this diagnosis is often difficult on clinical grounds alone, and here again, real-time ultrasound scanning is especially helpful.

In complete inversion, acute hypotension or shock complicates as many as half the cases. A characteristic comment in case reports is that the extent of the shock is more than can be attributed to the observed blood loss alone. A theory is that either stretching of the broad ligament or compression of the ovaries as they are drawn together results in a parasympathetic reflex, contributing to the cardiovascular collapse. Also recall that the estimation of blood loss at delivery or with any (postpartum) hemorrhage is notoriously inexact, and thus, the clinician's retrospective report on the extent of true blood loss is often far from accurate.

Diagnosis

The following are included in the differential diagnosis:

Upon clinical examination, the characteristic appearance of the inverted uterus, either within the vagus or externally, usually indicates the correct diagnosis. If the inversion is contained within the vagina, the most obvious clue is the absence of the uterine fundus upon abdominal palpation and the surgeon's inability to either visualize or palpate the cervix upon pelvic examination. However, depending on the degree of prolapse, as the adnexa are brought together in the midline, a central pelvic mass may be palpated, potentially misleading the clinician. Also, heavy bleeding may preclude observation of the cervix. When the fundus has not prolapsed externally, a peculiar globular mass approximately the size of a midtrimester pregnancy is present in the mid pelvis upon bimanual examination. The initial fleeting impression is of the attempted passage of a large leiomyoma or other tumor mass.

In the unusual case that the correct diagnosis is not apparent following bimanual examination, real-time ultrasound is best for investigating the pelvis. Upon longitudinal scanning, a normal uterine fundus cannot be visualized. Scanning of the corpus reveals a mass inside the uterus, namely the invaginated myometrium, strongly suggesting the correct diagnosis.

Management

Following uterine inversion, prompt treatment of any associated hemorrhage and shock is vital in limiting morbidity and avoiding mortality. Once the diagnosis is established, hypotension and hypovolemia require aggressive fluid resuscitation in accordance with the STAR protocol (ie, shock, treat aggressively, and repair). When possible, the best treatment of acute puerperal inversion is immediate uterine repositioning, performed as follows:

The best technique for rapid uterine replacement is controversial. Theoretically, in the presence of neurologic shock, a restretching of the pelvic viscera could potentiate the problem. In practice, once the diagnosis is established, the best management is immediate replacement. The longer the delay, the greater the risk for neurologic or hemorrhagic shock. Also, the longer the delay, the more firmly contracted the lower uterine segment/cervix becomes, rendering the replacement progressively more difficult. Because most deliveries now take place in labor rooms, this is the most frequent venue for replacement. At times, a reasonable delay is prudent while help is recruited (eg, anesthesiologist, nurses, assistants), laboratory tests are sent, blood bank assistance is assured, aggressive fluid resuscitation is begun, and the parturient is moved to an operating room. Reduction of the uterine inversion may be accomplished either by a conservative nonsurgical approach or by a surgical procedure.

Nonsurgical techniques

The literature includes descriptions of a number of nonsurgical replacement techniques. In the past, intravaginal packing had its advocates, as had the use of a pessary. These procedures are now of historical interest only.

In 1945, O'Sullivan described a method for the correction of partial inversions using hydrostatic pressure. In this technique, warm saline is rapidly instilled into the vagina. The fluid progressively distends the vaginal wall and then forces the fundus upward to resume its original position. Some clinicians favor a trial of this procedure in selected cases because of its simplicity.

With the advent of potent tocolytics, the technique of manual replacement has been greatly simplified. A variant of the manipulations, originally described by Johnson in 1949, is now the recommended procedure. In a manual replacement operation, the operator's open hand is placed in the vagina. The inverted fundus is positioned in the palm of the hand. The uterus is then forcefully lifted upward and anteriorly through the pelvis into the abdominal cavity in the pelvic curve to the level of the umbilicus.

This causes the uterine ligaments to stretch. The cervix opens, the uterus inverts, and the fundus is promptly replaced in its usual anatomic position. The uterus is held in place for several minutes to permit the supporting ligaments to return to their original state and to allow uterotonics to firm the myometrium. To facilitate the uterine replacement, terbutaline, magnesium sulfate, and nitroglycerine all have been successfully employed as uterine relaxants, with and without concomitant general anesthesia. As noted, following successful replacement, several doses of uterotonics are administered to avoid reinversion and to firm the myometrium.

If 2 or more attempts at manual replacement fail, surgery is indicated. In most instances, if the placenta has not separated before the replacement operation is attempted, the best plan is to leave it undisturbed until the patient is in the operating room. Immediate placental removal without replacement simply increases blood loss. Furthermore, in the uncommon event of a placenta accreta/increta/percreta, removal proves difficult or impossible and the attempt markedly increases blood loss. Because the diagnosis of abnormal placental adherence cannot be established until removal is attempted, the best plan is to wait for the safer confines of the operating room rather than to attempt immediate and perhaps incomplete removal in another, less well-equipped setting.

Surgical techniques

When surgery is necessary, the abdominal approach is favored. However, a vaginal technique has also been described. In the vaginal procedure, the bladder is dissected from the cervix, and the anterior lip of the cervix and the anterior wall of the uterus are incised to the extent necessary to permit replacement. After the uterus is repositioned, the uterine wall and cervical defects are repaired in layers. This operation has few modern proponents and is not recommended.

The favored approach follows the technique originally described by Huntington in 1921. A laparotomy is performed, and the round ligaments are identified. Following administration of a tocolytic, the surgeon applies gentle upward traction on the round ligaments. The process is repeated with the operator progressively pulling the round ligaments up into the peritoneal cavity until the fundus is completely restored to its normal configuration. Assistance by a second operator, applying upward pressure from below, facilitates this procedure. As the uterus begins to revert, the lower segment is squeezed to accelerate the replacement. As in the manual replacement technique, uterotonics are administered once the uterus has reverted to its normal position.

In the unusual instance that the Huntington operation fails, the more extensive Haultain procedure is required at laparotomy. In this technique, a posterior, longitudinal hysterotomy incision is performed. This acutely widens the lower uterine segment and facilitates uterine replacement. In this surgical approach, the posterior uterine wall is incised to avoid inadvertent injury to the bladder, with upward traction on the round ligaments to follow, as described above for the Huntington procedure.

Regardless of the procedure employed, after repositioning, uterine atony is common. Reinversion may occur. The prompt administration of 15-methyl F2 alpha prostaglandin (Hemabate), high-dose oxytocin, an ergot-derivative parenterally, or misoprostol per rectum is recommended. If magnesium sulfate was administered as a tocolytic, calcium gluconate can be administered to reverse the tocolytic effect.

Administration of a course of antibiotics has been advocated when inversion occurs, based on the idea that the necessary manipulations predispose to infection. Apparently, the risk is small. Yet, because this condition is at best uncommon and the reported series are small, many clinicians still prefer to administer a single prophylactic dose of a broad-spectrum first-generation cephalosporin or a similar drug at the time of repositioning.

Comments

Puerperal uterine inversion is a relatively rare but potentially dangerous complication of the third stage of labor. If hemorrhage or shock accompanies the inversion, timely diagnosis and aggressive management are mandatory. Prompt replacement of the malpositioned uterus by vaginal manipulation is recommended. Careful clinical observation following replacement and the administration of potent uterotonics prevents most reinversions. In the rare case when the inversion is long-standing or if manual replacement fails, surgical replacement is required. Consultation with an experienced clinician is prudent before attempting surgical replacement. If surgery is necessary, an above-and-below procedure with 2 operators improves success and reduces the risk of iatrogenic injury. The risk of recurrence of inversion in subsequent deliveries is unknown.

Successful management of the relatively rare, but potentially life-threatening, condition of uterine inversion requires a team effort. Skilled nursing assistance, an accomplished anesthesiologist, and immediate access to the operating room are important components of success.