Uterine inversion (uterine inversion) as a complication of childbirth. Postpartum uterine inversion
Displacement of the uterus with its mucous membrane turning outward is a postpartum uterine inversion. Most often, pathology occurs against the background of improper management of childbirth and the postpartum period. The condition is acute and requires immediate treatment, as it poses a danger to the woman’s health and life.Causes of uterine inversion
Most often, acute uterine inversion is diagnosed, which occurs simultaneously immediately after childbirth. But sometimes there is a chronic form of this pathology, which occurs in the postpartum period, that is, within a few days after the birth of the child. The problem may occur in the background:- lack of tension in the muscles of the uterus after the birth of a child (atony), which is accompanied by an increase in intra-abdominal pressure (sneezing, coughing);
- pressing too aggressively on the uterus to separate the placenta;
- tension of the umbilical cord (forceful pulling) with the placenta not yet separated.
- the presence of a large myomatous node on the fundus of the uterus;
- location of the placenta on the fundus of the uterus (the uppermost and widest area).
Symptoms and treatment of cervical inversion after childbirth
Cervical inversion after childbirth is manifested by severe symptoms:- scarlet discharge with clots from the genital tract;
- the woman’s skin becomes pale and covered in cold sweat;
- there are complaints of sudden acute pain in the lower abdomen (possible loss of consciousness due to painful shock);
- blood pressure levels become extremely low;
- upon examination, a mucous-type formation with a red surface is detected in the vagina.
- drugs from the group of cholinomimetics - actively act directly on the cervix, preventing its spasms;
- antiseptics - used to wash the uterine cavity, prevent the development of bacterial infection;
- drugs to increase and stabilize blood pressure.
(inversion uteri) is a serious complication of the afterbirth or, more rarely, the postpartum period. The essence of this pathological condition is that the fundus of the uterus begins to press into the uterine cavity and, protruding into it, forms a funnel. The funnel gradually deepens, the uterus is completely turned out and its inner surface, i.e., the mucous membrane, turns outward. The surface covered with the peritoneum forms a funnel into which the tubes, round and broad uterine ligaments, and in case of acute eversion, the ovaries are retracted. When the uterus inverts in the afterbirth period, it, together with the unseparated placenta, protrudes from the external genitalia. If an inversion occurs in the afterbirth period, then the inverted uterus remains in the vagina.
In some cases, under the influence of increased intraperitoneal pressure, the inverted uterus can be completely pushed out of the pelvis outward along with the inverted vagina, prolapsus totalis uteri inverse et vaginae occurs (G. G. Geiter).
Uterine inversion is rare and, according to I.I. Yakovlev, occurs once in 450,000 births. In the Snegirev maternity hospital in Leningrad, there were 2 uterine inversions out of 270,000 births. According to I.F. Zhordania, the frequency of uterine inversion is higher and occurs once in 40,000 births.
According to foreign authors, the frequency of uterine inversion is much higher. Thus, according to Daz, it is one inversion per 14,880 births, and Bell, G. Wilson indicate the frequency of uterine inversion equal to 1 in 4894 births, which is many times higher than the figures of domestic authors. According to Daz statistics, out of 297 uterine inversions, the latter most often occurs in the afterbirth period (72.3%), much less often - 2-24 hours after birth (14.2%), and even less often (in 9.8% of cases) - between the 2nd and 30th day after birth.
Etiology and pathogenesis of uterine inversion
It is customary to distinguish between violent and spontaneous inversion of the uterus. In the past, it was believed that all acute inversions of the postpartum uterus were violent and occurred as a result of pulling the umbilical cord with an unseparated placenta or with rough techniques used to squeeze out the placenta with a relaxed uterus.
However, V. G. Beckman, who described 100 cases of uterine inversion back in 1894, showed that most acute inversions occur spontaneously as a result of relaxation of the walls of the uterus during its atony. The normal tone of the uterus and its reflex contractions protect against eversion, despite the significant force used when squeezing the placenta according to Lazarevich-Crede or when pulling the umbilical cord. In an atonic state of the uterus, its inversion can occur as a result of an increase in intraperitoneal pressure during coughing, sneezing, pushing, sudden movements of the woman in labor, etc. Such inversion of the uterus is spontaneous and is observed soon after the birth of the placenta. Acute inversion of the uterus, which usually occurs when it is atony as a result of attempts to separate and release the placenta when pressing with the hand on the fundus of the uterus, pulling the umbilical cord, etc., is called violent; V. In most cases, it is observed due to improper management of the afterbirth period.
The occurrence of uterine inversion is facilitated by an unseparated placenta, especially located in the area of the uterine fundus. The placenta, going down due to gravity, carries with it the relaxed walls of the uterus. In the literature, there are descriptions of uterine inversions that occur in the postpartum period during the birth of submucous fibroids (oncogenetic inversions). A tumor born in the vagina, as a result of its severity and ongoing contractions of the uterus, pulls the fundus with it and it gradually turns out.
According to V.G. Bekman et al., uterine inversion occurs more often in primiparous women and this is usually associated with the fact that in them, much more often than in multiparous women, the placenta is located in the fundus of the uterus.
Uterine inversions are incomplete, or partial, if only the body of the uterus or part of it is inverted, and complete, when the entire uterus is completely inverted.
Clinicuterine inversion
Acute uterine inversion in the afterbirth or early postpartum period is accompanied by the sudden appearance of severe abdominal pain, the subsequent development of a state of shock and bleeding. Pain is the first symptom; it is explained by trauma to the peritoneal covering of the uterus during its inversion and tension of the ligaments when the topographic relationships in the pelvis change.
A state of shock sometimes does not develop immediately and occurs as a result of sharp irritation of the peritoneum, a rapid drop in intraperitoneal pressure and painful irritation when the ligaments are stretched. Bleeding, which can begin even before inversion occurs, depends on uterine atony. Subsequently, bleeding is maintained due to a sharp disruption of blood circulation in the inverted uterus and strong venous stagnation in it.
In acute uterine inversion, the pulse becomes frequent and thread-like, the skin turns pale, the face becomes covered in cold sweat, and the pupils dilate. Blood pressure drops, consciousness becomes dark.
With a severe clinical picture and delayed or incorrect implementation of therapeutic measures, death from shock and, less often, from bleeding may occur. In the future, the postpartum woman is at risk of infection. Mortality in acute inversion, according to various authors, ranges from 0 to 30%. Such inconsistency in mortality figures depends on the nature of therapeutic measures and their effectiveness. The widespread use in obstetric practice of blood transfusion and other measures in cases of shock makes it possible in our time to obtain the most favorable results in cases of uterine inversion. Spontaneous reduction of uterine inversion is extremely rare. This possibility cannot be excluded in case of oncogenetic reversals caused by a tumor. After removal of the tumor, the inversion can be reduced on its own, since there is no infringement in the cervical area.
Recognizing acute eversion is usually not difficult. Characteristic features include anamnesis, sudden pain, bleeding and shock in the placenta or postpartum period. An inverted uterus, located outside the genital slit or in the vagina, is defined as a soft, bright red spherical tumor (Fig. 122, 123). The diagnosis is even easier if there is an unseparated placenta on the walls of the inverted uterus (Fig. 124). Upon careful examination of this “tumor,” you can see the openings of the fallopian tubes. The body of the postpartum uterus cannot be identified through the abdominal wall; it seems to have disappeared. Upon palpation through the abdominal integument and with two-handed examination, a funnel-shaped depression is determined at the site of the uterine fundus (Fig. 125, 126).
Rice. 122. Acute inversion of the uterus after discharge of the placenta.
Rice. 123. Inversion of the uterus and vagina with prolapse
Rice. 124. Incomplete uterine inversion
Rice. 125. Inversion of the uterus. Inversion of the fundus of the uterus into its cavity.
Rice. 126. Complete inversion of the uterus. View from the abdominal cavity (1 – bladder)
Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983
Displacement of the uterus, in which it partially or completely turns the mucous membrane outward, is called uterine inversion.
This pathology occurs as a result of mistakes made during the management of the succession period. Hypotonia of the uterus and mechanical pressure on it contribute to this complication. There are complete and incomplete (partial) inversion of the uterus. Eversion can be acute (quick) or chronic (slowly occurring). Acute inversions occur more often, with 3/4 of them occurring in the afterbirth period, and 1/4 in the first postpartum day.
According to etiology, uterine inversions are divided into spontaneous and forced.
Forced eversion - occurs when pulling the umbilical cord or roughly performing the Credet-Lazarevich maneuver with a relaxed uterus.
Spontaneous inversion occurs as a result of a sharp relaxation of the uterine muscles and an increase in intra-abdominal pressure (for example, when coughing, vomiting).
Etiology
Forced inversion of the uterus occurs when the separated placenta is removed using the Credet-Lazarevich method, but the sequence of manipulation is not followed:
- emptying the bladder;
- bringing the uterus to the midline position;
- lightly stroking the uterus in order to contract it;
- grasping the fundus of the uterus with the hand, simultaneous pressure on the uterus with the entire hand in two intersecting directions.
In addition, the cause of uterine inversion can be a sharp tug on the umbilical cord.
The main reason for spontaneous eversion is relaxation of all parts of the uterus, loss of contractile ability by the myometrium. In this condition, even an increase in intra-abdominal pressure during pushing, coughing, or sneezing can lead to inversion of the uterus. The predisposing factor is the bottom attachment of the placenta.
Pathogenesis
First, a depression is formed in the area of the uterine fundus (eversion funnel), into which the fallopian tubes, round and broad ligaments of the uterus, and sometimes the ovaries are drawn. Then the inversion funnel increases, the inverted body of the uterus descends through the cervical canal into the vagina. If the area of the uterine fundus does not extend beyond the external os of the cervix, the inversion is called incomplete. With complete eversion, the uterus is located in the vagina, sometimes extending beyond the genital slit.
Clinical picture
Characteristic symptoms:
- sudden severe pain in the lower abdomen;
- state of shock;
- uterine bleeding.
Bleeding may begin before uterine inversion, due to its atony, and continue after the inversion is completed.
Diagnostics
When the uterus is inverted from the genital slit, the inverted mucous membrane of the uterus is shown in a bright red color.
Sometimes the uterus turns out with the afterbirth remaining.
Complete inversion of the uterus may be accompanied by inversion of the vagina. In this case, the uterus appears outside the vulva and the diagnosis is not difficult. With isolated inversion, the uterus is identified in the vagina when examined in a speculum. In both cases, upon palpation, the uterus is absent above the womb. With incomplete inversion of the uterus, the general condition is less severe and deteriorates much more slowly.
Differential diagnosis
For differential diagnosis with other complications (for example, uterine rupture), a bimanual examination is performed, which determines the location of the upper edge of the uterus that is unusually low for the placenta and early postpartum period or the presence of a funnel-shaped depression in place of the uterus.
Surgical treatment
Any inversion of the uterus requires medical intervention - manual reduction with preliminary manual separation of the placenta, or other surgical treatment.
Conditions for the operation.
Compliance with asepsis rules.
Conditions of a small operating room.
Preparing for surgery.
Antishock therapy and general anesthesia (deep intravenous anesthesia).
Treatment of the surgical field, hands of the surgeon and assistant.
Prevention of cervical spasm (1 ml of 0.1% atropine solution subcutaneously).
Emptying the bladder.
Operation technique.
Under anesthesia, the uterus is carefully adjusted through the uterine os. The uterus should first be treated with a solution of chlorhexidine and petroleum jelly, which helps in reduction.
Stages of the operation.
Grasp the inverted uterus with your right hand so that the palm is at the bottom of the uterus, and the ends of the fingers are near the cervix, resting against the area of the posterior vaginal fornix.
Pressing on the uterus with your hand, first push the inverted vagina into the pelvic cavity, and then the uterus, starting from its bottom or isthmus. The left hand is placed on the lower part of the abdominal wall, moving towards the screwed-in uterus.
In cases of recent uterine inversion, it can be adjusted without much difficulty. You should not massage the uterus with your fist, since against the background of shock and blood loss, squeezing thromboplastic substances from the uterus into the general bloodstream can lead to impaired blood clotting and continued uterine bleeding. Uterotonic agents should be administered (oxytocin, methylergometrine at the same time) and their administration should be continued for several days. If it is not possible to straighten the uterus using manual techniques, a posterior colpo-hysterotomy is performed: the posterior part of the vaginal vault and the posterior wall of the uterus are dissected, the inverted uterus is straightened and the integrity of the uterus and vagina is restored.
If medical care is delayed, when a day or more has passed since the inversion, it is necessary to remove the uterus. This is due to areas of necrosis that appear in the wall of the uterus due to sudden disruptions in blood supply and infection of the organ after inversion.
Complications
Inflammatory.
Thromboembolic.
Features of the postoperative period
Prescribed:
- course of antibacterial therapy;
- uterotonic drugs for 5-7 days or more.
Prevention
Correct management of the afterbirth period;
Isolation of the placenta by external means in the presence of signs of separation of the placenta without forced pulling on the umbilical cord.
Information for the patient
You should limit physical activity, do not lift heavy objects, and wear a bandage.
Forecast
With timely diagnosis and proper treatment, the prognosis is favorable. If urgent assistance is not provided, the postpartum mother may die from shock and blood loss, and in the following days from infection (peritonitis, sepsis). Spontaneous reduction of the inversion does not occur.
Uterine inversion is a rather rare pathological process when a woman’s reproductive organ is completely or partially turned outward by the mucous membrane. With inversion, the uterus is located in the vagina and can emerge from the genital slit. The ovaries and fallopian tubes descend behind the fundus of the uterus, but they do not plunge into the resulting funnel. What are the causes and symptoms of this rare pathology?
Reasons
Often, uterine inversion is spontaneous and occurs due to pathology of the uterus in the postpartum period. May occur due to increased intra-abdominal pressure due to sneezing or coughing.
The main reasons for this violation:
- no contraction of the uterus in the postpartum period,
- relaxed state of the uterus and loss of elasticity of its tissues,
- fundal attachment of the placenta,
- submucosal fibroids near the fundus of the uterus,
- prolapse or partial prolapse.
It happens that an eversion is violent due to the inexperience of the doctor, the reasons for which are:
- the Crede-Lazarevich method, performed in a rough form, when the doctor puts strong pressure on the uterus in order to separate the placenta from it,
- pulling on the placenta while it has not yet separated from the uterus.
If uterine inversion is diagnosed at the wrong time, the prolapsed body may become pinched and swelling may occur.
Symptoms
There are partial and complete inversion of the uterus. With complete inversion, the uterus extends beyond the genital slit, which is easy to recognize. Partial eversion requires a two-handed examination, which shows that a tumor-like formation has appeared in the vagina, and the body of the uterus has a funnel-shaped depression.
General symptoms characteristic of partial or complete inversion of the uterus:
- pallor of the skin and mucous membranes,
- cold sweat,
- gagging,
- sharp sharp pain in the abdomen,
- lowering blood pressure,
- dizziness,
- bleeding or spotting from the uterus,
- frequent but weak heartbeat,
- loss of consciousness,
- discomfort in the vagina,
- state of shock.
Uterine inversion can be acute, immediately after childbirth, or chronic, which develops over several days. In any case, this pathological process requires immediate treatment and special care from specialists.
Treatment
Before treatment, it is important to diagnose complete or incomplete uterine inversion:
- With complete inversion, the uterus may fall out of the vulva; if this does not happen, the doctor examines the patient using mirrors and palpation, in which the uterus is absent above the womb.
- In case of incomplete inversion, a bimanual examination is performed, during which it is concluded that the uterus is lower than necessary after childbirth.
Treatment must be quick and urgent, otherwise the woman may die from shock and blood loss, or contract an infection that is fatal (sepsis, peritonitis). The goal of treatment is not only to return the uterus to its normal position, but also to keep it in its usual place.
Treatment involves repositioning the uterus to its usual place using hands under anesthesia. The sequence of measures to reduce the uterus:
- carrying out anti-shock therapy and administering general anesthesia,
- disinfection of a surgeon's hands and a woman's genitals,
- injection of 1 ml of 0.1% atropine subcutaneously to prevent cervical spasm,
- if there is a placenta, it must be removed before the reduction process,
- grab the inverted uterus with your right hand so that the ends of your fingers are at its cervix and the base of your palm is at the bottom of the uterus,
- pressing on the uterus with your whole hand, you should straighten the vagina, and then the uterus into the pelvic area, starting from its isthmus or bottom,
- the left hand helps, going towards the screwed-in uterus, it is located on the lower part of the abdominal wall.
If treatment occurs immediately after diagnosis, there are no particular difficulties in its reduction. After reduction, uterine contracting drugs should be administered: methylergometrine and oxytocin, which are used by the patient for several days.
If it is impossible to straighten the uterus manually, they resort to surgical intervention, which consists of:
- administration of drugs to prevent cervical spasms,
- washing and disinfecting the genitals with an antiseptic solution,
- the size of the posterior wall of the uterus and vagina is performed,
- the uterus is reduced, the vaginal defect is eliminated,
- the uterus is sutured.
If medical care is not provided on time later than a day, you will have to have the uterus removed due to infection or necrosis. In this case, this is an irreversible process that cannot be treated differently.
Uterine inversion is a displacement of the uterus in which the uterus is partially or completely turned outward by the mucous membrane. As a rule, uterine inversion is associated with improper management of labor. This pathology poses a danger to a woman’s life and requires immediate initiation of treatment measures.
Causes
Uterine inversion can occur for a variety of reasons:
- uterine atony with increased intra-abdominal pressure;
- rough execution by the doctor of the Crede-Lazarevich maneuver (pressure with hands on the uterus to stimulate the separation of the placenta);
- pulling on the umbilical cord when the placenta has not separated;
- the presence of uterine tumors (for example, a polyp or myomatous node).
Unfavorable risk factors for uterine inversion may include:
- fundal attachment of the placenta;
- the presence of a large submucosal myomatous node in the fundus of the uterus.
Symptoms of uterine inversion
The main symptoms of uterine inversion may be:
Diagnostics
At the first stage, a medical history is collected, complaints are analyzed, and an obstetric and gynecological history is analyzed. The doctor gets acquainted with information regarding past gynecological diseases, surgical interventions, pregnancies, childbirth (their characteristics and outcomes).
During an objective examination, the pregnant woman is examined, blood pressure is measured, pulse is measured, and the abdomen and uterus are palpated. During an external obstetric examination, the doctor uses his hands to determine the shape and size of the uterus, as well as muscle tension. During the examination, a bimanual examination and examination of the cervix are performed using special instruments.
Classification
Uterine inversion can occur spontaneously or as a result of medical intervention. Spontaneous uterine inversion is associated with relaxation of the uterine muscles and an increase in intrauterine pressure. As for forced uterine inversion, it can occur when the umbilical cord is pulled when the placenta has not yet separated, as well as when the Credet-Lazarevich maneuver is roughly performed.
Uterine inversion can be complete or incomplete. With incomplete uterine inversion, the fundus of the uterus does not extend beyond the internal os of the uterus. With complete eversion, the uterus is located in the vagina with the mucous membrane facing out.
Due to its occurrence, uterine inversion can be postpartum and oncogenetic. Postpartum uterine inversion occurs in the postpartum period, and oncogenetic is associated with neoplasms of the uterus. The latter type of uterine inversion is extremely rare.
Depending on the time of occurrence, uterine inversion can be acute (occurs immediately after childbirth) or chronic, which develops slowly over several days after childbirth.
Patient Actions
Treatment of this disease is carried out by an obstetrician-gynecologist.
Treatment of uterine inversion
Treatment of uterine inversion is carried out by manual reduction of the uterus. In some cases, manual separation of the placenta from the walls of the uterus is necessary.
Drug treatment for uterine inversion consists of the use of cholinomimetics (prevent spasms), antiseptic drugs (prevent the spread of infections) and aqueous colloidal solutions.
Surgical treatment is performed in the form of colpohysterotomy. The doctor makes an incision in the posterior wall of the vagina and uterus, after which the uterus is reduced, and the defect of the vagina and uterus is sutured.
Complications
When the uterus is inverted, the following complications may develop:
- infectious complications (endometritis, peritonitis, sepsis);
- uterine necrosis;
- disseminated intravascular coagulation syndrome;
- hemorrhagic shock;
- mother's death.
Prevention of uterine inversion
The main preventive measures against uterine inversion are:
- competent planning of pregnancy and preparing a woman for it, timely registration of a pregnant woman;
- regular visits to an obstetrician-gynecologist;
- adherence to the principles of rational balanced nutrition;
- proper rest and sleep;
- taking vitamin and mineral complexes;
- giving up bad habits (smoking and drinking alcohol);
- avoiding stress and excessive physical activity.
