Uterine inversion (inversion of the uterus) as a complication of childbirth. Postpartum uterine inversion
The displacement of the uterus with eversion of its mucosa to the outside is a postpartum eversion of the uterus. Most often, pathology occurs against the background of improper management of childbirth and the postpartum period. The condition is characterized by an acute course and requires immediate treatment, as it poses a danger to the health and life of a woman.Causes of uterine inversion
Most often, acute uterine inversion is diagnosed, which occurs simultaneously immediately after childbirth. But sometimes there is also a chronic form of this pathology, which occurs in the postpartum period, that is, within a few days after the birth of a 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);
- too aggressive pressure on the uterus in order to separate the placenta;
- tension of the umbilical cord (forced pulling) with the placenta not yet separated.
- the presence of a large myomatous node on the bottom of the uterus;
- the location of the placenta at the bottom of the uterus (the uppermost and widest area).
Symptoms and treatment of cervical inversion after childbirth
Eversion of the cervix after childbirth is manifested by severe symptoms:- scarlet discharge with clots from the genital tract;
- the skin of a woman becomes pale, covered with cold sweat;
- there are complaints of sudden acute pain in the lower abdomen (possible loss of consciousness against the background of pain shock);
- blood pressure indicators become extremely low;
- when examined in the vagina, a mucous-type formation with a red surface is detected.
- drugs from the group of cholinomimetics - actively affect the cervix directly, prevent its spasm;
- antiseptics - used to wash the uterine cavity, prevent the development of a bacterial infection;
- drugs to increase and stabilize blood pressure.
(inversion uteri) is a formidable complication of the afterbirth or, more rarely, the postpartum period. The essence of this pathological condition lies in the fact that the bottom of the uterus begins to be pressed into the uterine cavity and, protruding into it, forms a funnel. The funnel gradually deepens, the uterus is completely everted 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 wide uterine ligaments are drawn, and in case of acute eversion, the ovaries. When the uterus is inverted in the afterbirth period, it, together with the unseparated placenta, protrudes from the external genital organs. If the eversion occurred in the succession period, then the everted uterus remains in the vagina.
In some cases, under the influence of increased intraperitoneal pressure, the everted uterus can be completely pushed out of the pelvis along with the everted vagina, prolapsus totalis uteri inverse et vaginae occurs (G. G. Geiter).
Inversion of the uterus 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 for 270,000 births. According to I. F. Zhordania, the frequency of uterine inversion is greater and occurs once in 40,000 births.
According to foreign authors, the frequency of uterine inversion is much higher. So, according to Daz, it is one eversion per 14.880 births, and Bell, G.Wilson indicate the frequency of uterine eversion equal to 1 per 4894 births, which is many times higher than the figures of domestic authors. According to Daz statistics, for 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 uterine inversion. In the past, it was believed that all acute inversions of the postpartum uterus were violent and occurred as a result of pulling on 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 in 1894 described 100 cases of uterine inversion, 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 eversion can occur as a result of an increase in intraperitoneal pressure when coughing, sneezing, trying, sudden movements of the woman in labor, etc. Such an eversion of the uterus is spontaneous and is observed shortly after the birth of the placenta. Acute inversion of the uterus, usually occurring when it is atony as a result of attempts to separate and isolate the placenta by pressing the hand on the bottom of the uterus, pulling on the umbilical cord, etc., is called violent; V. in most cases, it is observed with improper management of the afterbirth period.
The occurrence of uterine inversion is facilitated by an unseparated placenta, especially located in the region of the uterine fundus. The placenta, descending due to gravity, carries along the relaxed walls of the uterus. In the literature, there are descriptions of uterine eversion that occurred in the postpartum period with submucosal fibromyomas being born (oncogenetic eversion). A tumor born in the vagina, as a result of its severity and continued contractions of the uterus, pulls the bottom along with it and it gradually turns out.
According to V. G. Beckman et al., uterine inversion occurs more often in primiparas and this is usually associated with the fact that they are incomparably more likely than multiparous ones to have the location of the placenta in the bottom of the uterus.
Eversions of the uterus are incomplete, or partial, if only the body of the uterus or part of it is everted, and complete, when the entire uterus is completely everted outward.
Clinicuterine eversion
Acute uterine inversion in the afterbirth or early postpartum period, it is accompanied by a sudden onset of severe abdominal pain, the subsequent development of a state of shock and bleeding. Pain is the first symptom, they are explained by traumatization of the peritoneal cover of the uterus during its eversion and tension of the ligaments when the topographic ratios in the pelvis change.
The state of shock sometimes does not develop immediately and occurs as a result of a sharp irritation of the peritoneum, a rapid drop in intraperitoneal pressure and painful irritations when the ligaments are pulled. Bleeding, which can begin even before the occurrence of eversion, depends on the atony of the uterus. In the future, bleeding is maintained due to a sharp violation of blood circulation in the everted uterus and severe venous stasis in it.
The pulse in acute uterine inversion becomes frequent, thready, the skin turns pale, the face is covered with cold sweat, the pupils dilate. Arterial pressure falls, consciousness is clouded.
With a severe clinical picture and delayed or incorrect therapeutic measures, death from shock and less often from bleeding may occur. In the future, the puerperal is at risk of infection. Mortality in acute eversion, according to various authors, ranges from 0 to 30%. Such inconsistency in the numbers of lethal outcomes depends on the nature of therapeutic measures and their effectiveness. The widespread use in obstetric practice of blood transfusion and other measures in a state of shock makes it possible in our time to obtain the most favorable results with uterine eversion. Spontaneous reduction of uterine inversion is extremely rare. This possibility is not excluded in case of oncogenetic reversals caused by a tumor. After removal of the tumor, the eversion can retract itself, since there is no infringement in the neck area.
Recognition of acute eversion is usually not difficult. The anamnesis, sudden pains, bleeding and shock in the afterbirth or postpartum period are characteristic. An everted 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 more facilitated if there is an unseparated placenta on the walls of the everted uterus (Fig. 124). With a thorough examination of this "tumor" you can see the openings of the fallopian tubes. Through the abdominal wall, the body of the postpartum uterus is not determined, it seems to have disappeared. On palpation through the abdominal integument and with a two-handed examination, a funnel-shaped depression is determined in place of the fundus of the uterus (Fig. 125, 126).
Rice. 122. Acute eversion of the uterus after the release of the placenta.
Rice. 123. Eversion of the uterus and vagina with prolapse
Rice. 124. Incomplete eversion of the uterus
Rice. 125. Eversion of the uterus. Eversion of the fundus of the uterus into its cavity.
Rice. 126. Complete eversion of the uterus. View from the side of the abdominal cavity (1 - bladder)
Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983
The displacement of the uterus, in which it is partially or completely turned outward by the mucous membrane, is called uterine eversion.
This pathology occurs as a result of errors made in the management of the afterbirth period. Hypotension of the uterus and mechanical pressure on it contributes to this complication. Distinguish between complete and incomplete (partial) eversion of the uterus. Eversion can be acute (rapid) or chronic (slowly occurring). Acute inversions occur more often, and 3/4 of them occur in the afterbirth period, and 1/4 - on the first day of the postpartum period.
According to the etiology, uterine eversion is divided into spontaneous and violent.
Violent eversion - which arose when pulling the umbilical cord or rudely performing the Krede-Lazarevich technique with a relaxed uterus.
Spontaneous eversion occurs as a result of a sharp relaxation of the muscles of the uterus 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 according to the Krede-Lazarevich method, but the sequence of manipulations is not followed:
- emptying of the bladder;
- bringing the uterus to the middle position;
- light stroking of the uterus in order to reduce it;
- grasping the bottom of the uterus with the hand, simultaneous pressure on the uterus with the whole brush in two intersecting directions.
In addition, the cause of uterine inversion can be a sharp pull on the umbilical cord.
The main reason for spontaneous eversion is the relaxation of all parts of the uterus, the loss of contractile ability by the myometrium. In this state, even an increase in intra-abdominal pressure with an attempt, coughing, sneezing can lead to uterine eversion. A predisposing factor is the bottom attachment of the placenta.
Pathogenesis
Initially, a depression (eversion funnel) is formed in the region of the bottom of the uterus, into which the fallopian tubes, round and wide ligaments of the uterus, and sometimes the ovaries are drawn. Then the eversion funnel increases, the everted body of the uterus descends through the cervical canal into the vagina. If the area of the fundus of the uterus does not extend beyond the external os of the cervix, the eversion is called incomplete. With complete eversion, the uterus is located in the vagina, sometimes extends beyond the genital slit.
Clinical picture
Typical symptoms:
- sudden severe pain in the lower abdomen;
- state of shock;
- uterine bleeding.
Bleeding may begin before the uterine eversion, due to its atony, and continue after the eversion is completed.
Diagnostics
When the uterus is everted from the genital slit, the everted mucous membrane of the uterus is bright red.
Sometimes the uterus turns out with an unseparated afterbirth.
Complete uterine eversion may be accompanied by vaginal eversion. In this case, the uterus is outside the vulva and the diagnosis is not difficult. With isolated eversion, the uterus is determined in the vagina when viewed in mirrors. In both cases, there is no uterus above the womb on palpation. In case of incomplete eversion of the uterus, the general condition is less severe and worsens much more slowly.
Differential Diagnosis
For differential diagnosis with other complications (for example, with uterine rupture), a bimanual examination is performed, in which the location of the upper edge of the uterus, which is unusually low for the succession and early postpartum period, or the presence of a funnel-shaped depression in place of the uterus, is determined.
Surgery
Any uterine inversion requires medical intervention - manual reduction with preliminary manual separation of the placenta, or other surgical treatment.
conditions for the operation.
Compliance with the rules of asepsis.
Small operating room conditions.
Preparation for the operation.
Antishock therapy and general anesthesia (deep intravenous anesthesia).
Treatment of the surgical field, hands of the surgeon and assistant.
Prevention of spasm of the cervix (1 ml of a 0.1% solution of atropine s / c).
Emptying the bladder.
Operation technique.
Under anesthesia, the uterus is carefully reduced through the uterine os. Previously, the uterus should be treated with a solution of chlorhexidine and liquid paraffin, which helps to reduce.
Stages of the operation.
Grab the everted uterus with the right hand so that the palm is on the bottom of the uterus, and the ends of the fingers are near the cervix, resting on the area of the posterior fornix of the vagina.
Pressing on the uterus with your hand, first push the everted vagina into the pelvic cavity, and then the uterus, starting from its bottom or from the isthmus. The left hand is placed on the lower part of the abdominal wall, moving towards the screwed uterus.
With a recent inversion of the uterus, it is set without much difficulty. It is not necessary to massage the uterus on the fist, since against the background of shock and blood loss, the extrusion of thromboplastic substances from the uterus into the general bloodstream can lead to impaired blood clotting and continued uterine bleeding. It is necessary to introduce uterotonic agents (simultaneous oxytocin, methylergometrine) and continue their administration for several days. If it is not possible to set the uterus by manual methods, a posterior colpo-hysterotomy is performed: the posterior part of the vaginal fornix and the posterior wall of the uterus are dissected, the everted uterus is set and the integrity of the uterus and vagina is restored.
With belated medical care, 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 occur in the wall of the uterus due to severe circulatory disorders and infection of the organ after eversion.
Complications
Inflammatory.
Thromboembolic.
Features of the postoperative period
Appoint:
- a course of antibiotic therapy;
- uterotonic drugs for 5-7 days or more.
Prevention
Proper follow-up period;
Isolation of the placenta by external methods in the presence of signs of separation of the placenta without forced pulling of the umbilical cord.
Information for the patient
You should limit physical activity, do not lift weights, wear a bandage.
Forecast
With timely diagnosis and proper treatment, the prognosis is favorable. If urgent assistance is not provided, the puerperal may die from shock and blood loss, and in the following days from infection (peritonitis, sepsis). Spontaneous reduction of eversion does not occur.
Inversion of the uterus is a rather rare pathological process when the reproductive organ of a woman is completely or partially turned outward by the mucous membrane. With eversion, the uterus is located in the vagina and can come out of the genital gap. Behind the bottom of the uterus, the ovaries and fallopian tubes descend, but they do not sink into the formed funnel. What are the causes and symptoms of this rare pathology?
Causes
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 the appearance of this violation:
- no contraction of the uterus in the postpartum period,
- relaxed state of the uterus and loss of elasticity of its tissues,
- bottom attachment of the placenta,
- submucosal fibroids near the fundus of the uterus,
- omission or partial loss.
It happens that eversion is violent due to the inexperience of the doctor, the reasons for which are:
- the Krede-Lazarevich method, performed in a rough form, when the doctor strongly presses on the uterus in order to separate the placenta from it,
- pulling on the placenta at a time when it has not yet separated from the uterus.
If the inversion of the uterus is diagnosed at the wrong time, the prolapsed body may become pinched and swelling may appear.
Symptoms
Distinguish between partial and complete eversion of the uterus. With full eversion, the uterus extends beyond the genital gap, which is easy to recognize. Partial eversion requires a two-handed examination, which shows that a mass has appeared in the vagina in the form of a tumor, and the body of the uterus has a funnel-shaped depression.
Common symptoms characteristic of partial or complete uterine inversion:
- pallor of the skin and mucous membranes,
- cold sweat,
- gagging,
- sharp sharp pains in the abdomen,
- lowering blood pressure,
- dizziness,
- bleeding or spotting from the uterus
- fast but weak heartbeat
- loss of consciousness,
- discomfort in the vagina
- shock state.
Uterine inversion can be acute, immediately after delivery, or chronic, which develops over several days. In any of the cases, this pathological process requires immediate treatment and special care of specialists.
Treatment
Before treatment, it is important to diagnose complete or incomplete uterine inversion:
- With complete eversion, the uterus may fall out of the vulva, if this does not happen, the doctor examines the patient with the help of mirrors and palpation, in which the uterus is absent above the womb.
- In case of incomplete eversion, a bimanual examination is performed, in which it is concluded that the uterus is lower than necessary after childbirth.
Treatment must be prompt and urgent, otherwise the woman may die from shock and blood loss, or become infected with a fatal infection (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 means by itself, the reduction of the uterus to its usual place, with the help of hands under anesthesia. The sequence of actions for the reduction of the uterus:
- anti-shock therapy and the introduction of general anesthesia,
- disinfection of the hands of a surgeon and the genitals of a woman,
- injection of 1 ml of 0.1% atropine subcutaneously to prevent cervical spasm,
- if there is an afterbirth, it must be removed before the reduction process,
- grab the inverted uterus with the right hand so that the ends of the fingers are at its neck, and the base of the palm is at the bottom of the uterus,
- pressing on the uterus with the whole hand, you should set 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 the diagnosis is made, there are no special difficulties in its reduction. After repositioning, uterine contracting drugs should be administered: methylergometrine and oxytocin, which are applied to the patient for several days.
If it is impossible to set the uterus manually, they resort to surgical intervention, which consists in:
- the introduction of drugs that prevent spasm of the cervix,
- 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 defect of the vagina is eliminated,
- the uterus is sutured.
With untimely medical care later than a day, you have to go to remove the uterus due to infection or necrosis. In this case, it is an irreversible process that is not subject to other treatment.
Inversion of the uterus - displacement of the uterus, in which the uterus is partially or completely turned inside out by the mucous membrane. As a rule, uterine inversion is associated with improper delivery. This pathology poses a danger to the life of a woman and requires the immediate initiation of therapeutic measures.
Causes
Inversion of the uterus can occur for a variety of reasons:
- atony of the uterus with an increase in intra-abdominal pressure;
- rough execution by the doctor of the Krede-Lazarevich reception (hand pressure on the uterus to stimulate the separation of the placenta);
- sipping on the umbilical cord with a placenta that has not separated;
- the presence of neoplasms of the uterus (for example, a polyp or myomatous node).
Unfavorable risk factors for uterine inversion can be:
- bottom 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 can be:
Diagnostics
At the first stage, an anamnesis of the disease is collected, complaints are analyzed and an obstetric and gynecological anamnesis is analyzed. The doctor gets acquainted with information related to past gynecological diseases, surgical interventions, pregnancies, childbirth (their characteristics and outcomes).
With an objective examination, a pregnant woman is examined, blood pressure is measured, the pulse is measured, and the abdomen and uterus are palpated. With an external obstetric examination, the doctor determines the shape and size of the uterus, as well as muscle tension with his hands. During the examination, a bimanual examination and examination of the cervix using special instruments are performed.
Classification
Inversion of the uterus can occur spontaneously, or as a result of medical intervention. Spontaneous inversion of the uterus is associated with relaxation of the uterine muscles and an increase in intrauterine pressure. As for the forced inversion of the uterus, it can occur when pulling on the umbilical cord with the placenta not yet separated, as well as when performing the Krede-Lazarevich technique roughly.
Eversion of the uterus is complete and incomplete. With incomplete eversion of the uterus, the bottom 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 outward.
Due to the occurrence of uterine inversion, it can be postpartum and oncogenetic. Postpartum uterine inversion occurs in the postpartum period, and oncogenetic is associated with uterine neoplasms. The latter type of uterine inversion is extremely rare.
Depending on the time of occurrence, uterine inversion is acute (occurs immediately after childbirth) and chronic, which develops slowly, within a few days after childbirth.
Patient's 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 in the use of cholinomimetics (prevent spasm), antiseptic drugs (prevent the spread of infections) and aqueous colloidal solutions.
Surgical treatment is performed in the form of a colpohysterotomy operation. The doctor performs an incision in the posterior wall of the vagina and uterus, after which the uterus is set, and the defect of the vagina and uterus is sutured.
Complications
With uterine inversion, the following complications may develop:
- infectious complications (endometritis, peritonitis, sepsis);
- uterine necrosis;
- syndrome of disseminated intravascular coagulation;
- hemorrhagic shock;
- death of the mother.
Prevention of uterine inversion
The main preventive measures for uterine inversion are:
- competent planning of pregnancy and preparation of a woman for it, timely registration of a pregnant woman;
- regular visits to an obstetrician-gynecologist;
- adherence to the principles of a rational balanced diet;
- proper rest and sleep;
- taking vitamin and mineral complexes;
- giving up bad habits (smoking and drinking alcohol);
- exclusion of stress and excessive physical exertion.
