FIGURE 41 -7 Maternal death during home delivery caused by exsanguination from uterine inversion and a fundally implanted placenta accreta.
will prompt closer examination of the birth canal. Although complete inversion is usually evident, the partially inverted uterus can be mistaken for a uterine myoma, and sonography can aid diferentiation (Pan, 2015; Smulian, 2013). Many cases are associated with immediate life-threatening hemorrhage, and a fourth require blood replacement (eoad, 2017).
Once any degree of uterine inversion is recognized, several steps must be implemented urgently and simultaneously: 1.
Immediate assistance is summoned, including obstetrical and anesthesia personnel.
2.
Blood is brought to the delivery suite for potential use.
3.
he woman is evaluated for emergency general anesthesia.
Large-bore intravenous infusion systems are secured to begin rapid crystalloid infusion to treat hypovolemia while awaiting arrival of blood products.
4.
If the recently inverted uterus has not contracted and retracted completely and if the placenta has already separated, then the uterus may often be replaced simply by pushing up on the inverted fundus with the palm of the hand and ingers in the direction of the long axis of the vagina (Fig. 41-8). Some use two fingers rigidly extended to push the center of the fundus upward. Care is taken not to appy so much pressure as to peorate the uterus with the ingertips.
5.
If the placenta is still attached, then attempts are made to reposition the uterus with the placenta in situ. Many recommend a trial of an intravenously administered tocolytic drug such as terbutaline, magnesium sulfate, or nitroglycerin for uterine relaxation and repositioning (You, 2006). If these fail to provide suicient relaxation, then a rapidly acting halogenated inhalational agent is administered. After the uterus is replaced, the placenta is carefully manually removed.
6.
If uterine repositioning fails with the placenta attached, then it is peeled of and steady pressure with the fist, palm, or ingers is applied to the inverted fundus in an attempt to push it up into and through the dilated cervix as described in Step 4.
FIGURE 41-8 Incomplete uterine inversion repositioned by using the abdominal hand for palpation of the crater-like depression while simultaneously gently pushing the inverted fundus upward.
7. Once the uterus is restored to its normal coniguration, tocolysis is stopped. Oxytocin is then infused, and other utero tonics may be given as described for atony (p. 759). Meanwhile, the operator maintains the fundus in its normal anatomical position while applying bimanual compression to control further hemorrhage until the uterus is well contracted (see Fig. 41-4). The operator continues to monitor the uterus transvaginally for evidence of subsequent inversion. A Bakri balloon has been used to maintain the repositioned uterus (Haeri, 2015; Ida, 2015).
In most cases, the inverted uterus can be restored to its normal position by the techniques just described. Occasionally, manual replacement fails. One cause is a dense m) ometrial constriction ring. At this point, laparotomy is imperative. The anatomical coniguration found at surgery can be confusing as shown in