II. Epidemiology
- Incidence: 1 in 2500 deliveries (0.04%)
- More commonly affects Multiparous patients
- Iatrogenic cause most often
III. Pathophysiology
- Serious complication of Vaginal Delivery
- Rare, but life threatening if not replaced
IV. Signs
- Placenta appears at introitus attached to mass
- Inverted Uterus appears as bluish-gray mass protruding from vagina
-
Shock
- Bradycardia associated with vagal response
- Excessive Hemorrhage may be absent
V. Grading
- First Degree: Incomplete inversion
- Third Degree: Complete inversion to perineum
VI. Management
- Treat shock and blood loss
- Call for emergent Consultation
- Obstetrics
- General Anesthesia (consider Halothane)
- Immediate Manual Replacement (Johnson Maneuver)
- Replace Uterus in non-inverted position
- Administer Terbutaline or Nitroglycerin as below as needed to relax Uterus
- Consider General Anesthesia
- Repeat trial of Manual Replacement
- Surgical Replacement
- Pre-replacement uterine relaxants (Tocolytics) if contraction ring prevents replacement
- Magnesium Sulfate
- Terbutaline 0.25 mg SC
- Nitroglycerin
- Intravenous: 50 to 200 mcg IV
- Sublingual (200 mcg per spray): 2 sprays sublingual
- Post-Replacement Uterine Hemorrhage Management options
- Pitocin IV 40 u/L at 100-250 cc/h
- Hemabate 0.25mg IM Myometrium q15 minutes (max: 2 mg)
- Methyl-ergonovine (Methergine) 0.2 mg IM or PO every 6 to 8 hours
- Consider exploratory laparotomy if needed