II. Epidemiology

  1. Incidence: 1 in 2500 deliveries (0.04%)
  2. More commonly affects Multiparous patients
  3. Iatrogenic cause most often

III. Pathophysiology

  1. Serious complication of Vaginal Delivery
  2. Rare, but life threatening if not replaced

IV. Signs

  1. Placenta appears at introitus attached to mass
    1. Inverted Uterus appears as bluish-gray mass protruding from vagina
  2. Shock
    1. Bradycardia associated with vagal response
    2. Excessive Hemorrhage may be absent

V. Grading

  1. First Degree: Incomplete inversion
  2. Third Degree: Complete inversion to perineum

VI. Management

  1. Treat shock and blood loss
    1. Immediate Intravenous Access
    2. Intravenous Fluid Replacement
  2. Call for emergent Consultation
    1. Obstetrics
    2. General Anesthesia (consider Halothane)
  3. Immediate Manual Replacement (Johnson Maneuver)
    1. Replace Uterus in non-inverted position
      1. Replace last part out first (last out, first in)
      2. Leave placenta in place if still attached (removal increases bleeding)
      3. Johnson Method
        1. Grasp protruding uterine fundus with palm of hand and fingers toward posterior fornix
        2. Lift the Uterus back up into vagina, through Pelvis and into Abdomen
    2. Administer Terbutaline or Nitroglycerin as below as needed to relax Uterus
    3. Consider General Anesthesia
    4. Repeat trial of Manual Replacement
    5. Surgical Replacement
  4. Pre-replacement uterine relaxants (Tocolytics) if contraction ring prevents replacement
    1. Magnesium Sulfate
    2. Terbutaline 0.25 mg SC
    3. Nitroglycerin
      1. Intravenous: 50 to 200 mcg IV
      2. Sublingual (200 mcg per spray): 2 sprays sublingual
  5. Post-Replacement Uterine Hemorrhage Management options
    1. Pitocin IV 40 u/L at 100-250 cc/h
    2. Hemabate 0.25mg IM Myometrium q15 minutes (max: 2 mg)
    3. Methergine 0.2 mg IM or PO q6-8h
  6. Consider exploratory laparotomy if needed

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Ontology: Uterine Inversion (C0162482)

Definition (MSH) A complication of OBSTETRIC LABOR in which the corpus of the UTERUS is forced completely or partially through the UTERINE CERVIX. This can occur during the late stages of labor and is associated with IMMEDIATE POSTPARTUM HEMORRHAGE.
Concepts Pathologic Function (T046)
MSH D019687
ICD9 665.2
ICD10 N85.5
SnomedCT 199968003, 156232008, 199971006, 156233003, 267347009, 27215002
English Obstetrical inversion of uterus, Uterine Inversion, Inversion, Uterine, Inversion of uterus, Inversion of uterus NOS, Obstetric inversion of uterus NOS, Inversion of uterus unspecif., Obstetric inversion of uterus unspecified, Uterine Inversion [Disease/Finding], uterine inversion, inversion uterine, inversion of uterus, inversion uterus, Inversion of uterus (disorder), Obstetric inversion of uterus unspecified (disorder), Obstetric inversion of uterus NOS (disorder), uterine inversion (diagnosis), Uterine inversion, Uterine inversion (disorder), inversion; uterus, uterus; inversion, Uterine inversion, NOS, Inversion of Uterus, Uterus Inversion
Dutch inversio uteri obstetrisch, inversie; uterus, uterus; inversie, Inversie van uterus, baarmoederinversie, Inversio uteri, Uterusinversie
French Inversion obstétricale de l'utérus, Utérus inversé, Inversion de l'utérus, Inversion utérine
German Inversio uteri waehrend der Entbindungsphase, Uterusinversion, Inversio uteri
Portuguese Inversão obstétrica do útero, Inversão uterina, Inversão Uterina
Spanish Inversión obstétrica del útero, inversión uterina de causa obstétrica, no especificada (trastorno), inversión uterina de causa obstétrica, no especificada, inversión uterina de causa obstétrica, SAI (trastorno), inversión uterina de causa obstétrica, SAI, inversión uterina (trastorno), inversión uterina, Inversión uterina, Inversión Uterina
Swedish Livmoderinversion
Italian Inversione ostetrica dell'utero, Inversione dell'utero
Japanese シキュウナイハンショウ, 子宮内反症, 子宮内反
Czech uterus - inverze, Porodnická inverze dělohy, Inverze dělohy
Finnish Kohdun nurinkääntymä
Korean 자궁의 내번증
Polish Wynicowanie macicy
Hungarian Méh szülészeti inversiója, Méh inversio
Norwegian Uterusinversjon, Inversjon av uterus, Livmorinversjon