Reduction of subacute uterine inversion by Haultain’s method: A case report

Abstract

CASE REPORTUterine inversion is a rare but potentially life-threatening obstetric emergency of unknown aetiology, which is often associated with inadvertent traction on the umbilical cord before separation of the placenta. Here we report a case of a 26-year-old woman who presented with a day's history of uterine inversion after an attempt to remove a retained placenta following a second-trimester miscarriage. Reduction was attempted in casualty without success and she was taken to theatre for surgical reduction under anaesthesia. Reduction was eventually achieved using the Haultain method. Uterine inversion is defined as the 'turning inside out of the fundus into the uterine cavity' and the incidence is about 1 in 3 737. S Afr J Obstet Gynaecol[1]Active management of the third stage of labour resulted in a 4.4-fold decline in the incidence of uterine inversion.[1] The main causes of uterine inversion are thought to be mismanagement of the third stage of labour, such as premature traction of the umbilical cord with or without fundal pressure and manual placental removal after delivery before complete placental separation. Other associated factors include nulliparity, a morbidly adherent fundal placenta, short umbilical cord and rare connective tissue disorders. Spontaneous inversion has been reported in about 50% of the cases. [2,3] Case reportA 26-year-old patient, who had had two previous normal vaginal deliveries and one miscarriage presented with a day's history of a vaginal mass after an attempted removal of a retained placenta following a miscarriage that was managed at a local hospital. The mass was associated with vaginal bleeding and lower abdominal pain. She also reported having passed a fetus. She was unaware of the current pregnancy because of lactational amenorrhoea and gestation was estimated at a possible 18 weeks based on recent perception of fetal movements. She was using progesterone-only pills for contraception. An attempt to remove the placenta by cord traction at the local hospital resulted in the inversion. She was subsequently referred to Harare Central hospital. On examination she was ill-looking, markedly pale and had a tachycardia of 128 beats per minute. Her blood pressure was 115/55 mmHg and she had a normal urine output of 40 mL/h. Her haemoglobin level was 4.2 g/dL.Her abdomen was soft and non-tender without masses and the uterine fundus was not palpable abdominally. Vaginal examination revealed a globular and firm mass in the vagina; the cervix could not be visualised and the fornices were drawn upwards. A diagnosis of subacute uterine inversion was made and resuscitation was performed using ringer's lactate fluid and 4 units of packed red blood cells. She was commenced on intravenous antibiotics. A manoeuvre to correct the inversion by placing a cupped hand into the vagina and applying upward pressure, also known as Johnson's manoeuvre, was attempted in casualty to no avail. [2,3] She was taken to theatre and the procedure was attempted again under anaesthesia without success. We p...

Acute uterine inversion following an induced abortion

“…The other factors (maternal, placental, fetal, and iatrogenic) are more likely at advanced gestations. Ziki et al had reported that attempts to deliver the placenta by cord traction might cause an inversion at this early gestation, but our client denied this action 10 …”

“…The reported incidence of puerperal uterine inversions varies widely but is higher in remote rural areas where access to emergency obstetric care is inadequate. 8,10,11 Post-abortal uterine inversions are infrequent events, with only a handful of cases reported so far in our literature search, all from low-middle income nations. 6,7 The exact cause of puerperal uterine inversions remains undefined, with about 50% of cases reported in low-risk women with no precipitating factor identified.…”

“…The reported incidence of puerperal uterine inversions varies widely but is higher in remote rural areas where access to emergency obstetric care is inadequate 8,10,11 . Post‐abortal uterine inversions are infrequent events, with only a handful of cases reported so far in our literature search, all from low‐middle income nations 6,7 …”

“…Management goals involve immediate resuscitation with crystalloids and blood products to restore hemodynamic stability, followed by anatomical reduction of the inversion and prevention of reinversion. 8,10 Nonoperative maneuvers are first attempted to reverse uterine inversions. They include a manual reduction (Johnson's maneuver) or hydrostatic reduction (O'Sullivan method).…”

“…Ziki et al had reported that attempts to deliver the placenta by cord traction might cause an inversion at this early gestation, but our client denied this action. 10 Diagnosis is usually clinical, and most patients (94%) present with significant hemorrhage, with or without shock. During the physical examination, uterine inversion should be suspected on abdominal examination when the fundus is not palpated in the correct anatomical position.…”