Uterine inversion and concomitant perforation following manual removal of placenta

Abstract

A life-threatening puerperal uterine perforation and an acute uterine inversion can both be caused by placenta accreta [1,2], but seldom together.A 22-year-old woman, gravida 2, presented in labor to the emergency unit of the Gynecology and Obstetrics Department at 30 weeks of pregnancy with preterm premature rupture of membranes, breech presentation, thick meconium-stained liqueur, and nonlocalization of fetal heart sounds confirmed by ultrasound. Placenta was fundal, approaching the right lateral wall. A dead fetus weighing 1000 g was delivered but not the placenta. The patient was taken to the operating room for manual removal of the retained placenta (MRP). Under anesthesia, a cleavage was felt toward the lower edge of the placenta and separation was attempted. The placenta was delivered with a fleshy piece of tissue attached, possibly myometrium. The patient immediately went into shock. Per-vaginum examination revealed an acute incomplete inversion of the uterus with suspicion of a big rent. Laparotomy was immediately performed with infusion of blood. After uterine reposition per vaginum via the Johnson maneuver, a 5 cmÂ4 cm fundal perforation was discovered. Subtotal hysterectomy was performed, hemostasis was secured, and the patient was discharged on the 10th day. A histopathologic evaluation revealed placenta accreta.Classically, placenta accreta presents with a retained placenta and hemorrhage and postpartum hysterectomy remains the gold-standard treatment. Why uterine inversion occurs is unclear but strong traction on the umbilical cord with fundal placenta, excessive fundal pressure, relaxed uterus, placenta accreta (fundal), short umbilical cord, congenital weakness, or anomalies of the uterus and antepartum use of magnesium sulphate/ oxytocin are known culprits [1].Uterine inversion and retained placenta can both be fatal. Manual removal of the placenta is a standard practice for retained placenta, and uterine perforation following manual removal is very

A rare case of subacute uterine inversion managed by Haultain's repair

“…3 Factors associated with uterine inversion include short umbilical cord, excessive traction on the umbilical cord, fundal implantation of the placenta, antepartum use of magnesium sulphate, administration of oxytocin, umbilical cord traction with vigorous fundal pressure, especially in cases of a fundal placenta, rapid and long labour, and previous uterine inversion. [4][5][6] It is also more frequent in primipara and in women previously delivered by caesarean section. The diagnosis of the puerperal uterine inversion is mainly clinical.…”

Acute postpartum uterine inversion: report of two cases

“…Factors associated with uterine inversion include pathologic conditions of the uterus, 3,4 fundal implantation of the placenta, 4 antepartum use of magnesium sulphate, 3,5 administration of oxytocin 3 and umbilical cord traction with vigorous fundal pressure, especially in cases of a fundal placenta. [3][4][5] It is also more frequent in primiparas and in women previously delivered by caesarean section. 6 Despite the many conditions associated with uterine inversion, risk assessment is often lacking, making the condition usually unexpected at the time of presentation.…”

“…The surgeon should be instructed to communicate to the anaesthetist immediately before manipulation of the fallopian tubes and if pain is experienced on manipulation of the first tube, both fallopian tubes should be infiltrated with local anaesthetic before proceeding. 3 Acute postpartum uterine inversion: report of two cases Uterine inversion is a rare cause of obstetric shock that poses several problems to the obstetric anaesthesiologist. There is relatively little in the anaesthetic literature about management because of the rarity of the condition.…”

Clinical profile of patients presenting with uterus inversion

“…1 Various risk factors such as mismanagement of third stage of labour, strong traction on the umbilical cord attached to a fundal placenta, morbidly adherent placenta, relaxed uterus, etc., have been implicated. 2,3 Though the incidence of uterine inversion is low, it is a real entity and when it occurs, it requires prompt recognition and management.…”

“…1 Various risk factors such as mismanagement of third stage of labour, strong traction on the umbilical cord attached to a fundal placenta, morbidly adherent placenta, relaxed uterus, etc., have been implicated. 2,3 Though the incidence of uterine inversion is low, it is a real entity and when it occurs, it requires prompt recognition and management. A five-year (2000-2004) retrospective analysis of case records was carried out at the Department of Obstetrics and Gynaecology, Lady Hardinge Medical College and Associated Hospitals, which is a tertiary care centre with an annual delivery rate of approximately 13,500.…”