In this CritCases blog – a collaboration between STARS Air Ambulance Service , Mike Betzner and EM Cases, Dr. James Brokenshire presents a case of acute unstable Uterine Inversion and discusses key therapeutic maneuvers including the Johnson Maneuver, tocolytics and resuscitation of postpartum hemorrhage.

The Case:

You are asked to review a 28 year-old female in Janus General, a remote community hospital, for possible emergency transport. She has just delivered her fourth child by spontaneous vaginal delivery and is hemorrhaging post delivery. The Family Physician attending the delivery tells you that the bleeding picked up after a difficult attempt at removal of the placenta.

There is no obvious vaginal tear. He suspects a uterine inversion secondary to a difficult placenta removal, as there is a large palpable mass at the vaginal introitus. The hospital in question has anaesthesia backup, but no obstetrics. The local blood bank has 2 units of red cells. Past medical history is unremarkable.

Initial vital signs are: T = 37.3, HR = 121, BP = 80/42, RR = 27, SpO2 = 98% on NRB.

What is Uterine Inversion?

Acute Uterine Inversion is rare and scary complication of childbirth, which occurs when the uterine fundus is pulled inferiorly into the uterine cavity. The fundus may be present in the uterine cavity (incomplete), through the cervical os, at or through the vaginal introitus, as in this case. Most women present with abdominal pain, postpartum hemorrhage, a visible vaginal mass or palpable mass at bimanual exam. Point of care ultrasound can help to clarify the diagnosis of incomplete uterine inversion, revealing an abnormal fundal contour and uterine cavity mass.

What initial advice would you provide to the attending MD to manage this patient with uterine inversion?

I’m going on this flight. Grabbing 4 units red cells and 2 units pre-thawed plasma. -Rob Hall MD, FRCPC

Tell the local doc to stop oxytocin if it’s running. Walk her through manual maneuvers to reduce the uterus. -Paul Tourigny MD, FRCPC

If all else is failing, simply asking them to hold steady pressure on the uterus with a clenched fist in the vagina and fundal pressure from above, might be all they can reasonably do until you get there to take over +/- trying the Linton tube (or Bakeri Balloon (which they may or may not have) which is designed for endometrial tamponade. -Mike Betzner MD, FRCPC

In this patient, as in most patients with uterine inversion, shock out of proportion to apparent blood loss may occur as a result of unrecognized bleeding and/or increased vagal tone. Hence, focus your initial management on hemodynamic resuscitation and reduction of the inversion.

1) Give IV crystalloid boluses via rapid infuser (or pressure bags if rapid infuser is not available) followed by blood products as soon as available. Consider early activation of a massive transfusion protocol.

2) Do not remove the placenta as this is thought to precipitate further bleeding.

3) Stop all uterotonic medications (eg. oxytocin) to facilitate reduction.

Pitfall: Given that uterine atony is the most common cause of post partum hemorrhage and responds to oxytocin, continuation of oxytocin is a common pitfall in the management of uterine inversion. It is critical to recognize uterine inversion and stop all uterotonic medications to facilitate reduction. Otherwise, the patient will continue to hemorrhage.

4) Immediate manual reduction of the uterus by performing a Johnson Maneuver, whereby the uterine fundus is pushed through the cervical ring toward the umbilicus. An important challenge that you might be faced with during manual reduction of a uterine inversion is a cervical constriction ring. It can form as the cervix and lower uterine segment contract during uterine inversion. If a constriction ring is palpable, the tissue nearest this ring should be reduced first.

Penny Wilson (@nomadicgp) on Twitter suggested – “If you can replace it immediately – do so, but use side of hand / fist rather than fingers to avoid perforating.”

Case Continued

Your initial reduction attempt fails. The patient continues to bleed. Her heart rate is now 142 and BP is 70/38. Considering the lack of backup in Janus General, you make the decision to transport the patient to a tertiary care obstetrical centre.

In the interim, what are your immediate next steps for this patient with uterine inversion?

This patient needs blood products. Consider activation of your massive transfusion protocol if available. This hospital does not have a massive transfusion protocol so start giving red cells and plasma if available. Also consider a tranexamic acid bolus of 1g followed by a 1 g infusion over 8 hours.

If they can’t replace it, have them start nitroglycerin starting at 50 ug/min as a uterine relaxant and re-attempt reduction. If that doesn’t work, start 4 g MgSO4 over 20 min. Hopefully we’re there by that time. Make sure they don’t remove the placenta. -Paul Tourigny MD, FRCPC

Pitfall: Removal of the placenta prior to reduction of the uterine inversion may lead to increased hemorrhage and shock. It is imperative to delay removal of the placenta until the uterus has been definitively reduced.

Myometrial relaxation (tocolysis) may be used to facilitate reduction. However, hypotension is a common side effect of most tocolytics, which presents a significant dilemma in the unstable patient. The following are options to consider:

Magnesium sulfate 4-6g IV is often available on obstetrical floors, and has been suggested for tocolysis in the setting of Uterine Inversion. It is a weak tocolytic, however it has been suggested that this medication also relaxes a cervical constriction ring, which forms with prolonged uterine inversion and can thwart attempts at uterine reduction. The major disadvantage of magnesium sulfate is the hemodynamic effects of this treatment, and its long duration. After reduction, its effects may need to be reversed with oxytocin to obtain hemostasis.

Intravenous nitroglycerin in low doses (50-100mcg IVP/dose) has good tocolytic effects, and has been used in case reports for treatment of Uterine Inversion. Advantages are quick onset (~30sec), relatively quick duration (~1 min), and less hemodynamic effects as compared with magnesium sulfate. The decision to administer nitro to a patient in shock should be considered carefully.

Case Continued

You give IV nitroglycerin but manual reduction still fails, and you decide to accompany her for transport to a tertiary care obstetrical facility. She remains hemodynamically unstable.

After failed manual reduction of this uterine inversion and continued hymodynamic instability, what is your next move?

Blood products (red cells and plasma) are likely necessary for transport. It will be important to obtain blood labs on arrival to assess for coagulation status: CBC, Type and Cross, INR, PTT, fibrinogen levels.

The volatile anesthetics are smooth muscle relaxants and are very potent tocolytics, directly acting on uterine smooth muscle. Steady pressure with a fist on a relaxed patient (i.e. not screaming from the pain of what you are trying to do) whose uterus relaxes and gets re-inverted. Nitro can be used to relax the uterus but her BP will drop through the floor. You also need her not fighting you. So a general anesthetic, intubation and a volatile anesthetic. Then reduce the inversion. – Saul Pytka MD, FRCPC

Anand Swaminathan (@EMSwami) suggested on Twitter that tranexamic acid may be a consideration the patient with uterine inversion and hemorrhagic shock and that it is currently under investigation for postpartum hemorrhage in the WOMAN study

Surgical Reduction of Uterine Inversion

Reduction of uterine inversion can be successfully be achieved under general anaesthesia. Current volatile anaesthetics (Isoflurane, Desflurane, Sevoflurane) are excellent tocolytics. They also provide good conditions to facilitate this painful procedure. Notify Anaesthesia and Obstetrics early to facilitate OR availability. Failing relaxed manual reduction, surgical procedures can be performed (Huntington and Haultain procedures) to achieve reduction.

Uterotonic Medications are important if reduction is obtained, as uterine atony is common after reduction. Oxytocin +/- Hemabate, and Methergine are possibilities. Antibiotic coverage to prevent endometritis is also important.

Intubation is likely best delayed and accomplished in the OR, though balance of risk will need to be evaluated throughout transport.

Case Resolution

Your patient receives two units of red cells prior to transfer and additional 2 units en route. She is immediately brought to the OR and is given a volatile anesthetic. Reduction is successfully obtained using the Johnson Maneuver. Tocolytics are stopped and oxytocin is restarted following reduction to prevent recurrence.

Take-Home Points for Uterine Inversion

Acute Uterine Inversion typically presents with postpartum hemorrhage, shock, abdominal pain, a non-palpable uterine fundus, and a mass on bimanual exam.

Goals of care include management of hemodynamic instability, reduction of the inversion and prevention of recurrence using uterotonic medications.

Attempt manual reduction facilitated by tocolytic medications. Low dose IV nitroglycerin or volatile anaesthetics are probably most appropriate.

Placenta management is best left until after reduction has been confirmed.

Uterine inversion requires prompt management, with early Obstetrics consultation – in this case by timely transport.

Dr. Brokenshire, Dr. Misch, Dr. Thomas and Dr. Helman have no conflicts of interest to declare.

Expert Peer Review by Dr. Jacqueline Thomas, Obstetrician-Gynecologist Mt. Sinai Hospital, University of Toronto

Although every medical student is taught to apply suprapubic pressure when delivering the placenta to prevent uterine inversion, very few of us who practice obstetrics have ever seen this rare and serious complication.

The key to management is prompt diagnosis and replacement of the uterus with correction of hemodynamic instability. This is more difficult than it sounds.

The picture in this narrative demonstrates a full inversion of the uterus. It may confuse the clinician as the placenta is still attached and has become edematous.

The best chance at replacement of the uterus is in the immediate period following the inversion. As time goes on the uterus gets more swollen as venous return is prevented.

It is unclear if this patient has an epidural, as some sort of pain management will be necessary for the manipulation required to replace the uterus. As mentioned, volatile anaesthetics will relax the patient and the uterus thereby facilitating uterine replacement. The anaesthesiologist can also administer nitroglycerine to relax the uterus. Although 50 mcg of nitroglycerin is mentioned in the scant literature on this topic, many of my anaesthesia colleagues feel that this dose is insufficient to relax the uterus and doses up to 200 mcg may be necessary. With these options available, I do not think that the administration of magnesium sulfate is viable due to its delay to uterine relaxation.

If the above steps cannot be performed in the rural hospital it is reasonable to transport the patient. It is vital to stabilize the patient with whatever blood products available prior to transport.

References

Hsieh TT, Lee JD. Sonographic findings in acute puerperal uterine inversion. J Clin Ultrasound. 1991; 19:306.

Beringer RM, Patteril M. Puerperal uterine inversion and shock. British Journal of

Anaesthesia. 2004;92(3):439-41.

Johnson A new concept in the replacement of the inverted uterus and a report of nine cases. Am J Obstet Gynecol. 1949 Mar;57(3):557-62.

Hostetler DR, Bosworth MF. Uterine inversion: a life-threatening obstetric emergency. J Am Board Fam Pract. 2000 Mar-Apr;13(2):120-3.

Dayan SS, Schwalbe SS. The use of small-dose intravenous nitroglycerin in a case of uterine inversion. Anesth Analg. 1996 May;82(5):1091-3.

Momani AW, Hassan A. Treatment of puerperal uterine inversion by the hydrostatic method; reports of five cases. Eur J Obstet Gynecol Reprod Biol. 1989 Sep;32(3):281-5.

Ida A, Ito K, Kubota Y, Nosaka M, Kato H, Tsuji Y. Successful reduction of acute puerperal uterine inversion with the use of a Bakri postpartum balloon. Case Rep Obstet Gynecol. 2015;2015:424891. Epub 2015 Apr 12.

Yoo KY, Lee JC, Yoon MH. The effects of volatile anesthetics on spontaneous contractility of isolated human pregnant uterine muscle: a comparison among sevoflurane, desflurane, isoflurane, and halothane. Anesth Analg. 2006; 103:443.

Other FOAMed Resources on Uterine Inversion and Postpartum Hemorrhage

Justin Morgenstern on Postpartum hemorhage on First10EM

CoreEM on Postpartum hemorrhage