Definition

Uterine inversion is a condition where the top of the uterus (fundus) folds inward, causing some or all of the inside of the uterus to be outside the body. This condition is one of the most serious complications that can occur during childbirth, occurring in 1 out of every 2,000 to 23,000 deliveries. Although rare, uterine inversion can cause severe bleeding and a reduction in blood flow to other organs (shock), which can be life-threatening for the mother.

There are four degrees of uterine inversion, depending on how much of the uterus is inverted:

• First degree (incomplete): The top of the uterus collapses and starts folding into the uterine cavity.
• Second degree (complete): The uterine fundus folds and enters the cervix, like a sock being turned inside out.
• Third degree (prolapse): The uterine fundus enters the deepest part of the vaginal canal.
• Fourth degree (total): The uterus and vagina protrude outside the body.

Most cases of uterine inversion fall into the second and third-degree categories. This condition most commonly occurs within the first 24 hours after childbirth (acute uterine inversion). In other cases, uterine inversion occurs within one month of delivery (subacute uterine inversion) and after one month (chronic uterine inversion).

Shock is an emergency condition that could threaten life. If you want to find out more, you can read it here: Shock (Shock) - Definition, Cause, and Risk Factor.

Causes

The exact cause of uterine inversion is not known. One well-known theory suggests that the uterus can fold inward if the healthcare provider assisting in childbirth pulls too hard on the umbilical cord while trying to deliver the placenta. However, this is not the fault of the assisting provider but rather one of the complications that can occur during childbirth.

During childbirth, the provider will gently pull the umbilical cord to help deliver the placenta while massaging the top of the uterus. In some people, this process is believed to be more likely to cause uterine inversion if:

• The placenta is attached to the top of the uterus, so when stretched, it pulls the top of the uterus outward.
• The uterus does not contract after delivery (uterine atony). Normally, the uterus will contract and feel firm after the baby is born to expel the placenta and shrink blood vessels to limit bleeding.

However, this theory is hard to prove because uterine inversion can occur without these two factors. In rare cases, uterine inversion can also happen to mothers who undergo a cesarean section.

Risk Factor

The following are risk factors believed to be associated with uterine inversion:

• Short umbilical cord
• Prolonged labor (lasting over 24 hours)
• Use of medications that relax the uterus during labor
• First delivery
• A baby with above-average weight (macrosomia)
• Having a weak uterus or other uterine abnormalities
• Retained placenta (if all the placental tissue does not come out within 30 minutes after the baby is born)
• Severe preeclampsia, a serious condition characterized by elevated blood pressure and the presence of protein in the urine
• Placenta accreta, a condition where the placenta embeds deeply into the uterine wall, making it difficult to separate during delivery
• A history of uterine inversion in a previous delivery
• Placenta located at the top of the uterus

We also have preeclampsia articles that you can read here: Preeclamsia - Definition, Cause And Risk Factors.

Symptoms

Uterine inversion can cause heavy bleeding, which can lead to shock—a dangerous reduction in blood flow to the body's organs. Symptoms vary depending on the severity of the uterine inversion and may include:

• Vaginal bleeding, which can range from light to heavy.
• Heavy bleeding can cause a significant drop in blood pressure.
• Severe lower abdominal pain, which can be felt along with a sensation of downward pressure.
• A round, smooth mass protruding from the vagina.

When shock occurs, the mother may experience the following symptoms:

• Dizziness or feeling faint
• Weakness
• Thirst and dry mouth
• Muscle cramps
• Decreased consciousness
• Rapid breathing
• Cold, clammy skin
• Low blood pressure

Diagnosis

The diagnosis of uterine inversion is primarily made based on the clinical condition of the patient. Diagnosis is made quickly so that life-saving measures for the mother can be taken. In most cases, a diagnosis can be made if there is postpartum bleeding and the presence of a large, round, dark red mass protruding from the vagina. This protrusion may occur during or immediately after the placenta is delivered. In 60–70% of cases, the placenta is still attached to the uterus when uterine inversion occurs.

The doctor will also assess the mother's physical condition by measuring vital signs, such as blood pressure and respiratory rate, to identify signs of shock. The doctor may perform a physical examination by palpating the abdomen or performing an ultrasound (USG) to assess the mother's uterus. If the top of the uterus is not palpable or not visible on ultrasound, this may indicate uterine inversion.

In cases of uterine inversion that occur one month postpartum, making a diagnosis based on clinical signs and symptoms alone can be challenging. These cases are rare and can occur up to 14 weeks postpartum. Symptoms may include persistent vaginal bleeding, elevated body temperature, weakness, and lower back pain. A definitive diagnosis requires an ultrasound.

Management

Uterine inversion that occurs during childbirth is a medical emergency and must be addressed immediately. Fluid administration (and blood transfusion, if necessary) should be done immediately to stabilize the mother's bodily functions.

Manual Repositioning Procedure

The inverted uterus is returned to its normal position through a manual repositioning technique. This is performed by a healthcare professional who uses their hands to push the uterus back into place. This procedure must be done promptly because delaying it can make repositioning more difficult and increase bleeding.

If the placenta is still attached to the uterus, manual repositioning is typically not performed until intravenous fluids are given and medications that relax the uterine muscles are administered, such as nitroglycerin or inhaled general anesthetics. The doctor may also perform this procedure in an operating room. Antibiotics will be administered to prevent infection. If manual repositioning fails, surgery and hydrostatic reduction may be performed.

Hydrostatic Repositioning

Hydrostatic repositioning is a new technique that uses a fluid-filled balloon. The balloon is placed in the uterine cavity and filled with saline to push the uterus back into its normal position.

Surgical Procedure

Surgery can be performed through the vagina or by making an incision in the abdominal area. The uterus is repositioned by pulling the ligaments that normally hold the uterus in the abdominal cavity. This is done repeatedly until the uterus is back in its normal position.

Complications        

Complications can arise from the uterine inversion itself (primary complications) or as a result of its management (secondary complications).

Primary complications of uterine inversion occur due to the bleeding it causes and include damage to various organs, shock, and even death. If left untreated, bleeding will continue, and the mother's tissues may undergo necrosis (tissue death). Death may also occur if the condition is not promptly managed.

Secondary complications arising from treatment include infection, procedural failure, and saline embolism.

Prevention

Although uterine inversion cannot be avoided, it can be successfully treated if the medical professional treating you takes prompt action.

When to See a Doctor?

The person assisting with your delivery should take you to a hospital right away if they notice any signs of uterine inversion if you are giving birth other than in a hospital.

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