Uterine inversion in retained placenta,that’s why a good management of third stage of labor matters: A case report

Abstract

Uterine inversion is characterized by the folding of the fundus into the uterine cavity. While infrequent, it ranks among the most serious complications of childbirth, posing a significant risk of mortality primarily due to hemorrhage and shock. Retained placenta after vaginal delivery is diagnosed when placenta does not spontaneously deliver within 18–60 min. Manual placenta can be considered first if retained placenta occurs. A 29-year-old woman with parity status P2A0 came to maternal emergency referred from the first health care provider with severe post-partum hemorrhage after delivering her second living 3100 g baby 2 h before admission. The midwife reported that the placenta was hard to have. There was a resistance felt inside when she tried to do umbilical cord traction. The manual placenta was not done. After several trials, the placenta finally came out, followed by fundus of uterine. Acute hemorrhage occurred, causing a decrease of hemoglobin level to 7.8 g/dl. At maternal emergency, the placenta delivered spontaneously yet the fundus still inverted. Fast reposition of uterine done by doctor on duty to stop the hemorrhage. Following successful repositioning and 4 days of observation, the patient was discharged from the hospital with no signs of hemorrhage and favorable results on abdominal ultrasonography.

Introduction

Uterine inversion is a rare but life-threatening obstetric emergency. ¹ Although it does not often occur, it is one of the most severe complications of childbirth and carries a high risk of mortality due to hemorrhage and shock. The incidence varies considerably and can range from 1 case in 2000 to 1 case in every 50,000 birth.^1,2 This postpartum complication holds academic significance owing to its rare occurrence and severity. However, its low incidence makes obstetricians experience regarding this condition is scarce. ³ The cause of acute uterine inversion remains elusive. ³ It is usually reported as miss management of the third stage of labor, with premature traction on the umbilical cord and or fundal pressure before placenta has separated. ⁴ Other factors include relaxed uterus, lower uterine segment and cervix, uterine fibroid, placenta accrete, particularly at the uterine fundus, excessive fundal pressure, short umbilical cord, congenital weakness, or uterine anomalies. ³ Some studies have also hypothesized antepartum use of magnesium sulfate and oxytocin as a risk factor for uterine inversion; however, they are yet to be proven scientifically.^1–4 Though a physical examination of uterine inversion typically reveals a mass-like uterine fundus in the vagina, the diagnosis of uterine inversion is often difficult due to massive postpartum hemorrhage. ⁵ There are several therapeutic strategies describe in the literature including drugs, manual maneuvers called Johnson’s Maneuver and surgical intervention.^1,3,6,7

Case presentation

A 29-year-old woman with parity status P2A0 came to maternal emergency referred from the first health care provider with severe post-partum hemorrhage after delivering her second living 3100 g baby 2 h before admission. The midwife reported that the placenta was hard to have. There was a resistance felt inside when she tried to do umbilical cord traction. The manual placenta was not performed. After several trials, the placenta finally came out, followed by the fundus of uterine. An acute hemorrhage occurred. One ampule of oxytocin was administered, then the midwife referred the patient soon. At the maternal emergency, the hemorrhage persisted, with the patient remaining awake, having a Glasgow Coma Scale score of 15, blood pressure of 60/palpation, heart rate of 150 beats per minute, respiratory rate of 28 times per minute, body temperature of 36.6°C, and oxygen saturation of 99%. Fundal height was undetectable. Fluid resuscitation and control of hemorrhage was done. Dual intravenous lines were applied, one ringer lactate and colloid fluid administered. Methylergometrine intravenous and misoprostol 600 mg per rectal administered to control the hemorrhage. Massive hemorrhage causing shock and a decrease of hemoglobin level to 7.8 g/dl. At maternal emergency, the placenta delivered spontaneously yet the fundus still inverted. Manuals reposition of uterine was done by doctor on duty to stop the hemorrhage. After a successful reposition, the patient was observed for 2 h at emergency room. The vital signs showed improvement, with blood pressure rising to 100/70 mmHg, heart rate at 93 beats per minute, respiratory rate at 24 breaths per minute, temperature at 36.4°C, and oxygen saturation at 99%. The uterine fundus palpated around 1 cm below the umbilicus with a good contraction. There is also no subsequent inversion. Then, the patient was hospitalized and monitored for 4 days. Following this, the patient was discharged from the hospital with no signs of hemorrhage and favorable results on abdominal ultrasonography.

From her early pregnancy ultrasonography results, there is no sign of angular pregnancy, and the placenta was placed in a favorable position. In Figure 1, her first trimester ultrasonography revealed a single fetus intrauterine, equal as gestational age of 13 weeks and 3 days. And from the ultrasound result in her second trimester (Figure 2), showed the placenta is inserted at the fundus and extends into the corpus. The abdominal ultrasound post uterine reposition revealed uterine anteflexion, with endometrial line (+) and free fluid (−) (Figure 3). A follow-up for the patient’s condition was carried out 1 week after discharge in outpatient setting. The patient appeared without complaints and hemodynamically stable. The uterine fundus was no longer palpated, which demonstrated a good involution process.

Figure 1.

Patient’s first trimester abdominal ultrasound result. Single live intrauterine fetus. Crown-rump length measures 7.35 cm, consistent with a gestational age of 13 weeks and 3 days. Fetal heart rate is 162 beats per minute.

Figure 2.

Patient’s second trimester abdominal ultrasound result. Single live intrauterine fetus; exhibiting mobility. Biometric measurements correspond to a gestational age of 22 weeks and 2 days. Estimated fetal weight is 504 g. Fetal heart rate measures 158 beats per minute. The placenta is inserted at the fundus and extends into the corpus. Adequate amniotic fluid volume. Symphysis-fundal height measures 4.84 cm.

Figure 3.

Patient’s abdominal ultrasound picture obtained post manual reposition. Nongravid uterus with homogenous density and anteflexed position, measuring 14.14 × 7.89 × 11.14 cm. Endometrial lining (+).

Discussion

Uterine inversion is characterized by the inversion of the uterus, wherein the uterine fundus protrudes through the endometrial cavity and cervix, effectively turning the uterus inside out. While uncommon, this phenomenon can occur in two distinct clinical scenarios: during the postpartum period and spontaneously. Non-puerperal uterine inversion accounts for 5% of all uterine inversions. ¹ There are 4° of uterine inversion and can be classified into incomplete and complete uterine inversion. Based on timing, uterine inversion can be classified as acute (within 24 h after delivery), subacute (more than 24 h but less than 4 weeks after delivery), or chronic (more than 4 weeks after delivery). ² The etiology of the uterine inversion remains elusive and unexplained, generally associated with excessive cord traction in the third stage of labor.^1,3

In this case, it was reported that the placenta was hard to have and there was a resistance felt inside when she tried to do umbilical cord traction. The manual placenta was not performed. However, after several trials, the placenta finally came out, followed by the fundus of uterine. This underscores that the excessive umbilical cord traction to remove a retained placenta was the underlying cause of the uterine inversion. Retained placenta after vaginal delivery is diagnosed when placenta does not spontaneously deliver within 18–60 min. A retained placenta may arise due to substantial uterine atony, an abnormally adherent placenta such as in placenta accreta spectrum, or premature closure of the cervix before placental expulsion.^8,9 Angular pregnancy, that is associated with retained placenta due to ineffective contractile of retroplacental myometrial wall during the third stage of labor has been excluded from the early pregnancy in this patient. ¹⁰ The management of retained placenta involves manual placenta, as shown in Figure 4, under sufficient pain relief, as solely relying on medical interventions has not demonstrated efficacy. After placental removal, uterotonic medications, such as oxytocin, methylergonovine, carboprost, or alternative prostaglandins, should be given to enhance contraction. If attempts to remove the placenta are ineffective or only partly successful (i.e., if parts of the placenta persist in the uterus), or if bleeding persists despite placental delivery, surgical intervention with curettage is often the subsequent course of action.^8,9

Figure 4.

The procedures of manual placenta. ⁹

The incidence of uterine inversion underscores the importance of conducting a proper third stage of labor, as it is recommended to limit postpartum hemorrhages, including those resulting from uterine inversion. In fact, the occurrence of uterine inversion has decreased four-fold following the introduction of active management during the third stage of labor. Controlled cord traction, a critical element of active management of the third stage of labor, along with early cord clamping and prompt administration of prophylactic uterotonics, plays a significant role in averting such events.^11,12 By implementing this measure, it is anticipated that the morbidity resulting from excessive bleeding such as hypovolemic shock after delivery would be significantly reduced.

The diagnosis of uterine inversion is made clinically, typically involves observing the fundus protruding beyond the vaginal introitus in complete cases or palpating the fundus through the external ostium, which is the most common sign. Nevertheless, the diagnosis is often suspected in the presence of massive blood loss after childbirth or in the absence of the uterine fundus during abdominal palpation, hypotension, and tachycardia may supervene and evolve into hypovolemic shock. ¹ In this case, the diagnosis was established through the absence of uterine fundus upon abdominal palpation, the presence of postpartum hemorrhage leading to hypovolemic shock, and the identification of a protruding vaginal mass. Unfortunately, clinical documentation of this case was not obtained due to the emergency condition.

Uterine inversion is an emergency. Its management comprises two crucial aspects: promptly addressing hemorrhagic shock and restoring the position of the uterus. If such emergency occurred in any healthcare facility, this sequence of care must be implemented urgently and simultaneously (Figure 5). ¹²

Figure 5.

Sequence of recommendation to manage uterine inversion in healthcare facilities.

Resuscitation should start immediately while attempts are made to replace the uterus manually. ¹³ Uterus reversal can be performed called Johnson’s maneuver wherein manual pressure is applied on the fundus through the cervix in the direction of the long axis of vagina using palm of the hand.^3,6,12 This procedure should be performed promptly to minimize blood loss and enhance the likelihood of successful resolution, as delaying the maneuver reduces the success rate. This reduction of success rate is due to the involution of the cervix, which induces a rigid ring that makes restoration of normal uterus position difficult. ³ Tocolytic agents such as Terbutaline, magnesium sulfate, and nitroglycerin can be used to relax this constriction ring, thus enabling uterine reversion. However, their administration requires caution due to the potential risk of triggering hemorrhage. ¹²

If conservative management fails, alternative intervention such as hydrostatic reduction or surgical correction can be performed. The O’Sullivan hydrostatic replacement can be performed by introducing sterile warm saline into the vagina. Then, the clinician employs their hand or a silicone ventouse cup as a barrier to hold the fluid in place, creating intravaginal hydrostatic pressure, which helps correct the inversion. This method not only aids in preventing blood loss but also discourages reinversion of the uterus. Surgical options include Huntington and Haultin procedures, laparoscopic-assisted repositioning, and cervical incision with manual uterine repositioning. ¹² Successful uterine reposition should be monitored intravaginally for subsequent inversion. Then, any tocolytics should be stopped, and simultaneously oxytocin or other uterotonics is started to contract the uterus, thus stopping the hemorrhage. In case the hemorrhage was unresponsive to uterotonics, alternative methods should be carried out, such as performing bimanual uterine compression, uterine packing, or balloon tamponade to stop massive bleeding. Failures for all these require various surgical methods including hysterectomy. ¹⁴ In this case, both fluid resuscitation and control of hemorrhage through drug administration and manual uterine repositioning was done. Both interventions were executed successfully, resulting in the cessation of significant hemorrhaging and improvement in the patient’s vital signs. After observation, the patient’s condition remained stable, and the uterine contraction was good. Therefore, there is no need to perform any alternative methods such as hydrostatic replacement or surgical intervention.

Conclusion

Mismanagement of the third stage of labor poses a life-threatening risk. Successful management hinges on timely recognition, which should involve resuscitating maternal hypovolemic shock and repositioning the inverted uterine fundus.