Case Report
Successful Manual Reposition of Total Uterine Inversion in Post-Partum Patient at Abdulla Mzee Hospital, Tanzania
Fatma S Mohammed, Hidaya A Said, Mohammed O Khamis, Hamid F Hamad, Ali M Abdulla, Rashid S Hemed and Yan Ding*
Corresponding Author: Yan Ding, Department of Obstetrics and Gynecology, The Affiliated Hospital of Yangzhou University, Yangzhou 225001, China.
Received: September 21, 2024; Revised: October 11, 2024; Accepted: October 14, 2024 Available Online: October 25, 2024
Citation: Mohammed FS, Said HA, Khamis MO, Hamad HF, Abdulla AM, et al. (2024) Successful Manual Reposition of Total Uterine Inversion in Post-Partum Patient at Abdulla Mzee Hospital, Tanzania. Int J Med Clin Imaging, 9(1): 639-642.
Copyrights: ©2024 Mohammed FS, Said HA, Khamis MO, Hamad HF, Abdulla AM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Total uterine inversion is an uncommon and possibly life-threatening complication of the third stage of labor that should be treated as soon as possible to avoid maternal morbidity and mortality. Its incidence varies by population, with estimates ranging from one in 2000 to one in 50,000 births. This article recounts a postpartum patient's successful manual reposition of total uterine inversion.

Case presentation: A 21-year-old primigravida was admitted to the labor ward where spontaneous vertex delivery was suspected, unfortunately, her third stage of labor was hampered by shoulder dystocia, and on her successful management, the patient developed uterine inversion. Although under general anesthesia, manual uterine reallocation was succeeded.

Conclusion:
The low prevalence of uterine inversion in our surroundings, particularly in remote regions, has resulted in limited experience in treating this obstetric emergency. The best outcome occurs when uterine inversion is diagnosed early with timely treatment. Nevertheless, the unpredictability of this condition may lead to hysterectomy.

Keywords:
Uterine inversion, Atony, Manual uterine re-position, Shoulder dystocia
INTRODUCTION

Uterine inversion is a rare obstetric emergency after vaginal delivery that, if not treated promptly, can result in severe hemorrhage and shock, with a 15% maternal mortality rate [1]. In extremely rare cases it has also been described during cesarean section [2]. This article discusses a successful manual reposition of Total uterine inversion in a postpartum patient at Abdulla Mzee Hospital in Tanzania.

CASE REPORT

On September 12, 2024, at 03:00 h, a 21-year-old female prime gravida at 42 weeks gestation was admitted to Abdulla Mzee Hospital, complaining of labor pains that had persisted for 5 h. She had good fetal movements and had antenatal profile testing at each of her five prenatal visits. Her blood group was O- Positive, her prenatal hemoglobin level was 10.8%, and HIV and VDRL tests came back negative. She didn't have any noteworthy prior medical or surgical experiences.

Upon assessment, her general condition was fair, not pale, with a BMI of 24.7kg/m2. Fundal height was a term, longitudinal lie, and cephalic presentation. The fetal heart rate appeared to be normal. On vaginal examination, she had a cervical dilatation of 2cm and was admitted to the antenatal ward for observation. On the morning of September 13th, a second evaluation was performed, with a cervical dilatation of 4cm, and all other parameters were normal.

A partograph was initiated, and after 8 h of active labor, she experienced an atypical delivery compounded by a delayed second stage of labor due to shoulder dystocia. This necessitates a mediolateral episiotomy and the early use of the shoulder dystocia maneuver. Under teamwork, a male neonate weighing 3100g was successfully delivered with an Apgar score of 9 in the first minute and 10 in the fifth minute. Five minutes during placenta delivery by managing controlled cord traction, the placenta delivered from fundal placentation and passed through the introits.

Uterine inversion was diagnosed because the placenta and membranes were covering a solid mass that was determined to be the uterine cavity. The patient was bleeding heavily and not responding at that time, along with active vaginal bleeding, the amount of blood lost was not measured. Physical examination results in cold extremities, a prolonged capillary refill, tachycardia of 138 beats per minute, tachypnea of 27 breaths per minute, and hypotension of 78/56 mmHg. Examining the genitalia demonstrated complete uterine inversion along with lacerations around the episiotomy incision. Blood work at that time was performed which revealed anemia (hemoglobin 7g/dL, hematocrit 17.4%, erythrocyte 2.07 million/uL) and leukocytosis (19000/uL). Normal thrombocyte level (358.000/uL) was found.

The patient received fluid resuscitation using colloids and crystalloids, as well as a blood transfusion with discontinuation of the uterotonics drug. We successfully performed manual uterine repositioning under general anesthesia in the operating room, followed by 15 min of internal bimanual compression, however, no excessive hemorrhage was detected after repositioning. Therefore, balloon tamponade was not applied. The patient stabilized, and no surgical intervention was required. After the bleeding had been controlled, an episiotomy was repaired.

Repeated blood workup following the transfusion of 4 packed red cells shows hemoglobin of 9.8 g/dL, hematocrit of 28%, erythrocyte 3.66 million/uL, leucocyte 16.900/uL, and thrombocyte 150.000/uL. The patient's hemodynamics also stabilized and she regained consciousness. Seven days after admission, the patient recovered without difficulties. She was discharged in stable condition with a hemoglobin level of 10 g/dl and informed of the warning indications and the potential need to return to the hospital in the event of reinvasion, vaginal bleeding, or fever (Figure 1).

DISCUSSION

Acute uterine inversion is an uncommon but life-threatening complication of the third stage of labor in which the uterus is partially or turned inside out [3]. It can be classified by degree, with the first degree- The fundus is within the endometrial cavity, second degree - The fundus protrudes through the cervical opening; third degree -The fundus protrudes to or beyond the introitus and the fourth degree - The uterus and vagina are reversed [4].

Acute uterine inversion occurs within 24 h of delivery, subacute occurs more than 24 h but less than 4 weeks after delivery, and chronic occurs more than 1 month after delivery [5]. Ninety-five percent of uterine inversions happen during puerperal; non-puerperal uterine inversions are typically linked to malignancies outside the uterus [6]. As was the situation in our illustration, when uterine inversion occurred within 24 h of delivery and was of the fourth degree.

The precise cause of uterine inversion is still unknown and up for debate, but it can happen naturally or as a result of mismanagement of the third stage of labor with premature traction of the umbilical cord and fundal pressure before placental separation. Fundal placentation, having an abnormal delivery, prolonged labor, and prime para. Additional factors include congenital weakness or uterine malformations; relaxed uterus, lower uterine segment, and cervix; uterine fibroids; placenta accreta, especially at the uterine fundus; and short umbilical cord [6].

The usage of oxytocin and magnesium sulfate during pregnancy has also been suggested by some research as risk factors for uterine inversion, however, they have not yet been confirmed by Science [7]. Above those, our patients had risk factors for prime para, and their protracted second stage of labor because of shoulder dystocia, with fundal placentation. The clinical appearance of uterine inversion varies depending on its severity and timing. Clinically, incomplete uterine inversion can be modest, whereas total inversion is characterized by profuse vaginal bleeding, inability to palpate the fundus abdominally, and maternal hemodynamic instability. Primarily neurogenic shock is also severe due to nerve tension caused by stretching of the infudibulopelvic ligament and pressure on the ovaries when the fundus moves through the cervical ring [4]. The patient presents with abrupt lower abdomen pain that may or may not be accompanied by a bearing down sensation, supporting the primary clinical diagnosis. The uterine fundus may have a palpable depression or it may not exist at all. Upon vaginal examination, it is typically palpable and/or visible as a dark-reddish-blue bleeding mass at the cervix, vagina, or introitus. As we saw in our case, the medical staff performed admirably and contributed to the mother and infant's survival during delivery. Uterine inversion was diagnosed without the need for ultrasonography confirmation, which is helpful in cases where the clinical examination raises doubts but cannot provide a clear diagnosis. However, Ultrasonography images show signs such as target sign and recognizing an endometrial pseudo strip [8]. The major objective of treatment is to restore maternal hemodynamic stability and prevent fatal outcomes by controlling hemorrhage and doing fluid resuscitation. The goal of first care must be to promptly reverse the uterus as we applied in our reported case (Figure 1). The Johnson maneuver, which accomplished by placing a hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus. The sooner this operation is performed, the less blood loss will occur and the greater the likelihood of resolution; the longer the interval between the inversion and the procedure, the lower the success rate will be. This lower success rate is brought on by the cervix's involution, which creates a stiff ring that makes it challenging to realign the uterus to its natural position [9].

In addition, utero-relaxant medication and oxytocin infusion suspension are examples of therapeutic interventions. Due to their accessibility and regular use, magnesium sulfate, terbutaline, and salbutamol are the most often recommended medications. Magnesium sulfate takes approximately ten minutes to become effective, whereas terbutaline takes about two minutes. Nitroglycerin (50-500 µg) has been shown by certain writers to produce positive results for cervical ring relaxation. Because halothane, isoflurane, desflurane, and sevoflurane are good tocolytics, in general anesthesia these drugs may be administered when tocolytic medicines are unable to produce uterine relaxation. This is particularly useful in patients with hemodynamic instability due to its fewer effects on hemodynamics as we did in our case Furthermore, hydrostatic reduction can be employed to induce reduction by infusing heated fluid into the vagina under pressure. Other studies describe the use of intravaginal balloons to raise pressure on the uterine fundus and force it back to its original location. Some authors have described it as an alternative when manual reduction fails and surgical intervention is not required [10]. The use of an obstetric suction has also been shown to reverse the uterine fundus. It is imperative to carry out a surgical intervention when conservative therapy is unsuccessful. The literature now in publication describes several procedures, the most frequently reported being laparoscopic, Huntington, Halutzim, and Spinelli. [9] Due to the low occurrence of uterine inversion, no cohort studies large enough to determine the success rate of these procedures have been conducted too far. To avoid a recurrence, uterotonic medicines (oxytocin or misoprostol) must be administered following uterine relocation. A broad-spectrum antibiotic prescription is also indicated to avoid endometritis and sepsis [11] as we did in our instance. Bad enough, prompt management of uterine inversion usually mitigates long-term sequelae. It is unknown whether the condition affects future pregnancy prospects, but case reports exist of uncomplicated pregnancies. However, Women who have experienced uterine inversion need to be counseled that they run the risk of recurrence in subsequent pregnancies [12], therefore, care should be paid during labor monitoring for optimal results.

CONCLUSION

Puerperal uterine inversion is a rare but possibly fatal condition after vaginal birth. A potentially fatal complication that can be avoided by actively and carefully managing the third stage of labor and avoiding cord traction before the appearance of placental separation and fundal pressure. Quick treatment with either non-surgical or surgical procedures can prevent maternal death and other problems.

PATIENT’S PERSPECTIVE

The care provided was timely with a full explanation of the diagnosis and prognosis and a follow-up plan explained.

ACKNOWLEDGMENTS

We are humbly grateful for the support and encouragement given by the Obstetrics/gynecology, pediatric, and anesthetic departments at Abdulla Mzee Hospital.

TIMELINE

The patient was consulted in our hospital and management was initiated. The intervention was done, and the patient was admitted for 1 week. Preparation and completion of the case took one month.

AUTHOR’S CONTRIBUTION

Coauthors contributed to the management of the patient and the writing of the case report. All authors read and approved the final manuscript.

FUNDING

The cost of preparing this manuscript was covered by the Authors.

ETHICAL APPROVAL AND CONSENT TO PARTICIPATE

Written informed consent was obtained from the patient for publication of this case report.

CONSENT FOR PUBLICATION

Written informed consent was obtained from the patient for publication of this case and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. A copy of the clearance document is also available for review by the Editor-in-Chief of this journal.

COMPETING INTERESTS

The authors declare that they have no competing interests.

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