Trauma, uterine inversion & uterine rupture Flashcards
(18 cards)
What is uterine inversion?
the folding of the fundus into the uterine cavity in varying degrees
What is the pathophysiology and usual cause of uterine inversion?
- uterine atony
- soft dilated cervix
- fundal pressure or cord traction
- usually due to mismanagement of third stage beginning before uterus has contracted firmly and placental separation has occured
What are the three classifications of uterine inversion?
1st degree/incomplete: fundus protrudes through cervical os
2nd degree/complete: fundus descends into the vaginal introitus
3rd degree/prolapsed: extends beyond the vulva
What are some factors associated with a higher risk of uterine inversion?
- short umbilical cord
- multiparity
- abnormally adherant placenta
- fundal implantation
- VBAC
- fetal macrosomia
- antenatal use of MgSO4
- precipitate labour
- sudden increase in abdominal pressure (e.g. coughing)
What are the signs/symptoms of uterine inversion?
- severe abdominal pain
- shock
- haemorrhage
- unable to palpate fundus
- if palpable fundus may feel indented, globular or irregular
- pelvic examination reveals mass in vagina
- uterus visible at vulva
What is the procedure for manual replacement of an inverted uterus?
- call for assistance (CODE)
- tocolytics if needed (turbutaline or GTN) prior to replacement
- do not attempt to remove placenta
- immediately attempt manual replacement- sterile gloves, grasp uterus with palm and gently push back through cervix towards umbilicus, supporting with opposite hand on abdomen
- give oxytocic and keep hand in uterus until firm contraction is felt
- reinversion may occur
What are the 2 main priorities of management of uterine inversion?
- immediate replacement of uterus
- simultaneous maternal resuscitation
What are the main priorities of maternal resuscitation in managment of inverted uterus?
- call for assistance (CODE)
- lower bed to flat
- commence monitoring immediately (BP, P, RR, SO2)
- assess for signs of shock (cool, clammy, pale, tachycardic, hypotension)
- administer oxygen
- 2x 16G IV cannulae
- take blood (FBR, group & hold, crossmatch at least 4 units blood, coagulation profile)
- Fluid bolus, preferably with pressure infusion device e.g. normal saline, hartmann’s , gelafusine
- IDC, monitor output
- strong analgesia
- administer oxytocic if uterus successfully replaced and placenta born
- may need to transfer to theatre for manual removal of placenta
- administer prophylactic antibiotics ( cephazolin and metronidazole)
- otherwise resucitate and transfer to theatre
What other techniques may be used if first attempt at manual replacement is unsuccessful?
- O’sullivan technique - hydrostatic pressure, warm saline rapidly instilled into the vagina, distends cavity and forces fundus back up, several litres may be required
- surgical correction PV or via laparotomy
What is chronic inversion?
- inversion as late as 14/52 postpartum
- unusual, not well understood
- symptoms include PV bleeding, back pain, pelvic pressure, malaise, low grade fever
- diagnosed on USS
What are the main causes of trauma in pregnancy?
- car accidents
- domestic violence
- falls
What are the major risks associated with trauma in pregnancy?
- preterm labour
- placental abruption
- fetal-maternal haemorrhage
- pregnancy loss
- rupture of uterus/bladder
- acute shock
What is the correct way to wear a seatbelt in pregnancy?
- one strap as low as possible under the abdomen, other between breasts
Why are pregnant women particularly at risk for falls?
- changes in center of gravity
- changes in gait
- visual changes, can’t see feet
What are the priorities when managing trauma in pregnancy?
- diagnosis of damage (Xray, CT)
- resuscitation (continuous monitoring of maternal vital signs and fetus)
- IV access and fluid replacement
- take bloods (FBC, crossmatch, group & save, LFTs, coagulation studies, platelets, FDPS for DIC risk and Kleihauer)
- position woman left lateral
- administer oxygen (O2 sats to >90%)
- cathetre
- reassurance and followup CTG/USS
- postmortem or perimortem CS (up to 20 minutes)
What is uterine rupture?
- a life threatening emergency where there is a tear in the wall of the uterus
- often at the site of a previous cs scar
- can be complete (through all layers) or incomplete
What are risk factors for uterine rupture?
- uterine scar
- trauma
- obstructed labour
- prostaglandins and oxytocics
What are the signs/symptoms of uterine rupture?
- poor progress in labour
- abdominal or shoulder tip pain
- fetal heart rate abnormalities
- maternal shock
- haemorrhage
