WEEK 9 - Uterine Inversion / Massive PPH Flashcards
(8 cards)
Uterine inversion
Uterine inversion: when the uterine fundus collapses into the uterine cavity, causing the uterus to turn partially or completely inside out, potentially leading to severe blood loss and shock if not treated promptly
Anatomy and physiology relating to uterine inversion
- A dilated cervix with relaxed uterus and simultaneous downward traction on the fundus are possible factors leading to inversion of the uterus
- The inverted fundus becomes trapped within the cervix, creating progressive oedema and congestion due to interruption of venous and lymphatic drainage
- This becomes a vicious cycle, and the longer the time elapsed since inversion, the more difficult repositioning of the uterus
- As the inversion progresses, the round and infundibulo-pelvic ligaments and ovaries become indrawn into the inverting uterine fundus, which forms a depression
- The extent to which the ligaments and ovaries get drawn into it will depend on the degree of inversion
- The indrawing of the peritoneum, the ligaments, and the ovaries will result in significant pain and stimulation of the autonomic nervous system, resulting in neurogenic shock
- The degree of shock is out of proportion to the bleeding that is observed
- Significant hemorrhage due to poor retraction and congestion of the inverted uterus and partial separation of the placenta will follow and amplify these effects
Causes and risk factors for uterine inversion
- Mismanagement of third stage (applying traction on the cord before contraction of the uterus and applying fundal pressure)
- Uterine atony
- Fundal implantation of a morbidly adherent placenta
- Manual removal of the placenta
- Precipitate labour
- Short umbilical cord
- Placenta praevia
- Connective tissue disorders
- Sudden increases in intra-abdominal pressure (e.g., coughing, sneezing)
Recognition of uterine inversion
Inversion of the uterus is classified according to time elapsed from the time of birth and degree of descent
Can be seen as a uniform lump, or palpate like a foetal head and appear pinkish-white mass and become oedematous/bluish in colour
In a complete inversion, the inverted fundus can be palpated at the cervical os and impalpable abdominally
Vast majority of cases will present with haemorrhage or cardiovascular collapse
Severe abdominal pain, bleeding, shock, abnormal abdo palp
According to time of onset:
Acute - within 24 hours of birth
Subacute - between 24hours to 4 weeks after birth
Chronic - any time after 4 weeks of birth or in a non-pregnant woman
According to degree of descent :
First degree (incomplete) - fundus is inverted but is above the internal os
Second degree (incomplete) - fundus has extended beyond the os but remains within the vagina (most common)
Third degree (complete inversion) - fundus extends to or beyond the introitus
Fourth degree - the vagina has also inverted along with the uterus
Management of uterine inversion
- Call for Help (ABC)
- Treat shock
- Initial shock is neurogenic (bradycardia, hypotension)
- Hypovolemic shock will ensue due to haemorrhage
- Aggressive resuscitation is needed - Do not remove placenta - attempt manual replacement (Johnson’s maneuver)
- Operator introduces two-thirds of the forearm into the vagina and extends the hands at the wrist to place the palm of the inverted fundus and fingertips at the utero-cervical junction
- Lifting the uterus above the level of the umbilicus creates adequate tension for the cervical ring to dilate and for the fundus to revert to its normal position (should be held in this position for a few minutes and uterotonic drugs should be administered to aid contraction)
- Remove placenta only after repositioning the uterus and complete correction of the inversion to prevent shock / bleeding - If unsuccessful, attempt hydrostatic reduction
- The lower genital tract is made to distend by filling it with isotonic saline under pressure. This creates distension first in the vagina, and then in the cervical ring, which helps the uterus to restitute into its normal position - Consider tocolytics
- Terbutaline is the drug of choice due to rapid onset action and short half-life (0.25mg IV slowly)
- General anaesthesia & operating theatre - Surgical methods
- Huntingdon’s operation
- Haultain’s operation
- Hysterectomy
Complications which occur for the mother experiencing uterine inversion
Massive PPH
Hypovolemic shock - significant blood loss, low blood pressure, tachycardia, pale skin, ACS, organ failure if untreated
Neurological complications - traction on the uterus may stimulate the vagus nerve, causing cardiac arrest, bradycardia, hypotension, fainting
Infection (sepsis)
Uterine rupture or trauma
Anaesthetic complications
Retained placenta
Uterine atony
PTSD
Describe massive PPH and the causes
blood loss greater than 1500 - 2000 mls, and the resulting haematological changes which can lead to moderate to severe shock
- Tone (uterine atony) - overdistension, prolonged labour, rapid labor, oxytocin, high parity, chorioamnionitis
- Trauma (birth canal) - uterine rupture or inversion, episiotomy complications, instrumental delivery, macrosomic baby, precipitous labour)
- Tissue (retained products) - placenta, membranes, clots
- Thrombin (coagulopathy) - clotting disorders, placental abruption, DIC, sepsis
Describe the management of massive PPH
- HELP
- Massage uterus
- Reassure woman and explain what is happening - Assess
- Lie the woman flat
- ABC
- 10L oxygen via face mask
- Monitoring vital signs and conscious state
- Keep woman warm - Access
- 2x 16G IVC
- Take bloods (FBE, GNH, LFTs, - E+E, clothing)
- Crystalloid 2L fluid resuscitation
- Colloids 1.5L
- Blood transfusion ?fresh frozen plasma, platelets, cryoprecipitate - Cause
- VE & speculum (?cervical trauma)
- IDC
- Repair (trauma / tear) - Drugs
- Repeat oxytocic
- Give ergometrine (0.25mg IV or IM)
- 40mls syntocinon infusion
- Misoprostol PR
- Monitoring blood loss
- ? Prostaglandin - Team leader
- Haematology
- Partner/baby
- Runner
- Scribe
- Measure blood loss
