Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Subacute Puerperal Third Degree Uterine Inversion- A Rare Case

Dr Swati Agrawal*, Dr Kumar Jayant, Dr Susheela Khoiwal, Dr Rajendra Agrawal

Department of Obs & Gynae, M. S R. N. T Medical College, Udaipur, Rajasthan, India

Abstract: Acute uterine inversion is a life threatening and unpredictable obstetric emergency which if ignored can lead to severe haemorrhage and shock which may be out of proportion to haemorrhage. When managed promptly and aggressively, uterine inversion can result in minimal maternal morbidity and mortality. Incidence of puerperal uterine inversion greatly varies in literature ranging from 1:2500 to 1:20000. If the condition is promptly recognized before incarceration, manual repositioning of the uterus may be successful. However in neglected uterine inversion, incarceration may occur due to constriction ring formation, necessitating surgical intervention. Here we present a case of neglected subacute uterine inversion managed by Haultain`s repair.

Keywords: uterine inversion, obstetric emergency, Haultain method

Received November 21, 2013; Revised November 29, 2013; Accepted December 11, 2013

Citation: Dr Swati Agrawal, Dr Kumar Jayant, Dr Susheela Khoiwal, Dr Rajendra Agrawal, Subacute Puerperal Third Degree Uterine Inversion- A Rare Case. American Journal of Medical Case Reports, 1 (1). 9-11. January 2013. doi:10.12691/ajmcr-1-1-4

1. Introduction

Uterine inversion is defined as the prolapse of uterine fundus within the endometrial cavityand which may protrude outside the cavity. It can be either puerperal (obstetric) or non-puerperal (gynaecological) setting. Puerperal (obstetric) uterine inversion is a rare but potentially life threatening obstetric emergency. The incidence of uterine inversion varies and ranges from 1:2500, [1,2] to 1:20000 [2,3]. Uncommonly it has also been reported at the time of caesarean section.It is an obstetric emergency, with significant maternal morbidity and mortality.

The typical presentation is that of major obstetric haemorrhage and shock, with most patients needing blood transfusion. It is imperative that the condition is recognized quickly and managed promptly and appropriately by a multi-disciplinary team, in order to minimize the potential for maternal morbidity and even mortality.

2. Case Report

Here we report a case of 27 years old female para one, referred to our hospital, Pannadhaya Mahila Chikitsalaya Udaipur, India from peripheral health centre with shock and third degree inversion uterus. She was on ionotropic support, Dopamine 20 micrograms/kg/min and she was already cathaterised. Her vitals were –PR-120/min, feeble, BP-92/56 mmof Hg and temperature was 39 degree C. She was severely pale but conscious. On examination her abdomen was soft, uterus was not palpable and per vaginal examination showed third degree inversion of uterus.

According to patient’s relatives, she got delivered at home by traditional birth attendant by spontaneous normal vaginal delivery and placenta was also expelled spontaneously after around 20 min. After 24 hrs of delivery, she noticed something coming out through vagina when she went to toilet and it was followed by profuse vaginal bleeding. Then she was rushed to a primary health centre and after receiving basic medical care she was referred to our hospital which was at a distance of 6 hours.

All members of emergency obstetric team and anaesthetist were rapidly summoned to provide assistance. Patient was resuscitated first and all supportive measures were taken. Her initial Hb was 3g/dl and TLC was 20,000; so she was transfused 4 units whole blood and broad spectrum antibiotics were given. Manual reposition was not possible. Inverted uterus was dressed with povidone iodine. She was taken to the theatre, the next dayand repositioning was tried vaginally under general anaesthesia with good relaxation but was unsuccessful due to tight cervical ring. Then, O Sullivan’s hydrostatic method was tried, which also failed so a decision was taken to proceed for laparotomy and repositioning was done by Haultain method. A laparotomy was carried out; a cup shaped depression was seen with pulling in of the round ligaments. The uterus was pulled up and the posterior rim of the cup incised through both the thickness of the inverted wall. The inverted fundus was pulled up from above, aided by a fist passed through the vagina. The incision on uterus was stiched with interrupted sutures no 1vicryl and haemostasis achieved.

She made a good recovery and was discharged on post operative day 10. She is doing well on subsequent follow ups.

3. Discussion

The puerperal uterine inversion is a rare complication of the third stage of labour. Uterine inversion may be classified in two ways –according to anatomical severity and / or timing of the inversion.

3.1. Classification of Uterine Inversionaccording to Severity [3]

First degree: Inversion of the uterus is intrauterine, fundus remains within the cavity.

Second degree: Complete inversion of the uterine fundus through the cervix.

Third degree: Total inversion, with the fundus protruding through the vulva.

Forth degree: The vagina is also involved with complete inversion through the vulva.

3.2. Classification According to Timing of the Event [2,3]

The timing of the inversion may be acute (within 24 hours of delivery), subacute (more than 24 hours postpartum) or it may be chronic (more than 4 weeks postpartum), the prevalence of each class is 83.4%, 2.6% and 13.9% respectively [4].

A numberof predisposing factors have been implicated but often there is no clear cause. In about half of reported cases it appears to occur spontaneously, mostly in young primiparous women [5]. However, factors associated with puerperal uterine inversion are listed in the table below [6,7].

Table 1. Factors associated with puerperal uterine inversion

The presentation of the uterine inversion will vary depending on the severity of the inversion. The diagnosis of the puerperal uterine inversion is mainly clinical. It is based on three elements: haemorrhage, shock and a strong pelvic pain [8]. The haemorrhage strength is directly related to the duration of inversion. The bleeding is massive in more than 70% of cases and shock is the most constant sign [9,10]. It results from hypovolaemia which is secondary to bleeding and vagal reaction associated with stretching of the nervous fibres contained in uterine ligaments [8,9,10]. The sudden severe pain is less frequent and is present in 7 to 10% of cases. It can be covered by the anaesthesia [9]. Maternal morbidity may be significant with a uterine inversion and mortality rates approach 15% [11]. Therefore it is paramount that further assistance is promptly summoned, so that the patient can be effectively resuscitated and appropriately stabilized.

Puerperal uterine inversion should always be excluded in cases of sudden post-partum collapse and / or major post-partum haemorrhage.

The key approach which is usually successful if done immediately, is a non-surgical technique referred to as Johnson’s method. Once diagnosed an attempt is made to replace the uterus digitally; which entails manual replacement of the uterus through the vagina past the cervical ring.The hand is placed inside the vagina, with the cup of the inversion in the palm of the operator’s hand and the tips of the fingers towards the utero-sacral ligaments. The uterus is then forcefully lifted inside the abdominal cavity above the level of the umbilicus and held for 3 - 5 minutes until the passive action of the uterine ligaments corrects the inversion [12]. Should manual reposition fail to achieve uterine repositioning, then employing the use of hydrostatic method would be the next approach.If uterine inversion has persisted despite non-surgical approach, then surgery will usually be required. Although quite a number of surgical approaches have been described in the literature, the most common methods used are, Huntingtons technique, Haultain technique, Spinelli”s and Kustner technique. Spinelli and Kustner operations involve replacing the uterine fundus vaginally through the anterior and posterior transections respectively [13]. The abdominal route is preferred over the vaginal as the incision of the uterus is reduced to a minimum, traction on the round and broad ligaments helps in reposition, the uterine wall can be more accurately sutured and haemorrhage more efficiently controlled [14]. Therefore we also adopted the Haultain’s abdominal hysterotomy with a good surgical outcome.

In cases where the uterus is preserved, recurrence is rare in subsequent pregnancies if good obstetrical care is given. Haultain himself has reported good pregnancy outcomes following the correction.

Despite the fact that uterine inversion is uncommon, all obstetric care givers need to have a heightened awareness of the inherent dangers that can occur with uterine inversion. By being more aware and preparing for this obstetric emergency, we will be able to respond quickly and appropriately manage this potentially life threatening condition.

4. Conclusion

Uterine inversion is a rare life threatening complication of vaginal delivery. Its diagnosis is essentially clinical. If left unrecognized, it can result in severe life threatening hemorrhage, shock, and maternal death. Active management of third stage of labor and early recognition of the uterine inversion could significantly reduce the incidence and complications of uterine inversion. Manual manipulation aided by tocolytic or halogenated anesthetic agents is often successful in correcting the inversion. In the most resistant of inversions, surgical correction through the abdomen might be needed. Thus, it is important that physicians providing obstetric care be aware of the common signs of inversion so that the diagnosis can be determined and treatment initiated immediately.

Figure 1. Third degree subacute puerperal inversion

Conflicts of Interests

None identified.

References

[1]   | You WB, Zahn CM. Postpartum Hemorrhage: Abnormally Adherent Placenta, Uterine Inversion, and Puerperal Hematomas. Clinical Obstetrics and Gynecology. 2006; 49(1):184-97.
[2]   | Mirza FG, Gaddipati S. Obstetric Emergencies. Seminars in Perinatology. 2009; 33: 97-103.
[3]   | Coates T. Midwifery and obstetric emergencies. In: Fraser DM, MA C, editors. Myles  Textbook for Midwives. 15th ed. London: Churchill Livingstone; 2009. p. 625-47.
[4]   | Dali SM, Rajbhandadari S, Shrestha S. Puerperal inversion of the uterus in Nepal: case reports and review of literature. J ObstetGynaecol Res 1997; 23:319-25.
[5]   | Druzon ML, Platt LD: Acute puerperal inversion of the uterus. Am J ObstetGynaecol; 1981; 141: 187.
[6]   | Achanna S, Mohamed Z, Krishnan M. Puerperal uterine inversion: a report of four cases. Journal of Obstetric and Gynaecology Research 2006; 32 (3): 341-345.
[7]   | Harbinder S, Greenspoon JS, Platt LD, Paul RH. Journal of reproductive medicine 1989; 34 (2): 173-177.
[8]   | Lago J. Presentation of acute uterine inversion in the emergency departement. Am J Emerg Med. 1991; 9: 239-42.
[9]   | Chambrier C, Zayneh E, Pouyau A, Pacome JP, Bouletreau P. Uterine inversion: an anesthetic emergency. Ann FrAnesthReanim. 1991; 10: 81-3.
[10]   | Miras T, Collet F, Seffert P. Acute puerperal uterine inversion: two cases. J GynecolObstetBiolReprod (Paris) 2002; 31: 668-71.
[11]   | Hostetler DR, Bosworth MF. Uterine inversion: a life threatening obstetric emeregency. Journal of the American board of family practice 2000; 13:120-123.
[12]   | Johnson A. A new concept in the replacement of the inverted uterus and a report of nine cases. Am J ObstetGynaecol 1949; 57:557-562.
[13]   | Rocconi RH, Warner K, Chiang S. Postmenopausal uterine inversion associated with endometrial polyps. Obstetrics &gynaecology 2003; 102: 521-3.
[14]   | Macleod D, Howkins J. Operations to correct axial displacements and inversion of the uterus. In: Macleod D, Howkins J, editors. Bonney’s Gynaecological Surgery. 7th ed. London: Cassel 1964; 458-70.