Management of Uterine Inversion
Immediate manual repositioning of the inverted uterus is the cornerstone of management and must be attempted without delay, as prompt recognition and rapid intervention are critical to preventing maternal mortality and morbidity. 1
Immediate Resuscitation and Recognition
Uterine inversion presents with the classic triad of:
- Postpartum hemorrhage
- Hypovolemic shock
- Severe abdominal pain with bearing down sensation
The diagnosis is almost exclusively clinical 1, though imaging may aid in uncertain cases. Morbidity and mortality occur in up to 41% of cases 1, making this a true obstetric emergency requiring coordinated multidisciplinary response 2.
Initial Steps (Simultaneous Actions):
Aggressive resuscitation - Begin IV fluid resuscitation and blood transfusions immediately to address hypovolemic shock 1, 3
Call for help - Mobilize anesthesia, critical care, and additional obstetric personnel 2
Attempt immediate manual repositioning - Do NOT wait for placental removal if the placenta is still attached 1
Manual Repositioning Technique
The key principle: Replace the uterus manually as quickly as possible before the cervix contracts and traps the inverted fundus.
- Use steady, firm pressure to push the inverted fundus back through the cervix
- If the placenta is still attached, attempt repositioning first, then remove the placenta after successful reduction 1
- Apply pressure to the area that inverted last (usually visible as a dimple) and push it back first
If Manual Repositioning Fails:
Consider tocolytic agents to relax the uterus and facilitate repositioning:
- Terbutaline
- Nitroglycerin
- General anesthesia with halogenated agents (provides uterine relaxation)
Surgical Management
If manual repositioning is unsuccessful, proceed immediately to surgical intervention 1, 3:
Surgical Approaches:
Abdominal approach (Huntington or Haultain technique):
- Huntington: Traction on round ligaments to pull uterus back into position
- Haultain: Posterior incision through the cervical ring to release constriction, then reposition 4, 5
Vaginal approach (Spinelli technique):
- Anterior incision through cervical ring
- More appropriate for chronic cases
Combined abdominal-vaginal approach:
- Useful when vaginal myomectomy is needed first (if tumor present) 5
- Allows better visualization and control
Post-Repositioning Management
Once the uterus is successfully repositioned:
Administer uterotonics liberally - Oxytocin, methylergonovine, or carboprost to maintain uterine tone 2
Monitor for re-inversion - Keep hand on fundus initially; consider uterine packing or balloon tamponade
Address ongoing hemorrhage - May require uterine artery embolization, surgical ligation, or hysterectomy if conservative measures fail 6
Correct coagulopathy - Replace clotting factors as needed
Critical Pitfalls to Avoid
- Do NOT delay manual repositioning while waiting for imaging or placental removal
- Do NOT apply excessive cord traction during third stage (this is a known causative factor) 3
- Do NOT mistake early uterine inversion for prolapsed fibroid or cervical polyp 3 - maintain high index of suspicion with any protruding mass and shock
Future Pregnancy Considerations
If surgical replacement required an incision into the contractile portion of the uterus (Haultain technique), cesarean delivery is recommended in subsequent pregnancies 1, similar to management after classical cesarean section. However, reinversion in subsequent pregnancy is unpredictable, and there is no absolute consensus on delivery mode for all cases 1.
The evidence consistently emphasizes that successful outcomes depend entirely on rapid recognition and immediate intervention 1, 3, 2, 7. Time is the enemy - every minute of delay increases maternal morbidity and mortality risk.