Which of the following statements about uterine inversion is correct: the placenta should be removed prior to replacement of the uterus, bradycardia and shock are uncommon, the placenta appears at the introitus with a mass attached, or a firm uterus may facilitate the replacement maneuver?

Management of Uterine Inversion

The placenta should NOT be removed prior to replacement of the uterus in cases of uterine inversion, as this can worsen hemorrhage and shock.

Clinical Presentation and Pathophysiology

Uterine inversion is a rare but potentially life-threatening obstetrical emergency that occurs during the third stage of labor. The clinical presentation typically includes:

• The placenta appears at the introitus with a mass attached (the inverted uterus)
• Severe hemorrhage due to atony and vascular disruption
• Bradycardia and shock are common, not uncommon, due to parasympathetic stimulation from stretching of the peritoneum and ligaments 1
• Shock may be out of proportion to the visible blood loss 2

Management Algorithm

Immediate Management

1. Recognition: Prompt diagnosis is critical for reducing morbidity and mortality
2. Resuscitation: Address hypovolemic shock with IV access, fluid resuscitation, and blood products
3. Replacement: Manual replacement of the uterus should be attempted immediately

Key Points in Management

• Do not remove the placenta before uterine replacement - Removing the placenta prior to replacement increases blood loss and can worsen shock 3, 1
• A relaxed (not firm) uterus facilitates replacement - Uterine relaxants may be necessary if initial attempts fail 3
• After successful replacement, the placenta can be removed followed by administration of uterotonics to prevent reinversion

Uterine Replacement Techniques

Manual Replacement

1. Apply steady pressure to the inverted fundus with palm of hand
2. Push the fundus through the cervical ring toward the umbilicus
3. If initial attempts fail, pharmacologic uterine relaxation should be considered

Pharmacologic Adjuncts for Uterine Relaxation

• Tocolytics (terbutaline, magnesium sulfate)
• Nitroglycerin (IV) - offers pharmacodynamic advantages 4
• Halogenated anesthetics if general anesthesia is used

Alternative Techniques

• Hydrostatic pressure (O'Sullivan technique) - infusion of warm saline through a fluid administration set into the vagina
• Surgical correction (laparotomy) may be required for resistant cases 5

Post-Replacement Management

1. After successful replacement, remove the placenta if still attached
2. Administer uterotonics immediately to prevent reinversion
3. Monitor closely for recurrent hemorrhage or shock

Common Pitfalls to Avoid

• Removing the placenta before replacement - This increases blood loss significantly
• Assuming a firm uterus will facilitate replacement - A relaxed uterus is needed for successful replacement
• Underestimating the severity of shock - Shock in uterine inversion can be disproportionate to visible blood loss
• Delayed recognition - Mortality can be as high as 41% if not promptly recognized and treated 1

Uterine inversion requires immediate intervention with a systematic approach focusing on maternal resuscitation and uterine replacement with the placenta left in situ until after replacement is achieved.