Management of Uterine Inversion in the First Golden Hour with Critical Care Team
Immediate manual replacement of the inverted uterus should be attempted without delay, as maternal mortality is extremely high if left unrecognized, and successful treatment depends on prompt recognition and correction within minutes of occurrence. 1, 2
Immediate Recognition and Team Activation
- Diagnose clinically by identifying the inverted uterine fundus, which presents as a mass protruding through the cervix or visible at the introitus, typically accompanied by severe hemorrhage and hypovolemic shock 1, 2
- Immediately alert the anesthesia team, critical care personnel, maternal-fetal medicine specialists, and ensure blood products are ordered as part of the multidisciplinary response 3
- Obtain additional intravenous access immediately and activate massive transfusion protocols where available 3, 4
Simultaneous Resuscitation and Correction (First 15 Minutes)
Hemodynamic Stabilization
- Begin aggressive fluid resuscitation and transfusion with blood products (packed red cells, fresh-frozen plasma, and platelets at 1:1:1 ratio) to manage hypovolemic shock that accompanies uterine inversion 4
- Administer tranexamic acid 1 g intravenously over 10 minutes immediately, as effectiveness declines by approximately 10% for every 15 minutes of delay 5
- Avoid excessive fluid resuscitation while maintaining adequate perfusion, as this can worsen outcomes 3
Immediate Manual Replacement
- Attempt manual replacement immediately before the cervix contracts around the inverted fundus—this is the single most critical intervention 1, 6
- Use firm, steady pressure to push the inverted fundus back through the cervix and into its normal anatomical position 1
- Do not remove the placenta if it is still attached, as this will worsen hemorrhage; replace the uterus first, then remove the placenta after successful repositioning 1, 2
If Initial Manual Replacement Fails (15-30 Minutes)
Uterine Relaxation Strategies
- Administer uterine relaxants to facilitate manual replacement if initial attempts are unsuccessful 1, 6:
Hydrostatic Pressure Technique
- Apply hydrostatic pressure using warm saline instilled into the vagina while waiting for medications to take effect or general anesthesia to be induced 1
- This technique can be attempted as a temporizing measure while pharmacologic relaxation is being achieved 1
Surgical Intervention for Refractory Cases (30-60 Minutes)
- Proceed to surgical repositioning via abdominal (Huntington or Haultain procedure) or vaginal approach if manual replacement with uterine relaxants fails 6, 2
- Consider general anesthesia if not already administered, as it facilitates both uterine relaxation and surgical intervention 3
- Surgical correction may require laparotomy with incision of the posterior uterine constriction ring to allow repositioning 6, 2
Post-Reduction Management (Immediate Post-Correction)
- Immediately institute uterine massage and administer ecbolic agents (oxytocin, methylergonovine if not hypertensive) after successful replacement to prevent reinversion 6
- Monitor for coagulopathy which may develop following cardiovascular collapse, particularly if fibrinogen levels fall below 2 g/L with ongoing bleeding 5, 4
- Maintain vigilance for ongoing bleeding and have a low threshold for additional interventions including uterine tamponade with intrauterine balloons if atony persists 4
Critical Pitfalls to Avoid
- Never delay manual replacement to wait for anesthesia or medications—attempt immediate manual reduction first, as delay increases morbidity and mortality dramatically 1, 2
- Do not attempt to remove an adherent placenta before replacing the uterus, as this significantly worsens hemorrhage 1, 2
- Avoid using methylergonovine in hypertensive patients due to vasoconstriction risk 4
- Do not underestimate blood loss—morbidity and mortality occur in up to 41% of cases, primarily from hemorrhagic shock 2