In a postpartum woman (immediate puerperium) with uterine inversion—potentially complicated by fibroids, prior cesarean section, or coagulopathy—what are the recommended surgical techniques (Huntington, Haultain, Spinelli, Johnson) and their indications, including when hysterectomy is required?

Surgical Management of Acute Postpartum Uterine Inversion

Immediate manual replacement without uterotonic agents is the first-line treatment for acute uterine inversion, and if this fails after attempts with uterine relaxants, proceed directly to laparotomy with combined abdominal-vaginal repositioning using opposing pressure on the cervical ring from above and the fundus from below—the Johnson technique—reserving the Haultain procedure (posterior cervical incision) only when the cervical ring cannot be manually dilated. 1, 2, 3

Immediate Resuscitation and Diagnosis

• Activate massive hemorrhage protocol immediately upon recognizing uterine inversion, as morbidity and mortality occur in up to 41% of cases due to hypovolemic shock and hemorrhage. 4
• Establish large-bore intravenous access (two 14-16 gauge lines or ≥8-Fr central line) and begin aggressive fluid resuscitation with warmed physiologic electrolyte solutions. 5
• Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of delivery to reduce bleeding-related mortality. 5, 6
• The diagnosis is almost exclusively clinical: a mass protruding through the cervix or vagina with absence of the uterine fundus on abdominal palpation. 4

First-Line Manual Repositioning

• Attempt immediate manual replacement as soon as the diagnosis is made, before removing the placenta if it remains attached, because placental detachment often triggers massive hemorrhage. 1, 2
• Use the Johnson maneuver: place your fist against the inverted fundus and apply steady upward pressure through the vagina while an assistant applies counter-pressure on the cervical ring abdominally. 1
• Do not administer uterotonic agents (oxytocin, methylergonovine) until after successful repositioning, as these will cause cervical contraction and trap the inverted fundus. 2

Uterine Relaxation for Failed Manual Attempts

If initial manual replacement fails within 3-5 minutes:

• Administer magnesium sulfate 4-6 g IV bolus, terbutaline 0.25 mg subcutaneous or IV, or request general anesthesia with halothane to achieve uterine relaxation. 2
• Reattempt manual repositioning during maximal uterine relaxation. 2
• This approach succeeds in the majority of patients without requiring surgical intervention. 2

Surgical Techniques When Manual Repositioning Fails

Indications for Surgery

• Failure of manual repositioning despite uterine relaxants. 2, 3
• Subacute or chronic inversion (>24 hours). 2
• Inability to dilate the cervical constriction ring manually. 3

Surgical Approach Algorithm

Step 1: Combined Abdominal-Vaginal Access

• Place the patient in dorsal lithotomy position for simultaneous abdominal and vaginal access. 7, 3
• Perform midline vertical laparotomy for optimal visualization and access. 7
• A combined abdominal and vaginal approach is superior to either route alone (used in 27.1% of successfully managed cases). 3

Step 2: Attempt Repositioning Without Incision (Johnson Technique)

• Apply opposing pressures: one surgeon pushes the inverted fundus upward through the vagina while another applies traction on the cervical ring from the abdominal cavity. 1
• This technique resolves the majority of cases without requiring cervical incision. 1

Step 3: Haultain Procedure (Posterior Cervical Incision)

• Only if the cervical ring cannot be manually dilated, incise the posterior cervical ring vertically to release the constriction. 3
• The Haultain procedure was the most commonly used surgical repositioning technique (18.0% of cases) when incision was required. 3
• After repositioning, close the cervical incision in layers with absorbable suture. 3

Step 4: Alternative Incision Techniques

• Spinelli procedure (anterior cervical incision through the vagina): rarely used in modern practice; reserved for vaginal-only access when laparotomy is contraindicated. 3
• Huntington procedure (progressive upward traction on the round ligaments): has limited utility in acute complete inversion because the round ligaments are often inaccessible. 3

Hysterectomy Indications

Proceed directly to hysterectomy without attempting repositioning when:

• Uterine necrosis or gangrene is present (inversion >24-48 hours with vascular compromise). 3
• Malignancy is identified as the cause of inversion (32% of nonpuerperal cases). 3
• Uncontrollable hemorrhage persists despite repositioning and standard PPH interventions. 7
• In acute postpartum inversion, hysterectomy should be a last resort after all repositioning attempts have failed, as fertility preservation is usually feasible. 4, 3

Hysterectomy Technique

• Perform total hysterectomy rather than supracervical, because lower uterine segment bleeding typically precludes supracervical approach. 7
• Expect extensive vascular engorgement and friable tissues; involve the most experienced pelvic surgeon available. 7
• Careful retroperitoneal dissection with devascularization of the uterine corpus is required. 7

Post-Repositioning Management

• Immediately administer uterotonic agents (oxytocin 10-40 units in 1 L crystalloid infusion, methylergonovine 0.2 mg IM if not hypertensive) after successful repositioning to prevent reinversion. 2
• Perform vigorous uterine massage to maintain contraction. 2
• Place intrauterine balloon tamponade (Bakri balloon) if hemorrhage continues despite repositioning and uterotonics. 8, 6
• Continue hemodynamic monitoring for at least 24 hours postpartum. 5

Complicating Factors

Fibroids

• Fundal fibroids increase inversion risk and may prevent manual repositioning. 4, 3
• Leiomyomas are the most common cause of nonpuerperal inversion (56.2% of cases). 3
• Do not attempt myomectomy during acute repositioning; stabilize the patient first, then consider interval myomectomy if fertility preservation is desired. 3

Prior Cesarean Section

• Prior cesarean does not alter the surgical approach to acute inversion. 4
• If surgical repositioning required a cervical incision into the contractile uterine segment, recommend cesarean delivery in subsequent pregnancies (similar to classic cesarean section management). 4

Coagulopathy

• Obtain baseline labs urgently: CBC, PT/PTT, Clauss fibrinogen, type and crossmatch. 5
• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL: transfuse RBC, FFP, and platelets in 1:1:1 ratio. 6
• Withhold FFP until at least 4 units of RBC have been transfused unless early coagulopathy is documented. 6
• Administer cryoprecipitate or fibrinogen concentrate when fibrinogen <2 g/L. 6
• Maintain normothermia (>36°C) and correct acidosis, as both impair coagulation. 5

Critical Pitfalls to Avoid

• Never administer uterotonics before repositioning—this traps the fundus below a contracted cervical ring. 2
• Do not remove an adherent placenta before repositioning—this triggers massive hemorrhage; leave it in situ until the uterus is repositioned. 1, 2
• Do not delay surgical intervention beyond 15-20 minutes of failed manual attempts—prolonged manipulation increases tissue edema and vascular compromise. 4, 2
• Avoid the Huntington procedure in acute complete inversion—the round ligaments are typically inaccessible and this technique has poor success rates. 3
• Recognize that reinversion in subsequent pregnancies is unpredictable; counsel patients accordingly. 4