uterine inversion and prolapse

1
Uterine Inversion and Prolapse
2
S.P CHUWA
3
Uterine Inversion
4
Contents

• Clinical features
• Imaging
• Differential diagnosis
• Management
• Prevention

• Introduction
• Classification (based on extent and time of
  occurrence)
• Etiology
• Risk factors

5
Introduction

• Uterine inversion is a rare life-threatening
  condition whereby the uterine fundus collapses
  into the endometrial cavity, turning the uterus
  partially or completely inside out. It is a
  complication of vaginal or cesarean delivery.
• It occurs approximately 1 in 20,000 deliveries.
• If not promptly recognised and treated, it can
  lead to severe haemorrhage and shock, resulting
  in maternal death.

6
Classification extent

• Third degree (prolapsed)
• Fundus protrudes to or beyond the introitus.
• Fourth degree (total)
• Both the vagina and uterus are inverted

• First degree (incomplete)
• Fundus is within the endometrial cavity.
• Second degree (complete)
• Fundus protrudes through the cervical os.

7
(No Transcript)
8
Classification time of occurrence

• Acute- within 24 hours of delivery
• Subacute- more than 24 hours but less than 4
  weeks postpartum
• Chronic- more than 1 month postpartum.

9
Etiology

• Spontaneous
• Localized atony of the placental site
• Sharp rise of intra abdominal pressure
• Short cord
• Placenta accreta
• Induced Mismanagement of the third stage

10
Risk factors

• Nulliparity
• Uterine anomalies or tumors
• Retained placenta
• Placenta accreta spectrum
• Use of uterine relaxants

• Macrosomia
• Rapid or prolonged labor and delivery
• Short umbilical cord
• Preeclampsia with severe features

11
Clinical features

• Signs symptoms
• Mild to severe vaginal bleeding with offensive
  vaginal discharge.
• Mild to severe lower abdominal pain
• A smooth round mass protruding from the cervix or
  vagina with a shaggy look.
• Per vagina cervical rim felt high up in first
  and second degree but not in third and fourth
  degree.
• Sound test demonstrating shortness or absence of
  uterine cavity using a uterine sound is
  relatively confirmative.
• EUA to confirm the diagnosis
• Most common presentation uterine inversion with
  severe postpartum haemorrhage, often leading to
  hypovolemic shock.

12
Clinical features

• If complete inversion On vaginal examination,
  the inverted fundus fills the vagina. On
  abdominal palpation, the uterine fundus will be
  absent from its expected periumbilical position.
• If incomplete inversion speculum examination
  reveals a mass in the uterine cavity. On
  abdominal palpation, there will be a cup like
  defect (fundal notch) palpated in the area of the
  normally globular fundus.
• If recognition of inversion is delayed,
  increasing cervical constriction means that there
  will be a greater need for surgical intervention
  and the uterus may become oedematous and infected.

13
Imaging

• Ultrasound examination of uterine inversion shows
  an abnormal uterine fundal contour with a
  homogenous globular mass within the uterus.
• Imaging is only used to confirm inversion in
  cases of uncertain diagnosis when the patient is
  hemodynamically stable. The diagnosis of uterine
  inversion is based upon the clinical findings
  mentioned earlier (vaginal bleeding potentially
  resulting in shock, lower abdominal pain,
  presence of smooth round mass protruding from
  cervix or vagina).

14
Differential diagnosis

• Prolapsed fibroid differentiated by palpating
  the fundus. In uterine inversion, the fundus is
  absent from its normal position or markedly
  abnormal. With a prolapsed fibroid, the fundus is
  usually normal.
• Uterine prolapse
• Prolapsed hypertrophied ulcerated cervix
• Fungating cervical malignancy

15
Management Goals

• Replace the uterine fundus to its correct
  position
• Manage PPH and shock, if present
• Prevent recurrent inversion

16
Management

• Discontinue uterotonic drugs
• Call for immediate assistance
• Urgent Investigations Hb levels, blood grouping
  and crossmatch.
• IV fluids and blood transfusion
• Do not remove the placenta (until the uterus is
  returned to its normal position)

17
Management Cont

• Immediately attempt to manually replace the
  inverted uterus.
• If it fails and patient is hemodynamically
  stable- give uterine relaxants (sublingual
  nitroglycerin, terbutaline, magnesium sulphate,
  halogenated general anesthetics) and reattempt
  manual replacement.
• If it fails and patient is hemodynamically
  unstable- proceed to laparotomy.

18
Management Cont

• Operations for inversion of the uterus
• Haultains operation abdominal procedure.
• Spinellis operation vaginal procedure.

19
Management after uterus is replaced

• Hold uterus in place and monitor until firm and
  position is stabilised.
• Administer uterotonic drug misoprostol 1000mcg
  vaginally.
• Induces myometrial contraction
• Maintains uterine involution
• Prevents reinversion
• Antibiotic prophylaxis amoxicillin clavulinic
  acid (FDC) PO 625mg 8hrly 7 days.

20
Uterine Prolapse
21
Contents

• Clinical features
• Imaging
• Management
• Prevention
• Complications

• Introduction
• Classification
• Anatomy of uterine supports
• Risk factors
• Differential diagnosis

22
Introduction

• Definition Uterine prolapse is the herniation of
  the uterus through or beyond the vaginal canal.
• It occurs when pelvic floor muscles and ligaments
  stretch and weaken until they fail to provide
  enough support for the uterus. As a result, the
  uterus slips down into or protrudes out of the
  vagina.

23
Classification types of uterine prolapse

• Uterovaginal prolapse prolapse of the uterus,
  cervix and upper vagina.
• Most common type
• Cystocele followed by traction effect on the
  cervix. This causes retroversion of the uterus.
  The intraabdominal pressure pushes the uterus
  down into the vagina.
• Congenital does not involve cystocele. The
  uterus descends with inverted upper vagina.
• AKA nulliparous prolapse.
• Cause congenital weakness of supporting
  structures of the uterus.

24
Classification degrees of prolapse

• First degree uterus descends, cervix descends
  halfway to the introitus (still inside the
  vagina).
• Second degree uterus still inside the vagina,
  cervix extends beyond the introitus.
• Third degree cervix and body of the uterus
  extends beyond the introitus.
• Procidentia prolapse of uterus with eversion of
  the entire vagina.

25
Degrees of uterine prolapse
26
(No Transcript)
27
Anatomy of the uterine supports

• The uterus is supported in its normal antiverted,
  anti flexed state in the midpelvis under 3 tier
  systems, which work together to prevent uterine
  prolapse
• Upper tier endopelvic fascia, round ligaments,
  broad ligaments
• Middle tier (strongest support) pubocervical
  ligaments, cardinal ligaments, uterosacral
  ligaments, rectovaginal septum, endopelvic
  fascia.
• Inferior tier pelvic floor muscles (levator
  ani), endopelvic fascia, perineal body and
  urogenital diaphragm.

28
(No Transcript)
29
Anatomy of the uterine supports cont

• This balance can be altered if the supports are
  stretched during childbirth.
• if the woman tries to expel the fetus before full
  dilatation of the cervix
• if the woman strains for a long time in the
  second stage of labor
• if inappropriate or excessive force is used to
  expel the placenta
• Other than childbirth, possible causes include
  failure of the supporting tissues to properly
  develop and chronic constipation leading to
  straining.

30
Risk factors

• Multiparity (particularly vaginal birth)
• Older age because tissues become less resilient
• Menopause (because of decreased endogenous
  oestrogen -gt causes thinning of the vagina dn
  reduces strength of the connective tissues that
  support the uterus)
• Prior pelvic surgery (eg hysterectomy)

31
Risk factors cont

• Connective tissue disorders
• Factors associated with elevated intra-abdominal
  pressure (obesity, chronic constipation, COPD,
  repeat heavy lifting, large pelvic tutors,
  obstructed labor, traumatic delivery)
• Genetic predisposition

32
Differential Diagnosis

• Cervical elongation
• Prolapsed uterine fibroid
• Lower uterine segment fibroids
• Prolapsed cervical and endometrial tumors
• Ovarian cysts
• Chronic inversion

33
Clinical features

• Many women are asymptomatic.
• Vaginal/pelvic pressure or the sensation of a
  vaginal bulge or something falling out of the
  vagina. Vaginal bulge that may worsen at night or
  become aggravated by prolonged standing and
  vigorous activity of heavy lifting.
• Pain in the pelvis, abdomen or lower back.
  Relieved on lying down.
• Pain during intercourse.
• Protrusion of tissue from the vagina.
• If paired with cystocele
• Urinary dysfunction urinary incontinence,
  frequency or urgency, painful urination.
• May develop UTIs -gt unusual or excessive
  discharge.

34
Clinical features cont

• An abdominal examination is used to exclude the
  presence of an abdominal or pelvic tumor.
• A pelvic assessment is used to assess the degree
  of prolapse using a Sims speculum. Additionally,
  a digital examination in standing position allows
  a more accurate assessement of the degree of the
  prolapse.

35
Pelvic Organ Prolapse Quantitation System (POP-Q)

• Objective, site-specific system for describing,
  quantifying and static pelvic support in women.
• Useful in comparing patients examinations over
  time and among different examiners.

36
(No Transcript)
37
Imaging

• A pelvic ultrasound is useful to distinguish
  uterine prolapse from other pathologies.
• MRI can be used for prolapse staging but isnt
  usually indicated.

38
Management

• Asymptomatic or mild prolapse (POP-Q Stage 1 or
  2) conservative management.
• Low-dose vaginal oestrogen cream in
  postmenopausal women.
• Kegel exercises to strengthen pelvic floor
  muscles
• Pessaries Mechanical support devices. These are
  rubber/plastic doughnut shaped devices fitted
  around or under the cervix (positioned like a
  diaphragm) and hold the pelvic organs in their
  normal position. Not curative.

39
Pessaries

• Indications
• Puerperium- to facilitate involution
• Mild prolapse
• While awaiting surgical procedure
• Patients unwilling to have the surgical procedure
  done
• Risks pain, bleeding, ulceration, leukorrhea,
  infection.
• Used intermittently or may remain inside the
  vagina for up to 3 to 6 months at a time.
• Close follow-up with removal, vaginal
  examination, cleaning and replacement to ensure
  proper placement and hygiene.

40
Placement of a vaginal pessary
41
Management cont

• Surgical repair
• Uterovaginal prolapse Fothergills operation
  (uterus conserved), vaginal hysterectomy with
  pelvic floor repair (uterus removed)
• Congenital uterine prolapse cervicopexy or Sling
  operation (cervix mechanically pulled up via
  abdomen).

42
Prevention

• Pelvic floor exercises such as kegel exercises
  (do not reverse/treat existing symptomatic
  prolapse).
• These exercises involve tightening and releasing
  of the elevator ani muscles repeatedly to
  strengthen the muscles and improve pelvic
  support.
• A healthy diet to prevent constipation and
  maintain a healthy body weight.
• Avoid chronic straining
• Exercise with correct lifting techniques
• Quit smoking

43
Complications

• Ulcers in severe cases, the vaginal lining can
  be displaced and exposed. This can lead to
  vaginal ulcers that may become infected.
• Incarceration if the uterus is not replaced
  quickly enough, it may begin to enlarge and
  become trapped in the lower pelvis or vagina.
  Once it becomes edamatous, the uterus may become
  incarcerated and have its blood supply cut off.
• Prolapse of other pelvic organs, such as the
  bladder and rectum.

44
References

• Beckmann and Ling by Dr. Robert Casanova
• Fundamentals of Obstetrics and Gynaecology 10E
• Blueprints Obstetrics Gynecology by Dr. Tamara
  Callahan M.D.
• Medscape
• Uptodate
• Duttas Textbook of Gynecology