Displacement of the uterus

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Displacement of the uterus

• Dr sahar anwar rizk

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The uterus has central position in the pelvic The
ternal os is at the level of the ischial spine
It is ante verted ante flexed Anteverted
angle between axis of the cervic and vertical
axis of female . Ante flexed angle between
Axis of the uterine body and Axis of the cervix

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Retroversion of the uterus it mean that
the axis of the cervix become behind the
vertical axis of femal body . Retoflexion
axis of the uterine body become behind the ais
of female body .

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DEGREE First axis of the cervix is behind the
vertical axis of female but the fundus is above
the promontory . Second the fundus is below
the promontory but still above the external os
. Third the fundus is below the external os
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• Causes of RVF
• Acquired during LD
• 1-Bearing down
• 2- Forceps delivery
• 3-breach extraction before fully
  dilatation
• During puerperium
• No kegles ex
• No sims position
• heavy uterus fibroid , subinvolution
• Lax ligament pregnancy
• Adhesion inflammation

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symptoms

• Pain
• Low backache
• Dysmenorrheal
• Dysparunia
• Dyschasia
• Mid cyclic pain
• Menstrual disturbance polymenorrhea
• Leucorrhea

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Signs

1. Cervix is displaced
2. Fundus in dougls pouch
3. Absent of the uterus interiorly

4. Acute anterior angulation of the vagina 5.
The cervix positioned well behind the pubic
symphysis 6. A soft, smooth, nontender mass
filling the cul-de-sac
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investigation

• PV Examination -----fied or mobile uterus
• Hystrography---- position of the uterus
• Double pessary test

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complication

• Kinking of the uterine vessels----------
• congestion of utters-- dysmenorrhea
  ,abortion menorrhagia
• Congestion of the ovary
• polymenorrhra , anovulation ,mid cyclic
  pain
• Infertility
• anovulation, cervix away from seminal pool
  
• Uterine prolapse
• Prolapse of tube ovaries

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Management

• Prophylactic
• During labor ,avoid bearing down , breach
  extraction before full dilatation of the cervix
• During puerperium , sleeping in semis position
  empty of bladder , Hodge pessary

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Management Possible therapies for retroversion
or incarceration include the following Bladder
drainage by indwelling catheter Patient
positioning exercises (eg, intermittent
knee-chest or all-fours positioning, sleeping
prone) Manipulation of the uterus into its
usual anatomic position, with or without
tocolysis or anesthesia Colonoscopic
manipulation of the uterine fundus under
anesthesia Surgical exploration and replacement
(almost never indicated) Specialized and rarely
attempted techniques of replacement (eg,
employment of a mercury-filled Voorhees bag in
the vagina, amniocentesis with manipulation)
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Prolapse of the Uterus

• Prolapse of the uterus refers to the downward
  displacement of the vagina and uterus. The word
  prolapse is derived from the latin procidere
  which means with effect to fall.
• The uterus is held in position by adequate
  ligaments Besides, it has the support of the
  muscular structures of vagina and all other local
  tissues and muscles. Due to the laxity of support
  by muscles, tissue and ligaments, the uterus sags
  downwards.

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• Types of uterine prolapse
• True uterine prolapse
• False uterine prolapse
• DEGREE
• First degree external os lies behind ischial
  spine but inside the introitus
• Second degree external os lies outeside the
  introitus but the fundus is inside the introitus
• Third degree,fundus lies outside the introitus
  (procedentia )

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Vaginal prolapse

• Cystocoele bulge of bladder into anterior
  vaginal wall
• Urethrocoele bulge of post wall of urethra into
  vaginal wall
• Rectocoele bulge of anterior wall of rectum
  into post vaginal wall
• Prolapse of post vaginal wall bulge of lower
  posterior vaginal wall of into lumen of vagina
• Hernia of Dougls pouch bulge of loop of
  intestine into upper part of post vaginal wall
• Vault prolapse bulge of the scare of TAH

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causes

• Congenital
• Congenital prolapse ---at birth
• Virginal prolapse -----before marriage
• Acquired
• Labor 1-Bearing down
• 2- Forceps delivery
• 3-breach extraction before fully
  dilatation
• 4- large head without episiotomy
• 5-traction on cord
• 6-prolonged labour, an interference in
  the
  delivery by inexpert people,

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• During puerperium
• No kegles ex
• No sims position
• lack of exercise and bodily weakness
• lack of proper rest and diet in post-
  
  natal periods, repeated deliveries
  and manual work.
• heavy uterus fibroid , sub involution
• Lax ligament pregnancy
• Menopausal atrophy ----decrease of estrogen

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• Increase in intra abdominal pressure
• Abdominal mass
• Ascitis
• Chronic cough
• Chronic constipation
• Heavy uterus
• tumors of the uterus,
• Pregnancy
• Subinvolution

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symptoms

• She feels a sense of fullness in the region of
  the bladder and rectum.
• dragging discomfort in the lower abdomen, low
  backache, heavy menses and milk vaginal discharge
• . increase in the frequency of urination and the
  patient feels difficulty in total emptying of the
  bladder. burning sensation due to infection.
  sexual

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• The woman may experience difficulty in passing
  stools and complete evacuation of bowels.
• These symptoms become more pronounced before and
  during menstruation.
• The condition may also result in difficulty in
  normal sexual intercourse and sometimes
  sterility.

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Complications

• Cystocoele
• Cystitis
• Pyelonephrinits
• Kinking of the tube
• Uterine prolapse
• Keratinisation of the
• Decubital ulcer
• Kinking of the tube

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• prevention
• good antenatal care in pregnancy,
• proper management and timely intervention during
  delivery,
• Empty of bladder rectum
• Avoid bearing down
• Avoid piston technique in placental delivery
• good postnatal care
• with proper rest, correct diet and appropriate
  exercise so as to strengthen the pelvic
  musculature.
• sleeping in semis position empty of bladder ,
  Hodge pessary ,avoid early ambulation

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Uterine inversion

• Uterine inversion may occur immediately
  postpartum or, much less frequently, during the
  puerperium.
• Inversions are usually described as acute (lt30 d
  after delivery) or chronic (gt30 d after
  delivery).

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Degree

• In first-degree inversion, the inverted wall
  extends to but not through the cervix.
• In second-degree inversion, the inverted wall
  protrudes through the cervix but remains within
  the vagina.
• In third-degree inversion, the inverted fundus
  extends outside the vagina. In fourth degree or
  total inversion, both the vagina and uterus are
  inverted.

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• Possible etiology
• Reported associations for uterine inversion
  include the following
• Idiopathic
• Excessive cord traction or a short umbilical cord
  
• Credé (fundal) pressure
• Placenta accreta or increta or percreta
• Fundal implantation of the placenta
• Chronic endometritis
• Fetal macrosomia
• Trials of vaginal birth following cesarean
  delivery
• Myometrial weakness
• Precipitate labor
• drugs, including magnesium sulfate
• 
  
  
  

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SS

• The classic observations include
• postpartum hemorrhage,
• the sudden appearance of a vaginal mass, and
• varying degrees of cardiovascular collapseall
  usually occurring in the immediate puerperium.
• The postpartum hemorrhage is usually the most
  striking of the symptoms and initially commands
  the attention of the clinician.
• In other cases, the sudden and disconcerting
  protrusion of a large, dark red, polypoid mass
  through the vagina either accompanying or
  following the placenta is noted. The
  characteristic appearance of the inverted uterus
  either retained within the vagina or protruding
  externally is both surprising and startling and
  usually immediately establishes the correct
  diagnosis

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• Management
• Following uterine inversion, prompt treatment of
  hemorrhage and shock is vital in limiting
  maternal morbidity and the risk of mortality.
• Hypotension and hypovolemia require aggressive
  fluid resuscitation. The general principles of
  treatment follow the (STAR) protocol

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• Shock
• Initiate fluid resuscitation with 2 large-bore
  intravenous lines. Promptly administer 1 or more
  liters of an isotonic salt solution such as
  lactated Ringer parenterally.
• Submit specimens to the laboratory for possible
  transfusion and for determination of baseline
  values of hemoglobin (Hgb), hematocrit (Hct), and
  coagulation factors.
• Insert a Foley catheter.
• Immediately summon an anesthesiologist.
• Treat aggressively
• Order appropriate surgical equipment and
  assistants to ready the operating room for a
  possible laparotomy.
• Administer tocolytics to promote uterine
  relaxation. These may include nitroglycerin , or
  magnesium sulfate at 4-6 g IV over 20 minutes.

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• Attempt prompt uterine replacement. First,
  proceed with a trial of simple manual
  replacement. If this is unsuccessful, promptly
  perform a laparotomy for a surgical replacement
  At laparotomy, general anesthesia employing a
  uterine relaxing agent is best,

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• It is important that the part of the uterus that
  came out last (the part closest to the cervix)
  goes in first. 
• Figure P-52
• Manual replacement of the inverted uterus
•  

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• Repair
• Suture birth canal lacerations and any surgical
  incisions in cervix or vagina.
• Perform uterine massage (after replacement).
• Administer uterotonics. These may include methyl
  ergonovine maleate (Methergine 0.2

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• Surgical techniques
• If 2 or more attempts at manual replacement are
  unsuccessful, surgery is indicated. An abdominal
  approach for uterine replacement is favored. A
  vaginal technique has also been described but has
  few adherents.
• In the vaginal procedure, the bladder is
  dissected from the cervix, and the anterior lip
  of the cervix and the anterior wall of the uterus
  are incised to the extent necessary to permit
  replacement.

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• POST-PROCEDURE CARE
• Once the inversion is corrected, infuse oxytocin
  20 units in 500 mL IV fluids (normal saline or
  Ringers lactate) at 10 drops per minute
• - If haemorrhage is suspected, increase the
  infusion rate to 60 drops per minute
• - If the uterus does not contract after oxytocin,
  give ergometrine 0.2 mg or prostaglandins (Table
  S-8).
• Give a single dose of prophylactic antibiotics
  after correcting the inverted uterus
• - ampicillin 2 g IV PLUS metronidazole 500 mg IV
  
• - OR cefazolin 1 g IV PLUS metronidazole 500 mg
  IV.