What is Uterine Inversion?
Uterine inversion is one of the most extreme complications that can happen after childbirth. This condition is when the top part of the uterus, known as the fundus, collapses into the space inside the uterus. Even though it’s not common, it’s very serious because it can lead to heavy bleeding and shock, which can cause death.[1]
What Causes Uterine Inversion?
The two most frequently suggested reasons for uterine inversion (when the uterus turns inside out) are pulling too hard on the umbilical cord when the placenta is attached at the top of the uterus, and pressure on the top of the uterus when it is relaxed. Other potential risks could include going into labor quickly, the placenta growing into the uterine wall, manually removing the placenta, a short umbilical cord, using drugs to relax the uterus, the uterus being overly stretched, having a large baby, being in your first pregnancy, the placenta covering the cervix opening (placenta previa), disorders that affect your body’s connective tissues (like Marfan syndrome and Ehlers-Danlos syndrome), and having had a uterine inversion before during a previous pregnancy. However, in most cases, we can’t find a clear risk factor, which makes it hard to predict when this might happen.
There are different levels of severity when it comes to uterine inversion:
* Incomplete: The top of the uterus turns inside out but doesn’t move down to the opening of the uterus.
* Complete: The top of the uterus moves all the way down to the cervix and we can’t feel the top of the uterus in the belly.
* Prolapsed: The entire uterus moves down through the cervix, and the top of the uterus comes out of the vaginal opening.
We also classify uterine inversion based on how long it takes to happen after delivery:
* Acute: Happens 24 hours or less after delivery.
* Subacute: Takes longer than 24 hours after giving birth.
* Chronic: Takes longer than one month after giving birth.
Risk Factors and Frequency for Uterine Inversion
Uterine inversion, a condition where the uterus turns inside out, is rare, affecting around 1 in 2,000 to 23,000 childbirths. Interestingly, it is often seen in deliveries considered ‘low-risk’. The occurrence of this condition is about 3 times higher in India than in the United States. However, the rate of uterine inversion has significantly dropped to a quarter of what it once was, following the start of more proactive management in the late stages of childbirth.
Signs and Symptoms of Uterine Inversion
Uterine inversion is when the uterus turns inside out, often after childbirth. This is usually suspected when the top of the uterus (known as the fundus) cannot be felt during an abdominal examination. The main symptoms of uterine inversion include:
- Quick onset of heavy vaginal bleeding, which can lead to a sudden drop in the mother’s blood pressure and heart rate
- Feeling of strong pressure or pain in the lower abdomen
Classically, the shock resulting from this condition is thought to be disproportionate to the amount of blood loss, potentially due to overstimulation of the part of the nervous system that maintains homeostasis (the parasympathetic system) as a result of tissue stretching. It’s important to note, though, that blood loss can oftentimes be underestimated and thus, there may be a greater need for blood transfusion than initially assumed. Unfortunately, due to the severity of the shock, many women may not be able to express the discomfort they are experiencing. Uterine inversion can happen before or after the placenta has been detached.
Testing for Uterine Inversion
The diagnosis is typically made by performing a hands-on physical examination. During this examination, the doctor feels for the top part of the uterus, which may be found in the lower part of the uterus or within the vagina. In cases where the results from the physical examination are unclear, an ultrasound could be carried out to confirm the diagnosis. An ultrasound is a safe imaging procedure that uses sound waves to create pictures of the inside of your body.
Treatment Options for Uterine Inversion
If a woman is diagnosed with uterine inversion, a condition where the uterus turns inside out, it’s very important for doctors to act quickly. Delaying treatment could lead to more serious health consequences, including a higher risk of death. The initial goal is to stop any bleeding and ensure the woman’s general health remains stable. Here’s a general idea of what that action plan could look like:
- First, medical professionals raise the alarm and call for a specialist in anesthesia.
- To restore a woman’s blood volume and maintain a steady blood flow, a big needle (or cannula) is used to introduce fluids and possibly blood into her body.
- If the uterus has recently inverted and separated from the placenta (the organ connecting the baby with the wall of the womb), doctors often try to manually push it back to its normal position. This sometimes gets more difficult and risks additional bleeding if not done right away.
If the placenta is still attached to the uterus, doctors usually don’t detach it until the woman receives fluid replacements and medications to help the uterus relax (these medications might be inhaled or administered through an IV). They may also use other drugs for uterine relaxation and repositioning, such as magnesium sulfate, beta-mimetics, or nitroglycerine. After this, any part of the uterus that has come out through the vagina is put back in place. Once the placenta is removed, doctors apply steady pressure to the inverted area of the uterus to push it back through the dilated (or widened) cervix. They use their fingers to do this, but must be careful to avoid puncturing the uterus. After that, drugs that cause the uterus to contract are given to help the woman’s body prevent the uterus from inverting again.
Doctors may also give the woman antibiotics to prevent infection. If they aren’t able to manually put the uterus back in its place, they have a few other options.
- Hydrostatic Reduction: This technique uses the pressure of warm, sterile saltwater to help return the uterus to its usual position. The saltwater is introduced into the vagina using a special bag that’s lifted about 100 to 150 cm (or about 3 to 5 feet) above the body. A medical tool like a silicone ventouse cup, or the doctor’s hand, helps keep the water in the vagina. This technique can reduce blood loss and help prevent the uterus from inverting again, though it can sometimes result in infection, failure, or a saline embolus (a blockage of a blood vessel by a bubble of air or other matter).
- Surgical Options: If the above techniques don’t work, there are several surgical procedures available. Some of these procedures involve incisions in the abdomen (laparotomy) or the cervix. If these surgeries are performed, future pregnancies will require a cesarean delivery.
These are general procedures, and the exact treatment plan will be tailored for each patient depending on their unique circumstances. It’s important to trust your healthcare team and to ask any questions you might have about these procedures.
What else can Uterine Inversion be?
If you find a lump in the vagina or experience sudden weakness after giving birth, there could be different causes. It’s important to figure out the actual reason to provide the necessary treatment. The following conditions might be responsible:
- Severe uterine atony (weakness of the uterus after childbirth)
- Uterovaginal prolapse (slipping of the uterus into or through the vagina)
- Fibroid polyp (noncancerous growths in the uterus)
- Neurogenic collapse (fainting or other neurological disorders)
- Postpartum collapse (sudden loss of consciousness after childbirth)
- Retained placenta without inversion (part of the placenta remains in the uterus after delivery)
- Coagulopathy (a condition that affects the blood’s ability to clot)
What to expect with Uterine Inversion
Acute situations can cause severe bleeding leading to shock, but swift and proper treatment usually prevents long-lasting adverse effects. It’s unclear if this condition can impact future chances of pregnancy, but there have been cases reported of pregnancies that proceeded without complications.
Possible Complications When Diagnosed with Uterine Inversion
Uterine inversion, which is when the uterus turns inside out, can cause several issues. Problems come from the condition itself (primary) or from the treatment used to manage it (secondary). The main problem associated with the condition is bleeding and the dangers that go with it, such as damage to multiple organs, shock, Sheehan syndrome (a condition where the pituitary gland is damaged), and having to remove the uterus. If not treated, the condition can cause ongoing significant blood loss and tissue death. There can be additional problems related to the treatment, such as reactions to general anesthesia and blood transfusions.
Possible Complications:
- Bleeding
- Damage to multiple organs
- Shock
- Sheehan syndrome
- Having to remove the uterus
- Ongoing significant blood loss
- Tissue death
- Reactions to general anesthesia
- Reactions to blood transfusions
Preventing Uterine Inversion
Women who have had a condition known as uterine inversion, where the uterus turns inside out, should be aware that there is a chance this might happen again in future pregnancies. It’s important to discuss this with a healthcare professional who can provide advice and guidance.
