Acute postpartum uterine inversion is a relatively rare complication. The uterus inverts and the uterine fundus prolapses to or through the dilated cervix. It is associated with major postpartum haemorrhage with or without shock. Shock is sometimes out of proportion to the haemorrhage. Minimal maternal morbidity and mortality can be achieved when uterine inversion is promptly and aggressively managed. We present this report of three cases of acute uterine inversion complicated with major postpartum haemorrhage and managed with Rusch balloon. The paper highlights the importance of early recognition and the safety of the use of intrauterine balloon to manage major postpartum haemorrhage in these cases.
Acute postpartum uterine inversion is a relatively rare complication. The uterus inverts and the uterine fundus prolapses to or through the dilated cervix. It is associated with major postpartum haemorrhage with or without shock. Shock is sometimes out of proportion to the haemorrhage. Minimal maternal morbidity and mortality can be achieved when uterine inversion is promptly and aggressively managed. We present this report of three cases of acute uterine inversion complicated with major postpartum haemorrhage and managed with Rusch balloon. The case series highlights the importance of early recognition and the safety of the use of intrauterine balloon to manage major postpartum haemorrhage in these cases.
Acute uterine inversion is a rare obstetric emergency. In 30, 466 deliveries over 4.5 years we had three cases giving an incidence of about 1 : 10.000. All of them were recognized early but had major postpartum haemorrhage. There have been only very few reported cases of managing acute uterine inversion and related major postpartum haemorrhage with hydrostatic balloon [
Postpartum acute uterine inversion is an obstetric emergency where the uterine fundus passes through the cervix (complete inversion), or remains above this level (incomplete inversion).
Presentation of uterine inversion can be acute (within 24 hours of delivery), subacute (over 24 hours and up to the 30th postpartum day) or chronic (more than 30 days after delivery) [
Various aetiological factors have been linked to uterine inversion, though in the majority of cases no obvious causes are found. Attributable factors include short umbilical cord, excessive traction on the umbilical cord, fundal pressure, fundal implantation of the placenta, abnormal adherence of the placenta, rapid or long labours, previous uterine inversion, and certain drugs such as magnesium sulphate and other tocolytic drugs.
It presents most often with symptoms of a postpartum haemorrhage. In a series of 40 cases, postpartum haemorrhage complicated 65% of cases of acute uterine inversion, and 47.5% required blood transfusion [
Acute uterine inversion can be life threatening; however, it can be successfully managed with rapid recognition, intravenous fluids, blood transfusion, and immediate repositioning of the uterus and medical management for atonic uterus. The use of intrauterine balloon has proven to be useful to reduce blood loss and prevent recurrence as in our cases.
Prompt replacement of the uterus is best done manually and promptly as delay can render replacement progressively more difficult. Placenta should be left if still attached.
Johnson’s technique refers to the manual replacement method where the uterus is replaced by placing a fist on the fundus and gradually pushing it back into the pelvis through the dilated cervix. Bimanual uterine compression and massage should be maintained until the uterus is well contracted and bleeding has stopped. Should manual reduction fail to achieve uterine repositioning, then employing the use of hydrostatic replacement with Rusch balloon [
If the above are unsuccessful a surgical approach is required. Huntington procedure involves a laparotomy to locate the cup of the uterus. Allis forceps is used to gently apply upward traction until the inversion is corrected [
Uterine inversion is rare but carries high morbidity including major postpartum haemorrhage and blood transfusion. Delay in the diagnosis can lead to serious complications related to major postpartum haemorrhage. Increasing awareness regarding the detection and a multidisciplinary approach are essential components of management. Urgent replacement of the uterus, resorting early to blood transfusion, and use of uterine balloon catheter would reduce the morbidity from this condition. The advantage of Rusch balloon over other balloons is the capacity which no other balloon has. Though the use of Rusch balloon in major postpartum haemorrhage is not a new technique, this case reports highlight the safety of using it in cases of acute inversion complicated with postpartum haemorrhage and also add to the few reported cases on its safety in managing the acute inversion, related major postpartum haemorrhage, and possibly prevention of recurrence.
The authors declare that there is no conflict of interests.