Learning objectives

• Description and four degrees of uterine inversion
• Signs and symptoms of uterine inversion
• Management of uterine version

Definition and mechanisms

• Uterine inversion is a rare complication when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out
• A life-threatening obstetric emergency as it can lead to severe blood loss, shock, and even maternal death
• In extremely rare cases (5% of uterine inversions), fibroids or tumors cause uterine inversion
• Four degrees of uterine inversion:
  • 1st degree (incomplete): the fundus is within the endometrial cavity
  • 2nd degree (complete): the fundus protrudes through the cervical os
  • 3rd degree (prolapsed): the fundus protrudes to or beyond the introitus
  • 4th degree (total): both the uterus and vagina are inverted and protrude outside the body
• Time of occurrence:
  • Acute: within 24 hours of delivery
  • Subacute: more than 24 hours but less than four weeks postpartum
  • Chronic: ≥ 1 month postpartum
• The incidence ranges from 1 in 3500 to 20,000 deliveries

Signs and symptoms

• Postpartum bleeding
• Abdominal pain
• A smooth, round mass protruding from the cervix or vagina
• Urinary retention
• Hypotension
• Hemodynamic shock
• Bradycardia

Causes

• Mismanagement of the third stage of labor such as:
  • Fundal pressure
  • Excess cord traction during the third stage of labor
• Other natural causes can be:
  • Uterine weakness
  • Precipitate delivery
  • Short umbilical cord
• It is more common in multiple gestations than in singleton pregnancies

Risk factors

• Short umbilical cord
• Rapid or prolonged labor and delivery
• Use of uterine relaxants
• Nulliparity
• Fetal macrosomia
• Retained placenta
• Severe pre-eclampsia
• Uterine atony
• Placenta accreta spectrum
• Uterine anomalies or tumors (leiomyoma)

Complications

• Major hemorrhage
• Multi-organ damage
• Shock
• Sheehan syndrome
• Hysterectomy

Diagnosis

• Clinical findings
• Ultrasound examination shows an abnormal uterine fundal contour with a homogenous globular mass within the uterus

Management

Suggested reading

• Macones G. 2022. Peurperal uterine inversion. Up to date. 
• Wendel MP, Shnaekel KL, Magann EF. Uterine Inversion: A Review of a Life-Threatening Obstetrical Emergency. Obstet Gynecol Surv. 2018;73(7):411-417.
• Shepherd LJ, Shenassa H, Singh SS. Laparoscopic management of uterine inversion. J Minim Invasive Gynecol. 2010;17(2):255-257.