Puerperal inversion of the uterus JAMES D. KITCHIN Ill, M.D. SIVA THIAGARAJAH, M.B.B.S.(CEnoN) HARRY V. MAY,
JR.,
M.D.
W. NORMAN THORNTON,
JR.,
M.D.
Charlottesville, Virginia
Acute puerperal inversion of the uterus is an uncommon but potentially fatal obstetric complication. In the I 5 year period ending December 31, 1974, 11 inversions have been managed at the University of Virginia Hospital. All we·re recognized immediately and manually replaced and there was no significant postpartum morbidity. Successful management appears to depend largely upon prompt recognition, which can be achieved by routine postpartum examination of the vagina and cervix and manual exploration of the uterus.
termed incomplete if the uterine corpus does not invert beyond the cervix, or complete if any part of the corpus extends through the cervical ring. Although it has been suggested that further classification is arbitrary and that the only important considNation is whether inversion is complicated or uncomplicated, 10 acute inversion (before the cervical ring has formed) may be distinguished from subacute inversion or chronic inversion (present for one month or more). 14 · 15 Inversion requires cervical dilatation and relaxation of a portion of the uterine corpus. 4 Sudden emptying of the uterus after distension of its cavity has also been proposed as a necessary condition. 1' 6 Although it may occur "spontaneously", mismanagement of the third stage of labor is generally conceded to be the immediate cause. 7 The mechanism of inversion may depend upon certain predisposing factors as well as more immediate events3 • 16 :
AcuTE PUERPERAL inversion of the uterus is an obstetric emergency. It occurs infrequently, but must be considered immediately in all cases of postpartum hemorrhage and shock. Successful management and reduction of morbidity and mortality rates are dependent upon prompt recognition. As direct involvement with this condition by any one physician is limited or nonexistent, periodic review of the clinical course and methods of management is desirable. Most reports in the English language literature are concerned with small numbers of patients, although a number of reviews are available. 1- 10 Excellent historical reviews are available. 1 • 3 • 9 There is wide variation in the reported incidence of inversion, although all authors stress its rarity. Estimates range from one in several hundred thousand deliveries in the earlier literature to one in 4,000 or 5,000 in more recent reports. 10- 13 In a few smaller series, frequencies of 1:23002 and 1:7408 are given. Presumably inversion will occur more commonly when obstetric care is less enlightened 7 and incidence figures will be influenced by recognition of the condition and the willingness with which such a complication is reported.4 Puerperal inversion usually occurs during or immediately after the third stage of labor. It may be
A. Predisposing l. Pathologic conditions of the uterus and its contents (e.g.) adherent placenta, shon cord, congenital weakness or anomalies, weakening of the uterine wall at the placental attachment fundal implantation of the placenta, tumor) 2. Functional conditions of the uterus (e.g., relaxation of the uterine wall, disturbance of the contractile mechanism) B. Exciting 1. Manual removal of the placenta 2. Increase in intra-abdominal pressure 3. Mismanagement of the third stage of labor (e.g.)improper fundal pressure, tl'action on the cord, i~judicious use of oxytocics) The incidence of "spontaneous" inversion has been
From the Department of Obstetrics arul Gynecology, University of Virginia School of Medicine. Presented at the Thirty-seventh Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, Febru.ary2-5, 1975. Reprint requests: W. Norman Thornton, Jr., M.D.,
University of Virginia Hospital, Charlottesville, Virginia 22903. 51
52 Kitchin et aL .\Ill
Table I. Puerperal inversion of the uterus: Age incidence Age (yr.)
No. of patients
Under 20 20-24 25-29
4 6 1
Total
fl
Percentage 36.4 54.5
9.1 IOO.O
reported to be between 15 and 50 per cent. 1• 4 • 1'· 8 Some have taken this to indicate a congenital predisposition to inversion in some women, perhaps as a result of abnormalities in uterine musculature or innervation.2 This concept may be further supported by the relative proportion of primiparas in some inversion series (52 to 67 per cent), I. 2 • 4 • s by a tendency toward recurrence in subsequent pregnancies, 17 - 21 and by observations in cows where the incidence of inversion is high (I :517 deliveries), even though most deliveries are unattended and mismanagement of the third stage presumably unlikely. 16 "Spontaneous" inversion has been observed in human subjects at the time of cesarean section, u. 19 • 22 although in some of these cases oxytodcs had been given. The disparity between vigorous, aggressive conduct of the third stage and the rarity of inversion supports the importance of predisposing factors. 6 • 10 ' 23 The cardinal symptoms are hemorrhage, shock, and pain, either singly or in combination, although inversion may occur without either. 24 • 25 Shock may be out of proportion to recognized blood loss, 3 • 4 perhaps because of stretching of the broad ligament and peritoneal nerves as they are pulled into the inversion ring as well as compression of the ovaries by the same mechanism. 2 • 26 Palpable "cupping" or an apparent absence of the fundus on abdominal examination suggests inversion, but indentation is easily overlooked26 and diagnosis ultimately depends upon demonstrating the mass in the vagina. Routine examination of the cervix post partum will establish the diagnosis and may do so before the appearance of any symptoms. 6. 22-24, 21
Materials and methods Between January l, 1960, and December 31, 1974, there were 25,124 deliveries at the University of Virginia Hospital. During this period 11 puerperal inversions of the uterus were diagnosed and treated, an incidence of one in 2,284 deliveries. However, during the last 2 years of this study inversion occurred once in 551 to 604 deliveries.
Sqn('llliwr I. 1!17:> I Obsrct. ( ;, "'"' ,J.
The patients' ages are summarized in Table I. The youngest was 15 and the oldest 25. In this series inversion occurred in primiparas four times, with the second delivery in five patients and with fourth or more deliveries in two patients. Two of the patients classified in the para I group had had abortions. Previous abortions had occurred in two other· patients, twice in a patient pregnant for the seventh time when the inversion occurred and once in a patient pregnant for the second time with no previous term deliveries. The prenatal course, labor, and delivery, were uncomplicated in all but four of the II patients. In addition to age, parity, and period of gestation, some aspects of delivery, placental expression, and the recognition of the inversion are summarized in Table II. Patients 2 and 5 delivered healthy infants whose weights fell into the premature range ( 1,820 and 2,320 grams, respectively). Normal spontaneous vaginal delivery was accomplished in all 11 patients, although induction of labor using intravenous oxytocin was carried out in Patient 8, and oxytocin augmentation of labor in Patient 4. Patient 4 had received intravenous magnesium sulfate during the latter part of labor for symptoms of mild pre-eclampsia. Patient 2 had had spontaneous rupture of membranes 24 hours prior to onset of labor and had been begun on antibiotics for that reason. The longest labor was that of Patient 3, whose labor lasted 20 hours and 19 minutes. Patients 2, 4, 5, I 0, and 11 labored between 9 and 14 hours. Patients 1, 6, 7, 8, and 9 labored less than 4 hours and the delivery of Patient 9 was considered to be precipitous. Recognition of inversion was immediate in all 11 cases. As is indicated in Table II, third-degree (extension through the vulva) inversion was present in seven patients. In the other four, inversion was complete in that the fundus had passed through the cervical ring and classified as second degree in that it did not extend through the vulva. Expression of the placenta was done as indicated in Table II. The modified Crede maneuver as carried out at this institution implies gentle massage of the uterine fundus with minimal cord traction once the uterus is judged to have contracted and placental separation assumed to have occurred. Table III summarizes additional data regarding the clinical symptoms of the inversion and the estimated blood loss and replacement. The duration of rhe third stage is summarized as well. In Patients 5, 6, 7, 8, and 9 the placenta was manually removed before the uterus was repositioned. A small area of persistent placental
Puerperal inversion of uterus
Volume 1~:1 :--lumber 1
53
Table II. Puerperal inversion of the uterus De~rree
Period of gestation
Age
1
Patient
(yr.)
Parity
(wk.)
Delivery
Placenta,*
Recognition
invasion
2 3 4 5 6 7 8 9 10
18 23 24 15 21 18 21 22 25 19 23
2 2
38 33 40 40 38 39 44 42 41 39 37
Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous
Crede Tractiont Traction* Traction Credet Tractiont Credet Traction; Credet Spontaneous Crede Traction
Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate
Sec,md Thxd Th;rd Second Third Th1rd Third Thtrd Thtrd Second Setond
11
l
I
4 2 2 2 5 1 I
*Crede = modified Crede maneuver; traction = "minimal" cord traction. t Placenta manually removed before inversion replaced. tPlacenta manually removed after inversion replaced.
Table III. Clinical symptoms
Patient
2 3
4 5 6 7 8 9
10 II
Symptoms
Duration of third stage (min.)
Hemorrhage*
7 21 7 5 22 48 12 20 45 5 5
Yes Yes No No Yes Yes Yes Yes Yes No Yes
I
Shock
Yes Yes Yes
Estimated blood loss (ml.)
500 1800 200 300 1500 1500 1200 3000 2000 300 750
Hematocrit Replacement (mi.)
500 .1)00 2000 2000 1500 2000
Admission (%)
37 33 33 38 33 39 31 40 36
35 35
J
Di:;ctJarge (%)
34
30
37 36 30 31 35 36 42 39 29
*Estimated blood loss 500 mi. or more.
attachment was also manually separated in Patient 2 prior to repositioning. Hemorrhage (estimated blood loss 500 mi. or more) was present in eight patients, but shock (tachycardia, significant blood pressure drop) observed only in Patients 5, 6, and 9. Estimated blood loss ranged from 200 to 3,000 ml. Six patients had blood replacement: one unit in two patients, three units in one patient. and four units irl the other three. Hematocrit at the time of discharge from the hospital was no lower than 29 per cent in any patient. Further clinical data regarding management of the inversion and the subsequent course are summarized in Table IV. Immediate manual replacement without significant difficulty was achieved in all 11 patients. Although three patients were in clinical shock at the time, intravenous fluids had been started and whole blood either started or ordered. Patients 1, 2, and 4 had manual replacement by the Johnson technique 28 and Patient 5 by a variation which employs the use of
ring forceps on the cervix. 2 Packing of the uterus or vagina was not used. The postpartum cotirse was uncomplicated in all cases. Nine patients were given antibiotics. Patient 2 had been begun on antibiotics 24 hours before delivery because of spontaneous rupture of membranes and a mild febrile course. The other eight patients were never febrile. Hospital stay varied from 2 to 5 days (mean, 4.5). Three patients are known to have had subsequent pregnancies. Patient 8 returned one year after the inversion with an early intrauterine pregnancy and requested abortion by hysterectomy. Patient 5 had four subsequent uncomplicated vaginal deliveries and I 0 years after the inversion returned for inter· ruption of pregnancy by hysterotomy, at which time tubal ligation was accomplished. Patient 6 had two subsequent pregnancies, the first a normal spontaneous term delivery, and the second a spontaneous first-trimester abortion. Patient lO was lost to follow-up
54
Kitchin et al. Am.
Septembct I. I '1/.1 Ob>tet. (;\ ncnd.
J.
Table IV. Management
Patient
2
Anesthesia for delivery Pudendal N2 0
Management of inversion ~.fanual
replacement
Hospital hfl.rl11.m. --···· --- r--· -Pn(f
course TT ............................... I.: ........ + ..... ...l* V ULVH! puLau::::;u
10/n'\J
--~J
(da_~s)
."
4 5
Local N 20 N 20
Manual replacement Manual replacement Manual replacement Manual replacement
Uncomplicated* Uncomplicated Uncomplicated* Uncomplicated*
6
N 2 0-Trilene
Manual replacement
Uncomplicated*
5
7 8
N 20-Trilene N.o N 20-Trilene
Manual replacement Manual replacement Manual replacement Manual replacement Manual replacement
Uncomplicated* Uncomplicated* Uncom plica ted* Uncompiicated Uncom plica ted*
6 5 5 5
3
9 iO II
N20-Trilene Local
Subsequent pregnancies
5 5
4 4
4 (vaginal-uncomplicated) 2 (I term vaginalI aborted) I (T AH-abortion)
4
*Prophylactic antibiotics
2 weeks after discharge (now 11 years ago) and Patient 9 six years after inversion. She had had no known gynecologic problems.
Analysis of data The frequency with which acute puerperal inversion of the uterus has been diagnosed at the University of Virginia Hospital for the last 15 years certainly exceeds the generally reported incidence figures. It must be assumed that some, if not all, inversions were related to the conduct of the third stage of labor, by either excessive fundal pressure or cord traction or both. Although a number of the placentas were still adherent at the time the inversion occurred, no abnormally adherent placentas occurred in this series. That inversion in each case was immediately recognized is attributable to a significant degree to the policy of manually exploring the uterus after each delivery as well as inspecting the vagina and cervix. It is not possible to assume that any of these inversions occurred "spontaneously." The single most frequent symptom was that of hemorrhage, which occurred in 73 per cent of this series. Other reports have stressed the importance of this symptom 1 • 4 ' 9 and it is apparenr that a high index of suspicion of inversion of the uterus should be maintained in aii cases of postpartum hemorrhage. Shock was present in only 27 per cent and in no case was it considered to be out of proportion to recognized blood loss. It is possible that immediate replacement such as was carried out in this group of patients (and which was accompanied in all cases by rapid return to normal blood pressure) precluded the development of
the significant degrees of shock described in earlier reports. It is noteworthy that Patients 2, 5, 6, 7, 8, and 9 had the greatest estimated blood loss and that it was these who had manual removal of the placenta after inversion but prior to repositioning. Only three patients conceived subsequently. It is not known whether any of the other eight patients were involuntarily infertile but there is no evidence of abnormalities of menstruation in a careful review of their hospital records and all but two have had regular gynecologic examinations. Both Patients 5 and 6 who subsequently carried pregnancies to term did so without difficulty, although Patient 6 had a later spontaneous abortion. A pregnancy in Patient 8 was subsequently terminated at her request.
Comment Although "spontaneous" inversion may occur, preventive measures should be directed toward careful management of the third stage. Excessive fundal pressure and undue cord traction must be avoided. An awareness that inversion may occur with any delivery and routine inspection of the cervix and vagina and manual exploration of the uterus will allow immediate recognition. It is in those cases recognized immediately that replacement is most simply achieved. In all cases the usual n1easures to counteract shock should be undertaken and whole blood immediately cross-matched and available. Oxytocic agents should be withheld and an attempt made to reposition the uterus manually via the vagina. If there is a tendency tov.rard cervical contraction, general anesthesia may be required. The methods described for manual reposition
Volume 1~3 Number l
are generally variations on the following approach: if the bulk of the placenta is such that replacement is unlikely vvithout removing it or if most has already separated it should be manually removed from the inverted uterus. Ho,vever, since the myometrium is easily torn, bleeding may be increased and shock aggravated, maternal sinuses are exposed to sepsis, and pathologically adherent placentas do occur, removal of the placenta prior to replacement carries some risk. 7 Using the fingers of one hand in the vagina an attempt is made to replace the uterus by pressure. It may be possible to find an area adjacent to the cervix which repositions with relative ease and this should be pursued. It has been stressed that the portion of the uterus which inverted last should be replaced first in order to avoid multiple thicknesses of the myometrium in the cervical ring at the same time. Counter traction may be applied by the use of instruments such as ring forceps applied to the cervix. 2 Another variation of manual replacement involves lifting the uterus into the abdominal cavity above the level of the umbilicus with the vaginal hand, enabling passive action of the broad ligaments to help correct the malposition. 28 This method was used with success in three patients in the current series. Once the uterus has been replaced the hand should be left in the endometrial cavity until there is firm contraction and intravenous oxytocics are being administered. Whether uterine packing is necessary once good replacement has been achieved is a matter of controversy but has been stressed as an important factor in successful management. 1L 17, l9, 2 7. 29 A method of vaginal replacement using intravaginal hydraulic pressure through a douche apparatus has been described and shown to be effective in a number of cases. 20 • 30 • 31 Regardless of the method of vaginal replacement employed, careful manual exploration of the uterus afterward is essential to rule out the possibility of uterine rupture occurring either during the course of the inversion or its replacement. 5 • 20 • 2 L 32 • 33 It would seem that the keys to successful immediate replacement are (l) speed of recognition and institution of therapy, (2) preservation of antiseptic technique and prophylactic antibiotic coverage, and (3) anesthesia sufficient to allow the required manipulation. 7 In those patients in whom immediate replacement is not successful, an operative approach may be indicated. A relatively simple and effective procedure was first described by Huntington. 34 Through an abdominal incision the uterus is grasped with Allis forceps about three quarters of an inch below the inversion cup on both sides and upward traction exerted. Additional Allis forceps are placed below the original ones and the
Puerperal inversion of uterus
55
corpus and fundus thus further drawn up until inversion is completely reversed. The use of other instruments has been suggested 19 • 35 • 36 as replacements for the Allis forceps because of the tendency of tht· thin and friable myometrium to tear. Simultaneous pressure through the vagina by an assistant and adequate anesthesia may make this procedure easier. In those cases of chronic inversion where there is tight retraction of the cervical ring and some degree of involution of the uterus other procedures may be required. The procedure of Haultain 37 involve~ incision of the cervical ring posteriorly through an ahdominal approach. Abdominal anterior vaginocervical hysterotomy has been attributed to Ocejo. 38 Spmelli39 described a vaginal procedure in which the bladder is dissected away from the cervix and lower vterine segment. The cervical ring is then divided anteriorly. A similar procedure involves division of the cervictl ring posteriorly via a vaginal approach. 40 Other nonoperative 41 ' 44 and operative 2 • 18 • 4:!, 45 - 47 techniques have been described and reviewed in detail. Most are modifications of the above procedure~. The recurrence rate of this condition is difficult to assess. In a review concerned primarily with pre1~nancy following inversion it was found that in those women having manual replacement of the uterus the recurrence rate was 44 per cent. 18 In the same series no patients having operative replacement had recurrence of the inversion in subsequent pregnancies. Thne is at least one known instance of inversion associatt·d with rupture of the uterus which was replaced by means of a variation of the Huntington technique. Thre1~ years later another pregnancy resulted in inversion at the time of delivery. 21 • 48 In view of the high recurrence rate in the series cited above 18 some authors have recommended that further pregnancies be discouraged. 29 However. thne are numerous reports of uncomplicated deliveries in subsequent pregnancies. 4 • 6 • 10 • 36 • 49 • 50 Although one of three patients in this series known to have conceived later had a spontaneous abortion, it occurred after a normal term delivery. It is not known whet~Ier the abortion rate is increased after inversion nor whether fertility is affected. Reported postinversion CGmplications include rein version after replacement, 19 urinary retention, 7 • 27 • 35 • 38 • 5 t. 52 sepsis, anemia, and pituitary necrosis. 7 There was no maternal death in this serie; nor in recent isolated case reports but deaths do still occur. 6 • 10 As recently as 1963, four deaths in 6 years were considered attributable to this complication by the Committee on Maternal Health in one state:"' Earlier
56 Kitchin et at. :\m
from reviews indicated that the mortalitv' rate ranged o13.2 to 17.9 per cent. 1 • 4 • 9 Although higher mortality rates were reported prior to 1940 1 there was no significant over-all decrease between 1940 and 1953 4 despite more widespread availability of whole blood and antibiotics. It would appear that the benign postpartum course and successful outcome of all patients in this series can be attributed primarily to immediate recognition and rapid manual replacement. The former is ensured by a policy of routine examination of the cervix and vagina after delivery as well as manual exploration of the
Scplt'illbtT I. l ~l/,-, Ohsrcr. C\ Jll't n/
J
uterus. A high index of suspicion should be maintained for the possibility of inversion of the uterus in all cases of postpartum hemorrhage. Appropriate measures to counteract and prevent shock should be instituted early. The method of replacement will vary with the circumstances, but if immediate recognition is achieved and adeauate anesthesia available. manual reolact"ment should be possible in virtually all cases. A number of similar techniques are available for this purpose. Abdominal or vaginal operative procedures will rarely be required for acute inversion but are generally effective if needed. J
'
-,
-
-
REFERENCES 1. Das, P.: J. Obstet. Gynecol. Br. Emp. 47: 525, 1940. 2. Henderson, H., and Alles, R. W.: AM. J. 0BSTET. GYNECOL. 56: 133, 1948. 3. Schaefer, G., and Veprovsky, E. C.: Surg. Clin. North ~.l\n1. 29: 599, 1949. 4. Bell, J. E., Jr., Wilson, G. F., and Wilson, L. A.: AM. J. Vb~:"'T. GYNECOL. 66: 767, 1953. 5. Quigley, G.].: AM.]. OBSTET. GYNECOL. 69: 27i, 1955. 6. Bunke, J. W., and Hofmeister, F. J.: AM. J. 0BSTET. GYNECOL. 91: 934, 1965. 7. Donald, I.: Practical Obstetric Problems, ed. 4, Philadelphia, 1969, J. B. Lippincott Company, chap. 22, pp. 731737. 8. Harer, W. B., and Sharkey, J. A.:]. A. M. A. 114: 2289, 1940. 9. Fenton, A. N., and Singh, B. P.: Obstet. Gynecol. Surv. 5: 781, 1950. 10. Cosgrove, S. A.: AM.]. OBSTET. GYNECOL. 38:912, 1939. II. Davis, G. H.: AM. J. OBSTET. GYNECOL. 26: 249, 1933. 12. Brett, P. G.: Med. J. Aust. 1: 254, 1938. 13. Chisholm, A. E.:]. Obstet. Gynecol. Br. Emp. 51: 318, 1944. 14. Phaneuf, L. E.: Surg. Gynecol. Obstet. 71: 106, 1940. 15. KeUog, F. S.: AM.]. OBSTET. GYNECOL. 18:815, 1929. 16. Salvin, M.: West. J. Surg. 50: 147, 1942. 17. Gillespy, T.: W.Va. Med.J. 50: 121,1954. 18. Miller, N. F.: AM. J. 0BSTET. GYNECOL. 13: 307, 1927. 19. Loizeaux, L. S., and Mastraioinni, L: Obstet. Gynecol. 5: 193, 1955. 20. O'Sullivan, J. V.: Br. Med. J. 2: 282, 1945. 21. Steffen, E. A.: Wis. Med.]. 55: 1303, 1956. 22. Kaltreider, D. F., and West, G. B.: Bull. Sch. Med. Univ. Maryland 31: 144, 1946. 23. Pathak, U. N.: Br. J. Clin. Pract. 13: 299, 1959. 24. West, N. L.: Tex. State J. Med. 61: 613, 1965. 25. McGill, D. C., and Duggan, E. R.: N. Y. State]. Med. 51: 2481, 1951. 26. Spain, A. W.:J. Obstet. Gynecol. Br. Emp. 53:219, 1946.
Discussion Q.
Newport News, Virginia. The authors have described eleven cases of complete inversion of the uterus that occurred at their institution during a 15 year period ending December 31, 1974. All of these cases were recognized as acute, meaning that they had occurred before the cervical ring had formed and all were either second or third degree in DR. jOHN
HATTEN,
27. Hanton, E. M., and Kempers, R. D.: Postgrad. Med. 36: 541, 1964. 28. Johnson, A. B.: AM.]. 0BSTET. GYNECOL. 57: 557, 1949. 29. McHenry, A. G.: Obstet. Gynecol. 16: 671, 1960. 30. Enright, J. F.: Br. Med. J. 2: 714, ! 953. 31. Forster, F. M. C.: Med. J. Aust. 1: 326, 1956. 32. Carlisle, W. H.: J. Obstet. Gynecol. Br. Emp. 62: 452, 1955. 33. BalaKrishna, H., and Marx, G. F.: Can. Anaesth. Soc. J. 15: 34, 1968. 34. Huntington, J. L.: Boston Med. Surg. J. 184: 376, 1921. 35. McDuff, H. C., and Keegan, J.: AM. J. OasTET. GYNECOL. 76: 1299, 1958. 36. Burrus, J. H., and Lampley, C. G.: N.C. Med. J. 26: 502, 1965. 37. Haultain, F. W. N.: Br. Med. J. 2: 974, 1901. 38. Marcus, M. B., and Brandt, M. L.: Obstet. Gynecol. 9: 725, 1957. 39. Spinelli, P. G.: Ann. Gynecol. d'Obstet. 3: 195, 1900. 40. Lascarides, E., and Cohen, M.: Obstet. Gynecol. 32: 376, 1968. 41. Aveling, J. H.: Trans. Obstet. Soc. Lond. 20: 126, 1878. 42. Peterson, R.: Surg. Gynecol. Obstet. 5: 196, 1907. 13. Howell, D.: ~,.1ed. ] ..A.ust. I: 286, 1958. 44. Derjanecz, J. ].: Can. Med. Assoc. J. 110: 624, 1974. 45. Garde, S. N.: Obstet. Gynecol. Surv. 14: 618, 1959. 46. Huntington,]. L., Irving, F. C., and Keiiogg, F. S.: AM.]. 0BSTET. GYNECOL. 15: 34, 1928. 47. Irving, F. C., and Kellogg, F. S.: AM. J. OBSTET. GYNECOL. , -22:440, 1931. 48. Steffen, E. A.: AM. J. 0BSTET. GYNECOL. 74: 655, 1957. 49. Moldavsky, L. F.: Obstet. Gynecol. 29:488, 1967. 50. Shepler, L. G.: Obstet. Gynecol. 23: 598, 1964. 51. McKenzie, C. H., Duryea, M., Larson, D. M., and Hauge, E. T.: Minn. Med. 38: 700, 1955. 52. Plaut, G.S.: Postgrad. Med. J. 37: 164, 1961. 53. OSMA Committee on Maternal Health: Ohio Med. J. 59: 285, 1963.
that the uterine fundus had passed either through the cervical ring or completely outside the vulva. Each patient had normal spontaneous vaginal delivery. In comparing this series with other reported groups, it is important to emphasize that acure puerperal inversion, in more than 75 per cent of cases, takes place in the young para l or para 2 ,.vith an uncomplicated labor and delivery. In spite of the fact that so-called
JR.,
M.D.
W. NORMAN THORNTON,
JR.,
M.D.
Charlottesville, Virginia
Acute puerperal inversion of the uterus is an uncommon but potentially fatal obstetric complication. In the I 5 year period ending December 31, 1974, 11 inversions have been managed at the University of Virginia Hospital. All we·re recognized immediately and manually replaced and there was no significant postpartum morbidity. Successful management appears to depend largely upon prompt recognition, which can be achieved by routine postpartum examination of the vagina and cervix and manual exploration of the uterus.
termed incomplete if the uterine corpus does not invert beyond the cervix, or complete if any part of the corpus extends through the cervical ring. Although it has been suggested that further classification is arbitrary and that the only important considNation is whether inversion is complicated or uncomplicated, 10 acute inversion (before the cervical ring has formed) may be distinguished from subacute inversion or chronic inversion (present for one month or more). 14 · 15 Inversion requires cervical dilatation and relaxation of a portion of the uterine corpus. 4 Sudden emptying of the uterus after distension of its cavity has also been proposed as a necessary condition. 1' 6 Although it may occur "spontaneously", mismanagement of the third stage of labor is generally conceded to be the immediate cause. 7 The mechanism of inversion may depend upon certain predisposing factors as well as more immediate events3 • 16 :
AcuTE PUERPERAL inversion of the uterus is an obstetric emergency. It occurs infrequently, but must be considered immediately in all cases of postpartum hemorrhage and shock. Successful management and reduction of morbidity and mortality rates are dependent upon prompt recognition. As direct involvement with this condition by any one physician is limited or nonexistent, periodic review of the clinical course and methods of management is desirable. Most reports in the English language literature are concerned with small numbers of patients, although a number of reviews are available. 1- 10 Excellent historical reviews are available. 1 • 3 • 9 There is wide variation in the reported incidence of inversion, although all authors stress its rarity. Estimates range from one in several hundred thousand deliveries in the earlier literature to one in 4,000 or 5,000 in more recent reports. 10- 13 In a few smaller series, frequencies of 1:23002 and 1:7408 are given. Presumably inversion will occur more commonly when obstetric care is less enlightened 7 and incidence figures will be influenced by recognition of the condition and the willingness with which such a complication is reported.4 Puerperal inversion usually occurs during or immediately after the third stage of labor. It may be
A. Predisposing l. Pathologic conditions of the uterus and its contents (e.g.) adherent placenta, shon cord, congenital weakness or anomalies, weakening of the uterine wall at the placental attachment fundal implantation of the placenta, tumor) 2. Functional conditions of the uterus (e.g., relaxation of the uterine wall, disturbance of the contractile mechanism) B. Exciting 1. Manual removal of the placenta 2. Increase in intra-abdominal pressure 3. Mismanagement of the third stage of labor (e.g.)improper fundal pressure, tl'action on the cord, i~judicious use of oxytocics) The incidence of "spontaneous" inversion has been
From the Department of Obstetrics arul Gynecology, University of Virginia School of Medicine. Presented at the Thirty-seventh Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, Febru.ary2-5, 1975. Reprint requests: W. Norman Thornton, Jr., M.D.,
University of Virginia Hospital, Charlottesville, Virginia 22903. 51
52 Kitchin et aL .\Ill
Table I. Puerperal inversion of the uterus: Age incidence Age (yr.)
No. of patients
Under 20 20-24 25-29
4 6 1
Total
fl
Percentage 36.4 54.5
9.1 IOO.O
reported to be between 15 and 50 per cent. 1• 4 • 1'· 8 Some have taken this to indicate a congenital predisposition to inversion in some women, perhaps as a result of abnormalities in uterine musculature or innervation.2 This concept may be further supported by the relative proportion of primiparas in some inversion series (52 to 67 per cent), I. 2 • 4 • s by a tendency toward recurrence in subsequent pregnancies, 17 - 21 and by observations in cows where the incidence of inversion is high (I :517 deliveries), even though most deliveries are unattended and mismanagement of the third stage presumably unlikely. 16 "Spontaneous" inversion has been observed in human subjects at the time of cesarean section, u. 19 • 22 although in some of these cases oxytodcs had been given. The disparity between vigorous, aggressive conduct of the third stage and the rarity of inversion supports the importance of predisposing factors. 6 • 10 ' 23 The cardinal symptoms are hemorrhage, shock, and pain, either singly or in combination, although inversion may occur without either. 24 • 25 Shock may be out of proportion to recognized blood loss, 3 • 4 perhaps because of stretching of the broad ligament and peritoneal nerves as they are pulled into the inversion ring as well as compression of the ovaries by the same mechanism. 2 • 26 Palpable "cupping" or an apparent absence of the fundus on abdominal examination suggests inversion, but indentation is easily overlooked26 and diagnosis ultimately depends upon demonstrating the mass in the vagina. Routine examination of the cervix post partum will establish the diagnosis and may do so before the appearance of any symptoms. 6. 22-24, 21
Materials and methods Between January l, 1960, and December 31, 1974, there were 25,124 deliveries at the University of Virginia Hospital. During this period 11 puerperal inversions of the uterus were diagnosed and treated, an incidence of one in 2,284 deliveries. However, during the last 2 years of this study inversion occurred once in 551 to 604 deliveries.
Sqn('llliwr I. 1!17:> I Obsrct. ( ;, "'"' ,J.
The patients' ages are summarized in Table I. The youngest was 15 and the oldest 25. In this series inversion occurred in primiparas four times, with the second delivery in five patients and with fourth or more deliveries in two patients. Two of the patients classified in the para I group had had abortions. Previous abortions had occurred in two other· patients, twice in a patient pregnant for the seventh time when the inversion occurred and once in a patient pregnant for the second time with no previous term deliveries. The prenatal course, labor, and delivery, were uncomplicated in all but four of the II patients. In addition to age, parity, and period of gestation, some aspects of delivery, placental expression, and the recognition of the inversion are summarized in Table II. Patients 2 and 5 delivered healthy infants whose weights fell into the premature range ( 1,820 and 2,320 grams, respectively). Normal spontaneous vaginal delivery was accomplished in all 11 patients, although induction of labor using intravenous oxytocin was carried out in Patient 8, and oxytocin augmentation of labor in Patient 4. Patient 4 had received intravenous magnesium sulfate during the latter part of labor for symptoms of mild pre-eclampsia. Patient 2 had had spontaneous rupture of membranes 24 hours prior to onset of labor and had been begun on antibiotics for that reason. The longest labor was that of Patient 3, whose labor lasted 20 hours and 19 minutes. Patients 2, 4, 5, I 0, and 11 labored between 9 and 14 hours. Patients 1, 6, 7, 8, and 9 labored less than 4 hours and the delivery of Patient 9 was considered to be precipitous. Recognition of inversion was immediate in all 11 cases. As is indicated in Table II, third-degree (extension through the vulva) inversion was present in seven patients. In the other four, inversion was complete in that the fundus had passed through the cervical ring and classified as second degree in that it did not extend through the vulva. Expression of the placenta was done as indicated in Table II. The modified Crede maneuver as carried out at this institution implies gentle massage of the uterine fundus with minimal cord traction once the uterus is judged to have contracted and placental separation assumed to have occurred. Table III summarizes additional data regarding the clinical symptoms of the inversion and the estimated blood loss and replacement. The duration of rhe third stage is summarized as well. In Patients 5, 6, 7, 8, and 9 the placenta was manually removed before the uterus was repositioned. A small area of persistent placental
Puerperal inversion of uterus
Volume 1~:1 :--lumber 1
53
Table II. Puerperal inversion of the uterus De~rree
Period of gestation
Age
1
Patient
(yr.)
Parity
(wk.)
Delivery
Placenta,*
Recognition
invasion
2 3 4 5 6 7 8 9 10
18 23 24 15 21 18 21 22 25 19 23
2 2
38 33 40 40 38 39 44 42 41 39 37
Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous Spontaneous
Crede Tractiont Traction* Traction Credet Tractiont Credet Traction; Credet Spontaneous Crede Traction
Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate Immediate
Sec,md Thxd Th;rd Second Third Th1rd Third Thtrd Thtrd Second Setond
11
l
I
4 2 2 2 5 1 I
*Crede = modified Crede maneuver; traction = "minimal" cord traction. t Placenta manually removed before inversion replaced. tPlacenta manually removed after inversion replaced.
Table III. Clinical symptoms
Patient
2 3
4 5 6 7 8 9
10 II
Symptoms
Duration of third stage (min.)
Hemorrhage*
7 21 7 5 22 48 12 20 45 5 5
Yes Yes No No Yes Yes Yes Yes Yes No Yes
I
Shock
Yes Yes Yes
Estimated blood loss (ml.)
500 1800 200 300 1500 1500 1200 3000 2000 300 750
Hematocrit Replacement (mi.)
500 .1)00 2000 2000 1500 2000
Admission (%)
37 33 33 38 33 39 31 40 36
35 35
J
Di:;ctJarge (%)
34
30
37 36 30 31 35 36 42 39 29
*Estimated blood loss 500 mi. or more.
attachment was also manually separated in Patient 2 prior to repositioning. Hemorrhage (estimated blood loss 500 mi. or more) was present in eight patients, but shock (tachycardia, significant blood pressure drop) observed only in Patients 5, 6, and 9. Estimated blood loss ranged from 200 to 3,000 ml. Six patients had blood replacement: one unit in two patients, three units in one patient. and four units irl the other three. Hematocrit at the time of discharge from the hospital was no lower than 29 per cent in any patient. Further clinical data regarding management of the inversion and the subsequent course are summarized in Table IV. Immediate manual replacement without significant difficulty was achieved in all 11 patients. Although three patients were in clinical shock at the time, intravenous fluids had been started and whole blood either started or ordered. Patients 1, 2, and 4 had manual replacement by the Johnson technique 28 and Patient 5 by a variation which employs the use of
ring forceps on the cervix. 2 Packing of the uterus or vagina was not used. The postpartum cotirse was uncomplicated in all cases. Nine patients were given antibiotics. Patient 2 had been begun on antibiotics 24 hours before delivery because of spontaneous rupture of membranes and a mild febrile course. The other eight patients were never febrile. Hospital stay varied from 2 to 5 days (mean, 4.5). Three patients are known to have had subsequent pregnancies. Patient 8 returned one year after the inversion with an early intrauterine pregnancy and requested abortion by hysterectomy. Patient 5 had four subsequent uncomplicated vaginal deliveries and I 0 years after the inversion returned for inter· ruption of pregnancy by hysterotomy, at which time tubal ligation was accomplished. Patient 6 had two subsequent pregnancies, the first a normal spontaneous term delivery, and the second a spontaneous first-trimester abortion. Patient lO was lost to follow-up
54
Kitchin et al. Am.
Septembct I. I '1/.1 Ob>tet. (;\ ncnd.
J.
Table IV. Management
Patient
2
Anesthesia for delivery Pudendal N2 0
Management of inversion ~.fanual
replacement
Hospital hfl.rl11.m. --···· --- r--· -Pn(f
course TT ............................... I.: ........ + ..... ...l* V ULVH! puLau::::;u
10/n'\J
--~J
(da_~s)
."
4 5
Local N 20 N 20
Manual replacement Manual replacement Manual replacement Manual replacement
Uncomplicated* Uncomplicated Uncomplicated* Uncomplicated*
6
N 2 0-Trilene
Manual replacement
Uncomplicated*
5
7 8
N 20-Trilene N.o N 20-Trilene
Manual replacement Manual replacement Manual replacement Manual replacement Manual replacement
Uncomplicated* Uncomplicated* Uncom plica ted* Uncompiicated Uncom plica ted*
6 5 5 5
3
9 iO II
N20-Trilene Local
Subsequent pregnancies
5 5
4 4
4 (vaginal-uncomplicated) 2 (I term vaginalI aborted) I (T AH-abortion)
4
*Prophylactic antibiotics
2 weeks after discharge (now 11 years ago) and Patient 9 six years after inversion. She had had no known gynecologic problems.
Analysis of data The frequency with which acute puerperal inversion of the uterus has been diagnosed at the University of Virginia Hospital for the last 15 years certainly exceeds the generally reported incidence figures. It must be assumed that some, if not all, inversions were related to the conduct of the third stage of labor, by either excessive fundal pressure or cord traction or both. Although a number of the placentas were still adherent at the time the inversion occurred, no abnormally adherent placentas occurred in this series. That inversion in each case was immediately recognized is attributable to a significant degree to the policy of manually exploring the uterus after each delivery as well as inspecting the vagina and cervix. It is not possible to assume that any of these inversions occurred "spontaneously." The single most frequent symptom was that of hemorrhage, which occurred in 73 per cent of this series. Other reports have stressed the importance of this symptom 1 • 4 ' 9 and it is apparenr that a high index of suspicion of inversion of the uterus should be maintained in aii cases of postpartum hemorrhage. Shock was present in only 27 per cent and in no case was it considered to be out of proportion to recognized blood loss. It is possible that immediate replacement such as was carried out in this group of patients (and which was accompanied in all cases by rapid return to normal blood pressure) precluded the development of
the significant degrees of shock described in earlier reports. It is noteworthy that Patients 2, 5, 6, 7, 8, and 9 had the greatest estimated blood loss and that it was these who had manual removal of the placenta after inversion but prior to repositioning. Only three patients conceived subsequently. It is not known whether any of the other eight patients were involuntarily infertile but there is no evidence of abnormalities of menstruation in a careful review of their hospital records and all but two have had regular gynecologic examinations. Both Patients 5 and 6 who subsequently carried pregnancies to term did so without difficulty, although Patient 6 had a later spontaneous abortion. A pregnancy in Patient 8 was subsequently terminated at her request.
Comment Although "spontaneous" inversion may occur, preventive measures should be directed toward careful management of the third stage. Excessive fundal pressure and undue cord traction must be avoided. An awareness that inversion may occur with any delivery and routine inspection of the cervix and vagina and manual exploration of the uterus will allow immediate recognition. It is in those cases recognized immediately that replacement is most simply achieved. In all cases the usual n1easures to counteract shock should be undertaken and whole blood immediately cross-matched and available. Oxytocic agents should be withheld and an attempt made to reposition the uterus manually via the vagina. If there is a tendency tov.rard cervical contraction, general anesthesia may be required. The methods described for manual reposition
Volume 1~3 Number l
are generally variations on the following approach: if the bulk of the placenta is such that replacement is unlikely vvithout removing it or if most has already separated it should be manually removed from the inverted uterus. Ho,vever, since the myometrium is easily torn, bleeding may be increased and shock aggravated, maternal sinuses are exposed to sepsis, and pathologically adherent placentas do occur, removal of the placenta prior to replacement carries some risk. 7 Using the fingers of one hand in the vagina an attempt is made to replace the uterus by pressure. It may be possible to find an area adjacent to the cervix which repositions with relative ease and this should be pursued. It has been stressed that the portion of the uterus which inverted last should be replaced first in order to avoid multiple thicknesses of the myometrium in the cervical ring at the same time. Counter traction may be applied by the use of instruments such as ring forceps applied to the cervix. 2 Another variation of manual replacement involves lifting the uterus into the abdominal cavity above the level of the umbilicus with the vaginal hand, enabling passive action of the broad ligaments to help correct the malposition. 28 This method was used with success in three patients in the current series. Once the uterus has been replaced the hand should be left in the endometrial cavity until there is firm contraction and intravenous oxytocics are being administered. Whether uterine packing is necessary once good replacement has been achieved is a matter of controversy but has been stressed as an important factor in successful management. 1L 17, l9, 2 7. 29 A method of vaginal replacement using intravaginal hydraulic pressure through a douche apparatus has been described and shown to be effective in a number of cases. 20 • 30 • 31 Regardless of the method of vaginal replacement employed, careful manual exploration of the uterus afterward is essential to rule out the possibility of uterine rupture occurring either during the course of the inversion or its replacement. 5 • 20 • 2 L 32 • 33 It would seem that the keys to successful immediate replacement are (l) speed of recognition and institution of therapy, (2) preservation of antiseptic technique and prophylactic antibiotic coverage, and (3) anesthesia sufficient to allow the required manipulation. 7 In those patients in whom immediate replacement is not successful, an operative approach may be indicated. A relatively simple and effective procedure was first described by Huntington. 34 Through an abdominal incision the uterus is grasped with Allis forceps about three quarters of an inch below the inversion cup on both sides and upward traction exerted. Additional Allis forceps are placed below the original ones and the
Puerperal inversion of uterus
55
corpus and fundus thus further drawn up until inversion is completely reversed. The use of other instruments has been suggested 19 • 35 • 36 as replacements for the Allis forceps because of the tendency of tht· thin and friable myometrium to tear. Simultaneous pressure through the vagina by an assistant and adequate anesthesia may make this procedure easier. In those cases of chronic inversion where there is tight retraction of the cervical ring and some degree of involution of the uterus other procedures may be required. The procedure of Haultain 37 involve~ incision of the cervical ring posteriorly through an ahdominal approach. Abdominal anterior vaginocervical hysterotomy has been attributed to Ocejo. 38 Spmelli39 described a vaginal procedure in which the bladder is dissected away from the cervix and lower vterine segment. The cervical ring is then divided anteriorly. A similar procedure involves division of the cervictl ring posteriorly via a vaginal approach. 40 Other nonoperative 41 ' 44 and operative 2 • 18 • 4:!, 45 - 47 techniques have been described and reviewed in detail. Most are modifications of the above procedure~. The recurrence rate of this condition is difficult to assess. In a review concerned primarily with pre1~nancy following inversion it was found that in those women having manual replacement of the uterus the recurrence rate was 44 per cent. 18 In the same series no patients having operative replacement had recurrence of the inversion in subsequent pregnancies. Thne is at least one known instance of inversion associatt·d with rupture of the uterus which was replaced by means of a variation of the Huntington technique. Thre1~ years later another pregnancy resulted in inversion at the time of delivery. 21 • 48 In view of the high recurrence rate in the series cited above 18 some authors have recommended that further pregnancies be discouraged. 29 However. thne are numerous reports of uncomplicated deliveries in subsequent pregnancies. 4 • 6 • 10 • 36 • 49 • 50 Although one of three patients in this series known to have conceived later had a spontaneous abortion, it occurred after a normal term delivery. It is not known whet~Ier the abortion rate is increased after inversion nor whether fertility is affected. Reported postinversion CGmplications include rein version after replacement, 19 urinary retention, 7 • 27 • 35 • 38 • 5 t. 52 sepsis, anemia, and pituitary necrosis. 7 There was no maternal death in this serie; nor in recent isolated case reports but deaths do still occur. 6 • 10 As recently as 1963, four deaths in 6 years were considered attributable to this complication by the Committee on Maternal Health in one state:"' Earlier
56 Kitchin et at. :\m
from reviews indicated that the mortalitv' rate ranged o13.2 to 17.9 per cent. 1 • 4 • 9 Although higher mortality rates were reported prior to 1940 1 there was no significant over-all decrease between 1940 and 1953 4 despite more widespread availability of whole blood and antibiotics. It would appear that the benign postpartum course and successful outcome of all patients in this series can be attributed primarily to immediate recognition and rapid manual replacement. The former is ensured by a policy of routine examination of the cervix and vagina after delivery as well as manual exploration of the
Scplt'illbtT I. l ~l/,-, Ohsrcr. C\ Jll't n/
J
uterus. A high index of suspicion should be maintained for the possibility of inversion of the uterus in all cases of postpartum hemorrhage. Appropriate measures to counteract and prevent shock should be instituted early. The method of replacement will vary with the circumstances, but if immediate recognition is achieved and adeauate anesthesia available. manual reolact"ment should be possible in virtually all cases. A number of similar techniques are available for this purpose. Abdominal or vaginal operative procedures will rarely be required for acute inversion but are generally effective if needed. J
'
-,
-
-
REFERENCES 1. Das, P.: J. Obstet. Gynecol. Br. Emp. 47: 525, 1940. 2. Henderson, H., and Alles, R. W.: AM. J. 0BSTET. GYNECOL. 56: 133, 1948. 3. Schaefer, G., and Veprovsky, E. C.: Surg. Clin. North ~.l\n1. 29: 599, 1949. 4. Bell, J. E., Jr., Wilson, G. F., and Wilson, L. A.: AM. J. Vb~:"'T. GYNECOL. 66: 767, 1953. 5. Quigley, G.].: AM.]. OBSTET. GYNECOL. 69: 27i, 1955. 6. Bunke, J. W., and Hofmeister, F. J.: AM. J. 0BSTET. GYNECOL. 91: 934, 1965. 7. Donald, I.: Practical Obstetric Problems, ed. 4, Philadelphia, 1969, J. B. Lippincott Company, chap. 22, pp. 731737. 8. Harer, W. B., and Sharkey, J. A.:]. A. M. A. 114: 2289, 1940. 9. Fenton, A. N., and Singh, B. P.: Obstet. Gynecol. Surv. 5: 781, 1950. 10. Cosgrove, S. A.: AM.]. OBSTET. GYNECOL. 38:912, 1939. II. Davis, G. H.: AM. J. OBSTET. GYNECOL. 26: 249, 1933. 12. Brett, P. G.: Med. J. Aust. 1: 254, 1938. 13. Chisholm, A. E.:]. Obstet. Gynecol. Br. Emp. 51: 318, 1944. 14. Phaneuf, L. E.: Surg. Gynecol. Obstet. 71: 106, 1940. 15. KeUog, F. S.: AM.]. OBSTET. GYNECOL. 18:815, 1929. 16. Salvin, M.: West. J. Surg. 50: 147, 1942. 17. Gillespy, T.: W.Va. Med.J. 50: 121,1954. 18. Miller, N. F.: AM. J. 0BSTET. GYNECOL. 13: 307, 1927. 19. Loizeaux, L. S., and Mastraioinni, L: Obstet. Gynecol. 5: 193, 1955. 20. O'Sullivan, J. V.: Br. Med. J. 2: 282, 1945. 21. Steffen, E. A.: Wis. Med.]. 55: 1303, 1956. 22. Kaltreider, D. F., and West, G. B.: Bull. Sch. Med. Univ. Maryland 31: 144, 1946. 23. Pathak, U. N.: Br. J. Clin. Pract. 13: 299, 1959. 24. West, N. L.: Tex. State J. Med. 61: 613, 1965. 25. McGill, D. C., and Duggan, E. R.: N. Y. State]. Med. 51: 2481, 1951. 26. Spain, A. W.:J. Obstet. Gynecol. Br. Emp. 53:219, 1946.
Discussion Q.
Newport News, Virginia. The authors have described eleven cases of complete inversion of the uterus that occurred at their institution during a 15 year period ending December 31, 1974. All of these cases were recognized as acute, meaning that they had occurred before the cervical ring had formed and all were either second or third degree in DR. jOHN
HATTEN,
27. Hanton, E. M., and Kempers, R. D.: Postgrad. Med. 36: 541, 1964. 28. Johnson, A. B.: AM.]. 0BSTET. GYNECOL. 57: 557, 1949. 29. McHenry, A. G.: Obstet. Gynecol. 16: 671, 1960. 30. Enright, J. F.: Br. Med. J. 2: 714, ! 953. 31. Forster, F. M. C.: Med. J. Aust. 1: 326, 1956. 32. Carlisle, W. H.: J. Obstet. Gynecol. Br. Emp. 62: 452, 1955. 33. BalaKrishna, H., and Marx, G. F.: Can. Anaesth. Soc. J. 15: 34, 1968. 34. Huntington, J. L.: Boston Med. Surg. J. 184: 376, 1921. 35. McDuff, H. C., and Keegan, J.: AM. J. OasTET. GYNECOL. 76: 1299, 1958. 36. Burrus, J. H., and Lampley, C. G.: N.C. Med. J. 26: 502, 1965. 37. Haultain, F. W. N.: Br. Med. J. 2: 974, 1901. 38. Marcus, M. B., and Brandt, M. L.: Obstet. Gynecol. 9: 725, 1957. 39. Spinelli, P. G.: Ann. Gynecol. d'Obstet. 3: 195, 1900. 40. Lascarides, E., and Cohen, M.: Obstet. Gynecol. 32: 376, 1968. 41. Aveling, J. H.: Trans. Obstet. Soc. Lond. 20: 126, 1878. 42. Peterson, R.: Surg. Gynecol. Obstet. 5: 196, 1907. 13. Howell, D.: ~,.1ed. ] ..A.ust. I: 286, 1958. 44. Derjanecz, J. ].: Can. Med. Assoc. J. 110: 624, 1974. 45. Garde, S. N.: Obstet. Gynecol. Surv. 14: 618, 1959. 46. Huntington,]. L., Irving, F. C., and Keiiogg, F. S.: AM.]. 0BSTET. GYNECOL. 15: 34, 1928. 47. Irving, F. C., and Kellogg, F. S.: AM. J. OBSTET. GYNECOL. , -22:440, 1931. 48. Steffen, E. A.: AM. J. 0BSTET. GYNECOL. 74: 655, 1957. 49. Moldavsky, L. F.: Obstet. Gynecol. 29:488, 1967. 50. Shepler, L. G.: Obstet. Gynecol. 23: 598, 1964. 51. McKenzie, C. H., Duryea, M., Larson, D. M., and Hauge, E. T.: Minn. Med. 38: 700, 1955. 52. Plaut, G.S.: Postgrad. Med. J. 37: 164, 1961. 53. OSMA Committee on Maternal Health: Ohio Med. J. 59: 285, 1963.
that the uterine fundus had passed either through the cervical ring or completely outside the vulva. Each patient had normal spontaneous vaginal delivery. In comparing this series with other reported groups, it is important to emphasize that acure puerperal inversion, in more than 75 per cent of cases, takes place in the young para l or para 2 ,.vith an uncomplicated labor and delivery. In spite of the fact that so-called
