Puerperal uterine inversion: analysis of three cases managed by repositioning, and literature review

Introduction Acute puerperal uterine inversion, though rare, is a well-recognised obstetric complication. It must not be forgotten while dealing with a case of postpartum haemorrhage and shock. Successful management and reduction of morbidity and mortality rates are largely dependent upon prompt recognition. Although mismanagement of third stage of labour is generally conceded to be the immediate cause of puerperal uterine inversion, it may occur spontaneously depending upon certain predisposing factors (pathological conditions of the uterus and its contents e.g. adherent placenta, short cord, congenital weakness or anomalies, fundal implantation of the placenta, tumours etc.), or it may follow more obvious events such as a sudden increase in intra-abdominal pressure (such as coughing, sneezing or straining) before contraction of the uterine muscles (Kitchin et al., 1975) . The disparity between vigorous, aggressive conduct of third stage and the rarity of inversion supports the importance of predisposing factors (Bunke and Holmeister, 1965) . The cardinal symptoms are haemorrhage, shock (which may be haemorrhagic, neurogenic or a combination of both) and pain, although it could be symptomless. Palpable dimpling or an apparent absence of the fundus per abdomen suggests inversion, but is often overlooked and the diagnosis ultimately depends upon the demonstration of the mass in or outside of the vagina. Thus routine postpartum examination of the fundus per abdomen along with vaginal exploration when indicated will establish the diagnosis even before the appearance of any symptoms. This article describes three cases of acute uterine inversion, their management and outcome in a district general hospital.