CASE REPORT

Uterine Inversion
Supervised by :
dr. Hesty Duhita Permata, Sp.OG

Presented by :
Michael Humianto (2016 – 061 – 073)

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

RSUD R. SYAMSUDIN, S.H., KOTA SUKABUMI
ATMA JAYA FACULTY OF MEDICINE
2018
 INTRODUCTION – Uterine Inversion

Uterine inversion  rare

obstetric emergency
It can lead to = hypovolemic
shock or maternal death.
Unless promptly recognized
and managed appropriately,
associated bleeding often is
massive.
 INTRODUCTION – Uterine Inversion
Risk factors :
Alone or in combination of :
The incidence of uterine
- fundal placental implantation
inversion is variable and is
- delayed-onset or inadequate uterine usually different for vaginal and
contractility after delivery of the fetus for cesarean delivery
- uterine atony RANGE :
- cord traction before placental 1 in 2000 to 1 in 20,000
separation deliveries.
- abnormally adhered placentation
(accrete syndromes)
 INTRODUCTION

Many management strategies but they are poorly described and

dispersed in the medical literature.
THE MOST IMPORTANT THINGS : IMMEDIATE RECOGNITION OF
UTERINE INVERSION
Improves the chances of a quick resolution and good outcome.
 INTRODUCTION

In most cases the inverted

uterus can be restored to its In some cases, the uterus will again
normal position by reposition invert almost immediately after
technique. repositioning.
Occasionally, manual If this is a problem, then compression
replacement fails  at this sutures can be used to prevent
point, laparotomy is another inversion
imperative
Patient’s Identity
Name : Mrs. A
Date of birth / Age : August 10th 1987
Nationality : Indonesian
Address : Kampung Karawan Kulon RT 003/007
Marital status : Married
Occupation : Housewife
Religion : Moslem
Date of admission : July 14th, 2018 18.50
Date of examination : July 14th, 2018 18.50
History Taking - Chief Complaint
Patient, P3A0, 30 years old

Referred from RS Ridogalih came to RSUD Syamsudin S.H’s

obstetric and gynecology emergency room with :
Massive bleeding from birth canal since 2 hours before admission
after delivery in RS Ridogalih’s delivery room.
 History Taking – History of Present Illness
2 hours b.a.
• (16.40) delivered her child then she
was given 10 IU oxytocin IM
• Cord traction applied IMMEDIATELY
after signs of placental separtaion 
placenta passed through the introitus
followed by massive bleeding, flow
continuously
• Exploration : mass in the vagina
• Uterus did not protude through the
introitus but was not palpable from
abdominal palpation
1 hour b.a.
• Bleeding has not stopped
• Generalized weakness, lightheaded,
blurred vision, palpitation, and loss
of consciousness
• The midwives tried to resuscitate and
do the uterine reposition
• Oxygen 5 lpm and 2 IV line
immediately administered
• RL 500 cc + 20 IU oxytocin + 0.125
mg methylergonovine
• RL 500 cc
 Before Referral

•Several attemps of uterine reposition  Failed

•Total bleeding 2 full underpads (± 1050 cc)
•Referred to RS Syamsudin SH
•RL 2600 cc + 20 IU oxytocin + 0.125 mg methergine
had been administered
•BP: 91/64 mmHg
•HR: 92 x/minute
•RR : 24 x/minute
•Temperature : 36,0 oC
•SpO2 : 95%
 History Taking
• History of Past illness • Family History
 History of hypertension : denied • History of hypertension : denied
 History of asthma : denied • History of asthma : denied
 History of diabetes mellitus : denied
• History of diabetes mellitus :
 History of allergy : denied denied
 History of trauma : denied
• History of allergy : denied
 History of past surgery : denied
 History of tuberculosis : denied
 History Taking
• Menstruation History
 Menarche : 13 years old
 Menstrual cycle : 30 days, regular, 7 days duration, dysmenorrhea (-)
 Total pads : 2-3 pads/day (± 30 cc)

• Contraception History
 She only used condoms as contraception
History Taking
Antenatal Care
• Routine antenatal care per month at RS Ridogalih
• There was no abnormality detected during ANC
• USG result was normal
• Medications: iron supplementation and folic acid.

Marital History
• Married once, been married for 17 years
Gestational History
No Date Gestational Labor History Sex Birth Breast
Age (weeks) Weight Feeding
1 2002 39-40 Spontaneous Female 3800 g +
Vaginal Delivery
without complication

2 2011 39-40 Spontaneous Female 3000 g +

Vaginal Delivery
without complication

3 2018 39-40 Spontaneous Female 3130 g -

Vaginal Delivery
with HPP
Physical Examination
• General condition : Severely ill
• Consciousness : Somnolen (E3V3M5) GCS 11
• Blood pressure : 50/30 mmHg (MAP 37)
• Heart rate : 121 bpm, faint, regular pulse
• Respiratory rate : 30 x/minute
• Temperature : 35,9°C
• Weight : 58 kg
• Height : 152 cm
• BMI : 25.1 kg/m2 (overweight)
 Physical Examination – General Examination
• Eyes : anemic conjunctiva +/+, icteric sclera -/-

• Mouth : dry oral mucosa membrane

• Neck : thyroid enlargement (-), trachea in the middle

• Heart : regular 1st and 2nd heart sounds, murmur -, gallop -

• Lung:
Inspection : symmetric chest expansion in both static and dynamic breathing
Percussion : sonor on both lungs
Auscultation : vesicular breath sounds +/+ regular, rhonchi -/-wheezing -/-

• Mammae : areolar hyperpigmentation +/+, nipple retraction -/-, breast milk -/-

• Abdomen:
Inspection : convex, striae gravidarum +, linea nigra +
Palpation : supple in all abdominal region, tenderness -
Auscultation : bowel sound +, 4x/minute

• Extremities : CRT > 2s, cold, edema -/-/-/-, physiological reflex ++/++/++/++, pathological reflex --/--

• Skin : pale, slow skin turgor

Obstetric Examination
• Palpation : uterine fundus not palpable on abdomen
• Inspection
 Vulva/vaginal : vulva edema(-), massive blood continuously (+)

• Vaginal Toucher
 The vagina filled up by solid mass palpable in 1/3 distal from vaginal
opening, the shape was inverted fundus-like, uneven surface
 Portio firm and thick, no dilatation

• Inspeculo : not performed

 Result Unit Normal Value

Laboratory Hemoglobin
Hematocrit
6.7
21
g/dL
%
12-14
37-47

Examination WBC
RBC
30900
2.4
cell/ul
1000000 cell/ul
4000-10000
3.8-5.2

14/07/2018 MCV 88 fL 80-100

MCH 28 pg 26-34
MCHC 32 g/dL 32-36
Platelet 309000 cell/ul 150000-450000
BT 2’30’’ minutes 1-3
CT 8 minutes 5-15
Blood Sugar 305 mg/dL <140
SGOT 16 U/I <31
SGPT 11 U/I <32
Ureum 20 mg/WdL 15-36
Kreatinin 1.06 mg/dL 0.52-1.04
Laboratory
Examination
Natrium 134 mmol/L 137-150
Kalium 3.4 mmol/L 3.5-5.5
Calcium 7.7 mg/dl 8-10.4
Chloride 103 mmol/L 94-108
Working Diagnosis
• Mrs. A, 30 years old, P3A0, 30 post spontaneous vaginal delivery
with 3rd grade acute uterine inversion, hemorrhagic shock grade
III, and acute severe anemia.
Management
• Vital signs observation
• O2 15 lpm via NRM
• IVFD 2 line (Crystalloid : Ringer Lactate 500 cc; Colloid : Hydroxyethyl starch (HES)
500 cc) administered rapidly
• Prepare blood transfusion with PRC and Whole Blood
• Kaltrofen 100 mg suppositoria via rectal
• Reposition with Johnson manuever
Management
• Prepare the patient for Laparotomy CITO for reposition in the operating room with
huntington technique or haultaim technique, do the hysterectomy if after
administration of uterotonic agents the uterus fail to contracts adequately (uterine
atony)
• Informed consent
Reposition and Observation
• In RSUD R Syamsudin SH’s emergency department:
• Reposition of the uterus was performed several times using
Johnson manuever
 All attempts failed

• This is duee to ostium uteri externus dilatation (-). Constriction

ring (+)
 Reposition and Observation
Time BP HR T RR SpO2 IVFD Bleeding
(mmHg) (x/minute) (oC) (x/m) (%)

18.58 50/30 121 36 21 95 400 cc RL 1 full

underpad

19.05 50/40 118 36 26 98 RL 500 cc (1) + 1 full

HES 500 cc (2) underpad

19.15 60/40 124 36 28 100 RL 500 cc (3) + 2 full

HES 500 cc (4) underpads

19.25 90/60 106 36 26 100 RL 500 cc (5) + 1 full

HES 500 cc (6) underpads

3400 cc ± 2000 cc
Operating Room Report & Post Operation
Therapy
• The operation was performed under General Anesthesia
• Begin : 19.50 WIB
• End : 21.45 WIB
• Incision : Mediana Inferior
• Indication : Uterine Inversion
• Operation : Surgical Reposition with Exploratory Laparotomy,
Hysterectomy if uterine atony
 Operating Room Report & Post Operation
Therapy
• Patient in supine position
• Incision
• Uterine inversion noticed
• Abdominal uterine reposition was performed using Huntington technique :
 Two clamps are placed on the round ligament, near to its insertion in the uterus, and
traction is applied while the assistant exerts traction on the contralateral way through the
vagina

• Uterine successfully repositioned

Operating Room Report & Post Operation
Therapy
• Observation of the uterus : uterus did not contracts
adequately
• 0.25 mg methergine was injected to the uterus, the uterus
still did not contracts adequately – uterine atony
• Hysterectomy Supravaginalis was decided and performed by
the operator

• Bleeding : ± 1500 cc
POST OPERATION THERAPY
 Inpatient with Intensive Care Unit (ICU)
 Observe general condition, vital signs, and bleeding
 NPO (nil per os) until bowel sound (+)
 IVFD RL 1500 cc/24 hours
 Blood transfusion until Hb > 10 g/dl
 Ceftriaxone 2 x 1 g IV
 Fetik (Ketoprofen) 2 x 100 mg suppository
 Anesthesiologist : Midazolam 2 mg/hour, Morphine 1
mg/hour,
FINAL DIAGNOSIS
• Mrs. A, 30 y.o., P3A0, post Hysterectomy Supra Vaginalis indicated
by uterine atony post laparotomy reposition of 3rd grade uterine
inversion, with acute severe anemia
Follow Up After Delivery
Date Subjective Objective Assessment Planning
14/07/2018 - General Condition : severely ill Mrs. A, 30 y.o., Observe general
condition, vital
22.46 Consciousness : under anesthesia P3A0, post HSV signs, and bleeding
Vital Signs : indicated by uterine NPO (nil per os)
until bowel sound
BP : 134/50 mmHg atony post (+)
HR : 96 x/minute laparotomy IVFD RL 1500 cc/24
hours
RR : 19 x/minute reposition of 3 rd
PRC transfusion (1)
T : 36.3 oC grade uterine Ceftriaxone 2 x 1 g
IV
Anemic conjunctiva inversion POD 0, Fetik (Ketoprofen) 2
Bowel sound (-) with acute severe x 100 mg
suppository
Urine 110 cc on catheter anemia Anesthesiologist :
Post operation wound covered with Midazolam 2
mg/hour, Morphine
bandage without seepage 1 mg/hour,
Bleeding from birth canal (-)
Follow Up After Delivery
Date Subjective Objective Assessment Planning
14/07/2018 - General Condition : severely ill Mrs. A, 30 y.o., Observe general
condition, vital
23.54 Consciousness : under anesthesia P3A0, post HSV signs, and bleeding
indicated by NPO (nil per os)
until bowel sound
Vital Signs : uterine atony post (+)
BP : 85/50 mmHg laparotomy IVFD RL 1500 cc/24
hours change to
HR : 94 x/minute reposition of 3 rd
Gelafusal 1500
RR : 21 x/minute grade uterine cc/24 hours
PRC transfusion (1)
T : 36.3 oC inversion POD 0, Ceftriaxone 2 x 1 g
with acute severe IV
Fetik (Ketoprofen) 2
Anemic conjunctiva anemia x 100 mg
Bowel sound (-) suppository
Anesthesiologist :
Midazolam 2
Post operation wound covered with mg/hour, Morphine
1 mg/hour,
bandage without seepage
Bleeding from birth canal (-)
Follow Up After Delivery
Date Subjective Objective Assessment Planning
15/07/2018 - General Condition : severely ill Mrs. A, 30 y.o., Observe general
condition, vital
01.21 Consciousness : under anesthesia P3A0, post HSV signs, and bleeding
indicated by NPO (nil per os)
until bowel sound
Vital Signs : uterine atony post (+)
BP : 109/67 mmHg laparotomy IVFD Gelafusal
1500 cc/24 hours
HR : 80 x/minute reposition of 3rd PRC transfusion
RR : 19 x/minute grade uterine Ceftriaxone 2 x 1 g
IV
T : 36.5 oC inversion POD 1, Fetik (Ketoprofen)
with acute severe 2 x 100 mg
suppository
Anemic conjunctiva anemia Anesthesiologist :
Bowel sound (-) Midazolam 2
mg/hour,
Morphine 1
Post operation wound covered with mg/hour

bandage without seepage

Bleeding from birth canal (-)
 Date Subjective Objective Assessment Planning
15/07/2018 - General Condition : severely ill Mrs. A, 30 y.o., Observe general
condition, vital
11.00 Consciousness : under anesthesia P3A0, post HSV signs
indicated by NPO (nil per os)
until bowel sound
Vital Signs : uterine atony post (+)
BP : 118/68 mmHg laparotomy IVFD Gelafusal
1500 cc/24 hours
HR : 86 x/minute reposition of 3rd
RR : 20 x/minute grade uterine PRC transfusion

T : 36.4 oC inversion POD 1, Ceftriaxone 2 x 1 g

with acute severe IV
Fetik (Ketoprofen)
Anemic conjunctiva anemia 2 x 100 mg
Bowel sound (+), 1x/minute suppository
Metronidazole 3 x
CRT < 2s 500 mg I.V
Normal skin turgor
Anesthesiologist :
Midazolam 2
Post operation wound covered with mg/hour,
Morphine stop,
bandage without seepage Ketorolac 3 x 30
Bleeding from birth canal (-) mg IV
 Date Subjective Objective Assessment Planning
16/07/2018 Post operation wound pain, General Condition : moderately ill Mrs. A, 30 y.o., Observe general
condition, vital
11.00 VAS 3-4, Productive cough Consciousness : compos mentis P3A0, post HSV signs
indicated by IVFD RL 1000
cc/24 hours
Vital Signs : uterine atony post PRC transfusion
BP : 122/70 mmHg laparotomy (4) => Hb = 8 g/dl
Cefadroxil 2 x 500
HR : 92 x/minute reposition of 3rd mg P.O
RR : 20 x/minute grade uterine Mefenamic acid 3
x 500 mg P.O.
T : 36.5 oC inversion POD 2, Metronidazole 3 x
with acute severe 500 mg I.V
N-acetilcysteine 3
Anemic conjunctiva anemia x 1 P.O.
Bowel sound (+), 3x/minute NaCl 0.9%
nebulizer
CRT < 2s Anesthesiologist :
Normal skin turgor Ketorolac 3 x 30
mg IV
Patient
Post operation wound covered with hemodinamically
stable, transferred
bandage without seepage from ICU to
Bleeding from birth canal (-) Mawar Putih
Post operation
wound care
 Date Subjective Objective Assessment Planning

17/07/2018 Post operation wound pain, VAS General Condition : moderately ill Mrs. A, 30 y.o., P3A0,Urotractin 2 x 500 mg
P.O.
07.00 3, flatus (+), defecation (-), Consciousness : compos mentis post HSV indicated by Misoprostol 3 x 0.2
urination on catheter Vital Signs : uterine atony post mg tab
Mecobalamin 3 x 500
BP : 132/70 mmHg laparotomy ug
HR : 92 x/minute reposition of 3rd Observe general
condition and vital
RR : 20 x/minute grade uterine signs
T : 36.5 oC inversion POD 3, with
acute anemia
Anemic conjunctiva
Bowel sound (+), 6x/minute
CRT < 2s
Normal skin turgor

Post operation wound covered with bandage

without seepage
Bleeding from birth canal (-)

Laboratory Test :
Hb = 8 g/dl
Na 141; K 4.1; Cl 104; Ca 8.1
 Date Subjective Objective Assessment Planning
18/07/2018 Post operation wound pain, General Condition : moderately ill Mrs. A, 30 y.o., Urotractin 2 x 500
mg P.O.
07.00 VAS 2, flatus (+), defecation Consciousness : compos mentis P3A0, post HSV Misoprostol 3 x 0.2
(-), urination on catheter Vital Signs : indicated by mg tab
Mecobalamin 3 x
with bladder training BP : 120/80 mmHg uterine atony post 500 ug
HR : 80 x/minute laparotomy Bladder training
Observe general
RR : 18 x/minute reposition of 3rd condition and vital
T : 36.5 oC grade uterine signs

inversion POD 4,
Anemic conjunctiva with acute anemia
Bowel sound (+), 8x/minute
CRT < 2s
Normal skin turgor
Active mobilization

Post operation wound covered with

bandage without seepage
Bleeding from birth canal (-)
 Date Subjective Objective Assessment Planning
19/07/2018 Post operation wound pain, General Condition : moderately ill Mrs. A, 30 y.o., Urotractin 2
07.00 VAS 2, flatus (+), defecation Consciousness : compos mentis P3A0, post HSV x 500 mg P.O.
(-), urination on catheter Vital Signs : indicated by Misoprostol
with bladder training, BP : 110/70 mmHg uterine atony post 3 x 0.2 mg
cannot urinate without HR : 78 x/minute laparotomy tab
catheter RR : 20 x/minute reposition of 3rd Mecobalamin
T : 36.5 oC grade uterine 3 x 500 ug
Anemic conjunctiva inversion POD 5, P.O.
Bowel sound (+), 8x/minute with acute anemia Bladder
CRT < 2s training
Normal skin turgor Observe
Active mobilization general
Post operation wound covered with condition
bandage without seepage and vital
Bleeding from birth canal (-) signs
 Date Subjective Objective Assessment Planning
20/07/2018 Post operation wound pain, General Condition : moderately ill Mrs. A, 30 y.o., Outpatient,
07.00 VAS 1-2, flatus (+), Consciousness : compos mentis P3A0, post HSV with
defecation (+), Vital Signs : indicated by pharmacothe
spontaneous urination BP : 120/80 mmHg uterine atony post rapy as the
without catheter HR : 84 x/minute laparotomy patient given
RR : 19 x/minute reposition of 3rd before
T : 36.5 oC grade uterine
Anemic conjunctiva inversion POD 6,
Bowel sound (+), 8x/minute with acute anemia
CRT < 2s
Normal skin turgor
Active mobilization
Post operation wound covered with
bandage without seepage
Bleeding from birth canal (-)
Prognosis
• Quo ad vitam : dubia ad bonam
• Quo ad functionam : malam
• Quo ad sanationam : dubia ad bonam
CASE ANALYSIS
BASED ON
LITERATURE REVIEW
 UTERINE INVERSION
• Passage of the uterine fundus through
the endometrial cavity and cervix,
turning the uterus inside out.
• In the postpartum period and
spontaneously.
HPP
• Early hemorrhage post partum

• Postpartum hemorrhage is diagnosed when bleeding from

birth canal after delivery exceed 500 ml in vaginal delivery
and 1000 ml in caesarian section delivery.
• 4 T mnemonics
 Tonus
 Tissue  In this case, uterine inversion is tissue factor that causes
post partum hemorrhage
 Trauma
• Thrombin
 CLASSIFICATION
• 1st degree : the inverted fundus still
inside the cavity.
• 2nd degree : the inverted fundus reaches
but does not exceed the cervical external
os
• 3rd degree : the inverted fundus extends
out of the external os
• 4th degree : the fundus and vagina is
inverted and extends beyond the vaginal
introitus (complete inversion)
4th degree inversion of the
uterus
CASE
• In this case, the patient just delivered her baby, so she had
puerperial uterine inversion
• Total bleeding of the patient in 3 hours was 1050 cc, this indicates
hemorrhage post partum
• Uterine inversion in this case extends through the ostium uteri
externa, but didn’t extends through the introitus, so she had 3rd
grade uterine inversion.
RISK FACTOR
• Fundal placental implantation
• Delayed-onset or inadequate uterine contractility after delivery of the fetus,
that is, uterine atony
• Cord traction applied before placental separation
• Strong traction exerted on the umbilical cord
• Fundal pressure
• Abnormally adhered placentation (such as placenta accrete syndromes)
• Congenital or acquired weakness of myometrium
• Uterine anomalies
• Previous uterine inversion
CASE
• In this case, the exact risk factor for uterine inversion cannot be
obtained.
• Fundal placental implantation, fundal pressure, cord traction applied
before placental separation, and strong traction exerted on the umbilical
cord may be suspected
• This is due to normal USG result, the normal implantation of the placenta
should be fundal, anterior, or posterior
• The delivery was on RS Ridogalih, so what happened exactly at the third
stage of labor can’t be determined.
DIAGNOSIS
• Diagnosis of puerperium uterine inversion is based on clinical
features, with history taking and physical examination.
• The patient may just delivered her child, as in this case the
patient just delivered her child 2 hours before admission.
DIAGNOSIS
• The other clinical features to diagnose :
• Hemorrhage post partum with massive bleeding
• Depression in the uterine fundus or even an absent fundus
• Dark red–blue bleeding mass is palpable and often visible at the
cervix, in the vagina, or outside the vagina.

In this case, massive bleeding (+), uterine fundus was absent on

abdominal palpation, and solid mass is palpable on vaginal
toucher.
DIAGNOSIS
• Massive bleeding may cause patient may came with hypotension
and tachycardia may supervene and evolve into hypovolemic
shock with loss of consciousnes
• Hemorrhagic shock may divide into four classes.
DIAGNOSIS
• The patient came with blood loss >1500 ml, heart rate 121
x/minute, BP 50/30 mmHG, respiratory rate 30 x/minute, with
confused mental status. So, the patient had hemorrhagic shock
grade III.
DIAGNOSIS
• When a physical examination is inconclusive and the patient is
hemodynamically stable, the diagnosis can also be confirmed by
ultrasound

• In this case  conclusive from history taking and physical

examination
MANAGEMENT
• Immediate recognition of uterine inversion improves the chances of a
quick resolution and good outcome.
• Inexperienced attendants may have a delayed appreciation for an
inverting uterus, especially if it is only partial and thus not protruding
through the introitus
• Continued hemorrhage likely will prompt closer examination of the
birth canal. Many cases are associated with immediate life-
threatening hemorrhage, thus require blood replacement
• In this case, the patient require blood replacement according to her
hemoglobin level was 6.7 g/dl.
MANAGEMENT - STEPS
• Immediate assistance is summoned, including obstetrical and
anesthesia personnel.
• Blood is brought to the delivery suite in case it may be needed.
• The woman is evaluated for emergency general anesthesia.
• Large-bore intravenous infusion systems are secured to begin rapid
crystalloid infusion to treat hypovolemia while awaiting arrival of
blood for transfusion.
MANAGEMENT – STEPS
JOHNSON MANEUVER Don’t apply too much
pressure as to perforate
the uterus with the
fingertips.
MANAGEMENT – STEPS
JOHNSON MANEUVER

https://www.youtube.com/watch?v=GHVuMJjtVxc
Should be carried out as soon as possible to minimize the blood
loss and to improve the chances to resolve

The hand is placed inside the vagina, with the cup of the inversion
in the palm of the operator’s hand and the tips of the fingers
towards the utero-sacral ligaments.
The uterus is then forcefully lifted inside the abdominal cavity
above the level of the umbilicus and held for 3 – 5 minutes until the
passive action of the uterine ligaments corrects the inversion
 MANAGEMENT – STEPS
JOHNSON MANEUVER

https://www.youtube.com/watch?v=GHVuMJjtVxc
INVOLUTION OF THE CERVIX
 CONSTRICTION RING as in
this case happened
Utero-relaxant administration
 Terbutaline
Relaxation of cervical ring :
Nitroglycerine
 One hand in the vagina and one hand
MANAGEMENT – STEPS in the abdomen at the cervical Rim the
correction of the Inverted uterus tried
BIMANUAL METHOD gently

https://www.youtube.com/watch?v=GHVuMJjtVxc
 BIMANUAL METHOD
MANAGEMENT – STEPS

https://www.youtube.com/watch?v=GHVuMJjtVxc
MANAGEMENT – STEPS
HUNTINGTON’S PROCEDURE
LAPAROTOMY REPOSITION OF INVERTED

https://www.youtube.com/watch?v=GHVuMJjtVxc
UTERUS
The cup or dimple of the
inversion is identified
Two Allis clamps are placed on
each round ligament two
centimeters below the ring.
Gentle upward traction is exerted
on the clamps.
 MANAGEMENT – STEPS
HAULTAIN’S PROCEDURE
LAPAROTOMY REPOSITION OF INVERTED
UTERUS
Haultain’s
Procedure done
when Huntington’s
Procedure fails to
replace to uterus
MANAGEMENT
• Once the uterus is restored to its normal configuration, tocolysis is stopped
• Oxytocin is then infused, and other uterotonics may be given as described
for atony
• Meanwhile, the operator maintains the fundus in its normal anatomical
position while applying bimanual compression to control further
hemorrhage until the uterus is well contracted
• The operator continues to monitor the uterus transvaginally for evidence
of subsequent inversion.
MANAGEMENT
• If uterine atony persists :
Uterine compression sutures (B-Lynch)
Surabaya B-Lynch Modification Compression
Sutures
Uterine artery ligation
Internal iliac artery ligation
Hysterectomy (supracervical or total)
Uterine
compression sutures
(B-Lynch)
REFERENCES
• Leal RFM, Luz RM, de Almeida JP, Duarte V, Matos I. Total and acute uterine inversion after delivery: a case report. J Med
Case Reports. 2014 Oct 17;8:347.

• Rodiani R, Susianti S, Gemayangsura G. P2A0 Post Partum Hemorrhagic Post Partum Et Causa Inversio Uteri, Syok
Hemoragik dan Anemia Berat. J Agromedicine. 2017 Jun 1;4(1):97–102.

• Kouamé A, Koffi S, Adjoby R, Diomandé F, Effoh D, Oussou C, et al. Non-puerperal uterine inversion in a young woman: a
case report. J West Afr Coll Surg. 2015;5(3):78–83.

• Zia S. Placental location and pregnancy outcome. J Turk Ger Gynecol Assoc. 2013 Dec 1;14(4):190–3.

• Vincent J-L, De Backer D. Circulatory Shock. N Engl J Med. 2013 Oct 31;369(18):1726–34.

• Cunningham FG, et al. Williams obstetrics. 24th ed. New York: McGraw Hill Education; 2014.

• The Contraction Ring in Labour. - Gilliatt - 1933 - BJOG: An International Journal of Obstetrics &amp; Gynaecology - Wiley
Online Library [Internet]. [cited 2018 Jul 23]. Available from:
https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1471-0528.1933.tb05694.x

• An Unusual Case of Acute Puerperal Uterine Inversion : A Case Report and Review of Literature. International Journal of
Medical and Health Sciences. 2015.

• PNPK. Perdarahan Pasca Salin. POGI. 2016.