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Acute puerperal inversion of the uterus
Acute puerperal inversion of the uterus LAWRENCE D. PLATT, M.D. MAURICE L. DRUZIN, .M.B., B.CH* Los Angrlf's, California
A retrospective review was performed over a period of 5 years (July, 1972, to July, 1977) from the delivery records at Women's Hospital of the Los Angeles County/University of Southern California Medical Center. During this time period, there were 60,052 deliveries and 28 cases of puerperal uterine inversion for an incidence of 1 in 2,148. The mean age of the primiparous patients was 19.1 years (N = 15) and that of the multiparous patients was 23.2.years (N = 13). The mean blood loss was greatest in primiparous patients, although blood loss was significant in each group. All patients were delivered by house officers in their first postgraduate year of training or by students under supervision. There was no significant difference between the lengths of the first and third stages of labor in either the primigravid or multigravid patient groups. The length of the second stage of labor was decreased in the multiparous patients compared to the primigravid group. Shock was clinically diagnosed in only 8 of 28 cases (28.5%). It was noted that 9 of 28 patients (32"/o) had received parenteral magnesium sulfate as therapy for the diagnosis of preeclampsia. In addition, six of these nine patients were receiving concomitant oxytocin infusion for augmentation of labor. There were three other patients receiving oxytocin infusion only. Prophylactic antibiotics were used in 11 patients and febrile morbidity occurred in two patients (18%). There were four cases (23%) of puerperal infectious morbidity among the 17 patients who did not receive antibiotics. The difference between these groups is not significant. These data would suggest: (1) that parenteral magnesium sulfate administration with or without concomitant oxytocin infusion may be an additional predisposing cause of acute puerperal uterine inversion and (2) that treatment with prophylactic antibiotics offers no additional benefit. (AM. J. Oesrer. GYNECOL. 141:187, 1981.)
ACUTE PUERPERAL INVERSION of the uterus is a serious managt:ment problem for the clinician. Fortunately, this obstetric emergency is rare. When it occurs, immediate measures must be undertaken to replace the uterus to prevent maternal morbidity and possible mortality. The true incidence of uterine inversion remains controversial. In Kitchen and associates' 1 recent study covering a 15-year period, the incidence of inversion was I From the Departmmt of Obstetrics and Gynecology, University of Southern California School tY{ Medicine, and Women's Hospital, Los Angeles County/University of Southern California Medical Crnter. Received for publication October 14, 1980. Revised 1Harch 26, 1981.
in 2,284 deliveries. However, it was found that the incidence over the last 2 years of the study was increased to lin 551 and 604, respectively. This breakdown may explain why the incidence in the literature varies so widely from one in several hundred thousand deliveries to as low as I in 704. 2 Another possible explanation for the varied incidence is that many cases remain undetected. By definition, complete inversion (third degree) occurs when the uterine fundus extends down to the perineum. Second-degree inversion is defined as protrusion through the cervical ring but not to the perineum. Incomplete uterine inversion occurs when the uterine corpus extends to the area of the cervix but does not project beyond the cervical ring. It is probable that some of the latter groups are often not detected.
Accepud April3, 1981. Reprint rt"quests: Lawrence D. Platt, M.D., Women's Hospital, Room 5K22, 1240 North Mission Rd., Los Angeles, California 90033. *Present address: Department tY{ Obstetrics and Gynecology, New York Hospital-Cornell Medical Center, 525 East 68th St., New l'ork, New York 10021. 0002-9378/81/180187+04$00.40/0© 1981 The C. V. Mosby Co.
Material and methods The medical records of patients delivered at Women's Hospital, Los Angeles County/University of Southern California Medical Center during the period July, 1972, to July, 1977, were reviewed. During this 187
188 Platt and Druzin
Septerubu i ~'• l9ii J \m.
Table I. Type of inversion
f
Obsr<·t.
Cvne
tients and l(~ast in the multiparous patients ;n !he time of liw irnersu;n or during the remaindn of' dwu hu~
Type of invenion
pital sl:n Patient
First dRgree
S,·cond degree
Third degr"'
Primigravid Multigravid
:.!
II R
3
~
5-year period, there were 60,052 deliveries, in which the diagnosis of uterine inversion was made in 28 cases. The overall incidence of uterine inversion was l i11 2, 148 deliveries. This incidence was not significantlv different between the years of study. The mean age of the study groups was 2l.l years (range 15 to 35). The lowest age was found in primigravid patients with a mean of 19.1 years. Greater than half of the patient' (53.6!';f) were primiparous, an identical incidence to that in the review by Das.a Seven patients (25%) were secundigravid. Five had two previous pregnancies and one patient had three previous deliveries. All cases occurred at 38 weeks' gestation or greater (mean 40.1 weeks).
Results Type of inversion. The diagnosis of second-degree inversion was made in 19 patients (68%). Third-degree inversion, with the fundus protruding at the perineum, was noted in six patients. The remaining three patients sustained only incomplete inversions (Table I). Imersion of the uterus occurred for the first time in each of our cases. Patient profile. Patients· weights were similar in all groups. The mean birth weight was greater in the multigravid group than in the primigravid group (3,48H versus 3,316 gm). Similarly, the respective placental weights were greater in the multigravid patients (770 versus 625 gm). There was no association with delivery of either low-birth-weight (small for gestational age or premature) or macrosomic (>4,000 gm) infants. Length of labor. The lengths of the first and third stages of labor were similar in both groups. There was<~ shorter second stage of labor in the multigravid patients (Table II). The mean duration of ruptured membranes was greater in the primigravid patients (i hours, 52 minutes) than in the multigravid patients (f1 hours, 6 minutes). The longest period of time from rupture of the membranes to delivery was in a secundigravid patient (24 hours). Only two patients were dt>livcred with intact membranes. Blood loss. Clinical shock was diagnosed in eight patients, all compatible with estimated blood loss. Five were primiparous and three were multiparous. Estimated blood loss was greatest in the primiparous pa-
i
>nh rln ce ,{' 13 multiparous patients
reyuin·d blond tr.ansfusiun:;. There were no complications \e.g., anaplwlaxis, hepatitis, et< .) direnly auributed to the transfusions. l.fowe\·t:r, it is po>sibk that 'orne patielits 1dJO were lo~t to follow-up cuulct haw~ developed hepatitis. An association between e-;tirnater! blood loss 111 the groups of primiparous p;nients was 1.260 rnl and the suhsequent fall in hematocrit was 9.Wk. lu the other patient group, the mean blood loss was 800 ml with a fall in hematocrit of !-1.31 (;; . Delivery. The method~ of delin:rv in both groups were similar except lor the increased use of forceps in primigravid patients (Table Ill). In both groups delivery was lompleted hy a member nf the hou~e staff at the first-year level. cxn:pt on two occa~ion!> in which deliverv wa;, pt>rfonned br medical swdents under supcrnsion.
Anesthesia. Ddil•ny. Pudendal block was utilized for delivery in 24 patients (Table IV). Fom patients receivt~d regional anesthesia lspinal or epidural). lnuersion. Replacement of the uterus was successful without the ust> of additional anesthetic agentsjn six of 15 primiparous patients while eight required a general anestht>tic agent (halmhane). In the remammg primiparous patient, all attempts to reduce the utenis \aginally \H'lt' unsuccessful and a laparotomy was performed. In s1x of 1:3 muhigravid patients, replacement 1\as achieved without ,mesthesia. The rt'maining seven patients required a general anesthctk agent. Thus 16 of 28 patients (57.19(\ required a general anesthetic agent for successful replacenwnt of rhe uterus. Morbidity and mortality; There was no maternal or fetal mortality in this series and the overaJI morbidity rate was low. Prophvlactic antihiotics were used in 12 parients of whom 11\'0 develc>ped puerperal febrile morbidity, Of the I!i patients whu did not receive prophvlactil anribimics, tour reyuired antibiotic treatnwnt for febrile morbiditv. The dHferenu: between these two groups is not signihcanL No serious infectious morbidity occurred. The mean hospital stay of each group of patients was similar regardless of whether or not prophylactic antibiotics were utilized (2.-1 days tor primigravid patients and 3.:~ davs for multigravid patients). Predisposing factors. One interesting finding was the association of the administration of parenteral magnesium sulfate (MgS0 4)and utex:ine inversion. We !(mnd that seven of 15 primigravid patient.s (46%) and two of the. multigravid patients received intravenous ·MgS04 for the treatment of pre-eclampsia. In addition
Acute puerperal inversion of uterus
Volume 141 Number 2
189
Table II. Uterine inversion
Third
Duration of membrane rupture (min)
17.5 18.5
472.7 306.10
Length of labor (min) Patient
First
Primigravid Multi gravid
781.61
743
I
Second
83 46.88
I
six of these nine patients also received intravenous oxytocin for augmentation of labor. Three other patients not on MgS04 received oxytocin infusion.
Comment The overall incidence of uterine inversion in this series ( 1 in 2, 148) is somewhat higher than that in other reported studies. 2 · 3 This higher incidence might be explained by the fact that the vast m£tiority of deliveries were done by either house officers at the first year level or medical students under supervision. Because of their limited experience, it is not unrleasonable to assume that exCf:ssive traction on the umbilical cord may have occurred in the patients in whom the third stage did not occur promptly. This may be supported by the relatively shor:: third stage of labor in this series. Information reg2trding cord traction was unobtainable in this retrospective review. The mean length of labor in this group of patients (845 minutes) might certainly be considered prolonged. The association between prolonged labor and uterine inversion was first described by McCullagh 4 and later confirmed by others. However, in a recent article by Watson and associates,> the authors were un· able to confirm this finding when they compared the cases of inverted uterus to the delivery that followed each of the inversions. A previously unreported possible predisposing factor for uterine inversion was the association with administration of MgS04 in preeclamptic patients. Forty-six per cent of the primigravid patients were receiving MgS0 4 for preeclampsia. This finding might be explained by the presumed uterine musculature relaxation that occurs with the administration of MgS04 • It has long been thought that preeclamptic patients receiving MgS04 are at greate:r risk for postpartum hemorrhage, 6 perhaps through the mechanism of slowing of uterine contractions. A recent study by Steer and Petrie' reported that MgS04 was used effectively as a tocolytic agent in patients with premature labor. This study suggested that the administration ofMgS04 (4 gm intravenous bolus and 2 gm per hour) effectively eliminates uterine activity in patients in whom cervical dilatation is less than 2 em at the time of admission to the study. The mechanism of action of MgS04 is through the stabiliza-
Mean blood loss (ml)
Clinical shock 5/15 3/13
1,260
799.2
Table III. Type of delivery
Patient
Spontaneous
Primigravid Multigravid
8 11
Vacuum
6
l
0
2
Table IV. Anesthesia Deliveries Patient
Pudendal/local
Spinal
Primigravid Multigravid
13
2
ll
0
tion of the muscle cytoplasm and its membrane which consequently leads to relaxation of the uterine musculature. Subsequently, a delay in separation of the placenta may occur at which time the physicians may be tempted to facilitate delivery by increasing traction on the cord. The clinical presentation of patients was similar to that of previous studies except that the incidence of shock (28.5%) was lower.• This observation also coincides with a smaller estimated blood loss in this series compared to previous studies. The increased frequency of this entity at our hospital may explain why blood loss is diminished as there is, perhaps, earlier recognition and, therefore, appropriate intervention. The benefit of available in-house anesthesia coverage further prevents delay in administering general anesthesia in indicated cases. Once this condition is diagnosed, an attempt should be made to replace the uterus without the aid of general anesthesia (completed in 12 of 28 cases in this series), but if this is unsuccessful general anesthesia should be administered. Bell and associates~ have described the most common technique of replacement of the uterus. Pressure should be applied in an area adjacent to the cervix in order to replace the portion of the uterus which has inverted last. By doing this, one avoids multiple thickness in the uterine musculature at the site of the cervical ring. A variety of other replacement techniques have previously been described, 9 • 10 none of which was
190
Platt and Druzin
i '•. l~lH I ( ~l.;f){"('(lj_
unlited in this series. In •.Jill' l a~e in which 1·aginal n placellll'llt was not successful. laparotonJ\ wa:- 1 r. qui red. The same guideline' utili1ed in 1aginal 1 t'·
patients 111 1d•om proplnlanit :IntihiO!ic;, \\CH' admini,tercd, two p:ttienis de~t·lopcd p;Ivrpt·I ,d lch1 i!e lll!JI· hidm·. ()f the 17]Mlienh Ill 11ltom antihi()1t<·· \\'l'lt'll
placement an: followed iu the ;!bdoniinal approach. 1.('., 11le area doseS! to the llfcnnc ring should bt· rc-
utilized, !om patie!ll\ developed febrile morhidm. ·'Jeither group of patients developed se1 iol!~ Jllfc< tiou.' morhiditv In •Jfhospitali;atHHt ot the.:.c group:- Wt:H.' similar \'hus, mdikc \lw I'Cj'>tHh o\
pl:u.cd lirst. Thi.-; ~~ be't an:o1nplished bv grad11al de' ,It ion o{ the utnus just helm, thl' inH:rsion site lllltil
rlw entire lund us is 1 isualift·d. The use ot proplnlattic antibiotics in this study did not lead ro a decrease in febrile morbidity 01 the I~
Kitchen and a~sociate.'' and Donald," this .
REFERENCES J. Kitchen, D., Thiagar<~jah, S., M<~y, V., and Thorton, V. Puerperal inversion of the uterus. AM. J OnsTET. CYNEC:Ol.. 123:51, 197!1. ~. Lee. \V .. \Ving1 K., Haggish, M.S .. and Lashari, ~f.: Acute inversion of the uterus, Ohstet. Gvnecol. 51: l 44. 1978. :1. Das, P.J.: Inversion oft he utetus,j. Obstet. Gvnaccol. B1. Emp. 4:525, 1940. l. :'vlcCullagh. W. l\1. M.: Inversion of the merus. A rcpm t of three cases and an analysis of 233 recently recorded cases, J. Obstet. Gynaerol. Br. Emp. 32:280. 1925. :,. Watson, I'., Beach. !\:., and Bowe~. W.: Management of acute and subacute puerperal in\'ersion of the uteru~. Ob,tet. Cvnem\. 55:12. \9RO.
6. Donald, !.: Practical Obstetric l'robkrm, nl. l. Lippincot, Philadelphia. 1969, J. R. Lippincou C6mparn. p. 609. '. Steer. C. \f., and Petrie, R. H.: A comparison of magnesitnn sulfate and akohol for the prevemifin of premawre labor, AM. J Ossn:r. C rNt:coL 129: I, 1977. R. Bell, J E.. Wilson, G. F., and Wilson. LA.: Puerperal inversion of the utc:ms, AM. J. ()BS'ITI'. GYNEcOL.66:767. 1963. U. Hailes, R. W.: The tm; of intravagin;.~l hydrolk pressun: douches, A'>l.J OsSTFT G'YNF.Ccn .. 56:\:Ct), 191R. 10. Sullivan, J V.: The use of uttrine .packing ro as'inre a good replacement. B. Med. J. 2:282, 1945.
A retrospective review was performed over a period of 5 years (July, 1972, to July, 1977) from the delivery records at Women's Hospital of the Los Angeles County/University of Southern California Medical Center. During this time period, there were 60,052 deliveries and 28 cases of puerperal uterine inversion for an incidence of 1 in 2,148. The mean age of the primiparous patients was 19.1 years (N = 15) and that of the multiparous patients was 23.2.years (N = 13). The mean blood loss was greatest in primiparous patients, although blood loss was significant in each group. All patients were delivered by house officers in their first postgraduate year of training or by students under supervision. There was no significant difference between the lengths of the first and third stages of labor in either the primigravid or multigravid patient groups. The length of the second stage of labor was decreased in the multiparous patients compared to the primigravid group. Shock was clinically diagnosed in only 8 of 28 cases (28.5%). It was noted that 9 of 28 patients (32"/o) had received parenteral magnesium sulfate as therapy for the diagnosis of preeclampsia. In addition, six of these nine patients were receiving concomitant oxytocin infusion for augmentation of labor. There were three other patients receiving oxytocin infusion only. Prophylactic antibiotics were used in 11 patients and febrile morbidity occurred in two patients (18%). There were four cases (23%) of puerperal infectious morbidity among the 17 patients who did not receive antibiotics. The difference between these groups is not significant. These data would suggest: (1) that parenteral magnesium sulfate administration with or without concomitant oxytocin infusion may be an additional predisposing cause of acute puerperal uterine inversion and (2) that treatment with prophylactic antibiotics offers no additional benefit. (AM. J. Oesrer. GYNECOL. 141:187, 1981.)
ACUTE PUERPERAL INVERSION of the uterus is a serious managt:ment problem for the clinician. Fortunately, this obstetric emergency is rare. When it occurs, immediate measures must be undertaken to replace the uterus to prevent maternal morbidity and possible mortality. The true incidence of uterine inversion remains controversial. In Kitchen and associates' 1 recent study covering a 15-year period, the incidence of inversion was I From the Departmmt of Obstetrics and Gynecology, University of Southern California School tY{ Medicine, and Women's Hospital, Los Angeles County/University of Southern California Medical Crnter. Received for publication October 14, 1980. Revised 1Harch 26, 1981.
in 2,284 deliveries. However, it was found that the incidence over the last 2 years of the study was increased to lin 551 and 604, respectively. This breakdown may explain why the incidence in the literature varies so widely from one in several hundred thousand deliveries to as low as I in 704. 2 Another possible explanation for the varied incidence is that many cases remain undetected. By definition, complete inversion (third degree) occurs when the uterine fundus extends down to the perineum. Second-degree inversion is defined as protrusion through the cervical ring but not to the perineum. Incomplete uterine inversion occurs when the uterine corpus extends to the area of the cervix but does not project beyond the cervical ring. It is probable that some of the latter groups are often not detected.
Accepud April3, 1981. Reprint rt"quests: Lawrence D. Platt, M.D., Women's Hospital, Room 5K22, 1240 North Mission Rd., Los Angeles, California 90033. *Present address: Department tY{ Obstetrics and Gynecology, New York Hospital-Cornell Medical Center, 525 East 68th St., New l'ork, New York 10021. 0002-9378/81/180187+04$00.40/0© 1981 The C. V. Mosby Co.
Material and methods The medical records of patients delivered at Women's Hospital, Los Angeles County/University of Southern California Medical Center during the period July, 1972, to July, 1977, were reviewed. During this 187
188 Platt and Druzin
Septerubu i ~'• l9ii J \m.
Table I. Type of inversion
f
Obsr<·t.
Cvne
tients and l(~ast in the multiparous patients ;n !he time of liw irnersu;n or during the remaindn of' dwu hu~
Type of invenion
pital sl:n Patient
First dRgree
S,·cond degree
Third degr"'
Primigravid Multigravid
:.!
II R
3
~
5-year period, there were 60,052 deliveries, in which the diagnosis of uterine inversion was made in 28 cases. The overall incidence of uterine inversion was l i11 2, 148 deliveries. This incidence was not significantlv different between the years of study. The mean age of the study groups was 2l.l years (range 15 to 35). The lowest age was found in primigravid patients with a mean of 19.1 years. Greater than half of the patient' (53.6!';f) were primiparous, an identical incidence to that in the review by Das.a Seven patients (25%) were secundigravid. Five had two previous pregnancies and one patient had three previous deliveries. All cases occurred at 38 weeks' gestation or greater (mean 40.1 weeks).
Results Type of inversion. The diagnosis of second-degree inversion was made in 19 patients (68%). Third-degree inversion, with the fundus protruding at the perineum, was noted in six patients. The remaining three patients sustained only incomplete inversions (Table I). Imersion of the uterus occurred for the first time in each of our cases. Patient profile. Patients· weights were similar in all groups. The mean birth weight was greater in the multigravid group than in the primigravid group (3,48H versus 3,316 gm). Similarly, the respective placental weights were greater in the multigravid patients (770 versus 625 gm). There was no association with delivery of either low-birth-weight (small for gestational age or premature) or macrosomic (>4,000 gm) infants. Length of labor. The lengths of the first and third stages of labor were similar in both groups. There was<~ shorter second stage of labor in the multigravid patients (Table II). The mean duration of ruptured membranes was greater in the primigravid patients (i hours, 52 minutes) than in the multigravid patients (f1 hours, 6 minutes). The longest period of time from rupture of the membranes to delivery was in a secundigravid patient (24 hours). Only two patients were dt>livcred with intact membranes. Blood loss. Clinical shock was diagnosed in eight patients, all compatible with estimated blood loss. Five were primiparous and three were multiparous. Estimated blood loss was greatest in the primiparous pa-
i
>nh rln ce ,{' 13 multiparous patients
reyuin·d blond tr.ansfusiun:;. There were no complications \e.g., anaplwlaxis, hepatitis, et< .) direnly auributed to the transfusions. l.fowe\·t:r, it is po>sibk that 'orne patielits 1dJO were lo~t to follow-up cuulct haw~ developed hepatitis. An association between e-;tirnater! blood loss 111 the groups of primiparous p;nients was 1.260 rnl and the suhsequent fall in hematocrit was 9.Wk. lu the other patient group, the mean blood loss was 800 ml with a fall in hematocrit of !-1.31 (;; . Delivery. The method~ of delin:rv in both groups were similar except lor the increased use of forceps in primigravid patients (Table Ill). In both groups delivery was lompleted hy a member nf the hou~e staff at the first-year level. cxn:pt on two occa~ion!> in which deliverv wa;, pt>rfonned br medical swdents under supcrnsion.
Anesthesia. Ddil•ny. Pudendal block was utilized for delivery in 24 patients (Table IV). Fom patients receivt~d regional anesthesia lspinal or epidural). lnuersion. Replacement of the uterus was successful without the ust> of additional anesthetic agentsjn six of 15 primiparous patients while eight required a general anestht>tic agent (halmhane). In the remammg primiparous patient, all attempts to reduce the utenis \aginally \H'lt' unsuccessful and a laparotomy was performed. In s1x of 1:3 muhigravid patients, replacement 1\as achieved without ,mesthesia. The rt'maining seven patients required a general anesthctk agent. Thus 16 of 28 patients (57.19(\ required a general anesthetic agent for successful replacenwnt of rhe uterus. Morbidity and mortality; There was no maternal or fetal mortality in this series and the overaJI morbidity rate was low. Prophvlactic antihiotics were used in 12 parients of whom 11\'0 develc>ped puerperal febrile morbidity, Of the I!i patients whu did not receive prophvlactil anribimics, tour reyuired antibiotic treatnwnt for febrile morbiditv. The dHferenu: between these two groups is not signihcanL No serious infectious morbidity occurred. The mean hospital stay of each group of patients was similar regardless of whether or not prophylactic antibiotics were utilized (2.-1 days tor primigravid patients and 3.:~ davs for multigravid patients). Predisposing factors. One interesting finding was the association of the administration of parenteral magnesium sulfate (MgS0 4)and utex:ine inversion. We !(mnd that seven of 15 primigravid patient.s (46%) and two of the. multigravid patients received intravenous ·MgS04 for the treatment of pre-eclampsia. In addition
Acute puerperal inversion of uterus
Volume 141 Number 2
189
Table II. Uterine inversion
Third
Duration of membrane rupture (min)
17.5 18.5
472.7 306.10
Length of labor (min) Patient
First
Primigravid Multi gravid
781.61
743
I
Second
83 46.88
I
six of these nine patients also received intravenous oxytocin for augmentation of labor. Three other patients not on MgS04 received oxytocin infusion.
Comment The overall incidence of uterine inversion in this series ( 1 in 2, 148) is somewhat higher than that in other reported studies. 2 · 3 This higher incidence might be explained by the fact that the vast m£tiority of deliveries were done by either house officers at the first year level or medical students under supervision. Because of their limited experience, it is not unrleasonable to assume that exCf:ssive traction on the umbilical cord may have occurred in the patients in whom the third stage did not occur promptly. This may be supported by the relatively shor:: third stage of labor in this series. Information reg2trding cord traction was unobtainable in this retrospective review. The mean length of labor in this group of patients (845 minutes) might certainly be considered prolonged. The association between prolonged labor and uterine inversion was first described by McCullagh 4 and later confirmed by others. However, in a recent article by Watson and associates,> the authors were un· able to confirm this finding when they compared the cases of inverted uterus to the delivery that followed each of the inversions. A previously unreported possible predisposing factor for uterine inversion was the association with administration of MgS04 in preeclamptic patients. Forty-six per cent of the primigravid patients were receiving MgS0 4 for preeclampsia. This finding might be explained by the presumed uterine musculature relaxation that occurs with the administration of MgS04 • It has long been thought that preeclamptic patients receiving MgS04 are at greate:r risk for postpartum hemorrhage, 6 perhaps through the mechanism of slowing of uterine contractions. A recent study by Steer and Petrie' reported that MgS04 was used effectively as a tocolytic agent in patients with premature labor. This study suggested that the administration ofMgS04 (4 gm intravenous bolus and 2 gm per hour) effectively eliminates uterine activity in patients in whom cervical dilatation is less than 2 em at the time of admission to the study. The mechanism of action of MgS04 is through the stabiliza-
Mean blood loss (ml)
Clinical shock 5/15 3/13
1,260
799.2
Table III. Type of delivery
Patient
Spontaneous
Primigravid Multigravid
8 11
Vacuum
6
l
0
2
Table IV. Anesthesia Deliveries Patient
Pudendal/local
Spinal
Primigravid Multigravid
13
2
ll
0
tion of the muscle cytoplasm and its membrane which consequently leads to relaxation of the uterine musculature. Subsequently, a delay in separation of the placenta may occur at which time the physicians may be tempted to facilitate delivery by increasing traction on the cord. The clinical presentation of patients was similar to that of previous studies except that the incidence of shock (28.5%) was lower.• This observation also coincides with a smaller estimated blood loss in this series compared to previous studies. The increased frequency of this entity at our hospital may explain why blood loss is diminished as there is, perhaps, earlier recognition and, therefore, appropriate intervention. The benefit of available in-house anesthesia coverage further prevents delay in administering general anesthesia in indicated cases. Once this condition is diagnosed, an attempt should be made to replace the uterus without the aid of general anesthesia (completed in 12 of 28 cases in this series), but if this is unsuccessful general anesthesia should be administered. Bell and associates~ have described the most common technique of replacement of the uterus. Pressure should be applied in an area adjacent to the cervix in order to replace the portion of the uterus which has inverted last. By doing this, one avoids multiple thickness in the uterine musculature at the site of the cervical ring. A variety of other replacement techniques have previously been described, 9 • 10 none of which was
190
Platt and Druzin
i '•. l~lH I ( ~l.;f){"('(lj_
unlited in this series. In •.Jill' l a~e in which 1·aginal n placellll'llt was not successful. laparotonJ\ wa:- 1 r. qui red. The same guideline' utili1ed in 1aginal 1 t'·
patients 111 1d•om proplnlanit :IntihiO!ic;, \\CH' admini,tercd, two p:ttienis de~t·lopcd p;Ivrpt·I ,d lch1 i!e lll!JI· hidm·. ()f the 17]Mlienh Ill 11ltom antihi()1t<·· \\'l'lt'll
placement an: followed iu the ;!bdoniinal approach. 1.('., 11le area doseS! to the llfcnnc ring should bt· rc-
utilized, !om patie!ll\ developed febrile morhidm. ·'Jeither group of patients developed se1 iol!~ Jllfc< tiou.' morhiditv In
pl:u.cd lirst. Thi.-; ~~ be't an:o1nplished bv grad11al de' ,It ion o{ the utnus just helm, thl' inH:rsion site lllltil
rlw entire lund us is 1 isualift·d. The use ot proplnlattic antibiotics in this study did not lead ro a decrease in febrile morbidity 01 the I~
Kitchen and a~sociate.'' and Donald," this .
REFERENCES J. Kitchen, D., Thiagar<~jah, S., M<~y, V., and Thorton, V. Puerperal inversion of the uterus. AM. J OnsTET. CYNEC:Ol.. 123:51, 197!1. ~. Lee. \V .. \Ving1 K., Haggish, M.S .. and Lashari, ~f.: Acute inversion of the uterus, Ohstet. Gvnecol. 51: l 44. 1978. :1. Das, P.J.: Inversion oft he utetus,j. Obstet. Gvnaccol. B1. Emp. 4:525, 1940. l. :'vlcCullagh. W. l\1. M.: Inversion of the merus. A rcpm t of three cases and an analysis of 233 recently recorded cases, J. Obstet. Gynaerol. Br. Emp. 32:280. 1925. :,. Watson, I'., Beach. !\:., and Bowe~. W.: Management of acute and subacute puerperal in\'ersion of the uteru~. Ob,tet. Cvnem\. 55:12. \9RO.
6. Donald, !.: Practical Obstetric l'robkrm, nl. l. Lippincot, Philadelphia. 1969, J. R. Lippincou C6mparn. p. 609. '. Steer. C. \f., and Petrie, R. H.: A comparison of magnesitnn sulfate and akohol for the prevemifin of premawre labor, AM. J Ossn:r. C rNt:coL 129: I, 1977. R. Bell, J E.. Wilson, G. F., and Wilson. LA.: Puerperal inversion of the utc:ms, AM. J. ()BS'ITI'. GYNEcOL.66:767. 1963. U. Hailes, R. W.: The tm; of intravagin;.~l hydrolk pressun: douches, A'>l.J OsSTFT G'YNF.Ccn .. 56:\:Ct), 191R. 10. Sullivan, J V.: The use of uttrine .packing ro as'inre a good replacement. B. Med. J. 2:282, 1945.