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Uterine inversion

Uterine inversion is a rare but potentially life-threatening obstetric emergency characterized by the collapse of the uterine fundus into the endometrial cavity, which may protrude through the cervix and into or beyond the vagina.^[1] It typically occurs during or shortly after the third stage of labor, most often following vaginal delivery, though it can also arise postpartum or in non-puerperal settings such as after gynecologic procedures.^[2] The condition is classified by degree—first (fundus within the cavity), second (fundus at the cervix), third (fundus in the vagina), and fourth (fundus outside the body)—with complete inversions posing the highest risk of severe complications.^[3] The incidence of uterine inversion is estimated at 1 in 3,700 to 20,000 vaginal deliveries and is approximately 1 in 1,860 cesarean deliveries, making it an uncommon event overall but one with significant morbidity when it occurs.^[4] Risk factors include excessive traction on the umbilical cord during placenta delivery, fundal pressure, short umbilical cord, primiparity, use of uterine relaxants, and abnormal placentation such as placenta accreta.^[1] Pathophysiologically, it results from sudden relaxation of the uterus combined with traction forces that pull the fundus downward, leading to inversion of the uterine walls.^[2] Active management of the third stage of labor, including controlled cord traction and uterotonics, has reduced its occurrence by up to fourfold in some settings.^[1] Clinically, uterine inversion presents with profound postpartum hemorrhage, severe lower abdominal pain, and hemodynamic instability, including shock, due to vagal stimulation and blood loss.^[1] The inverted fundus may be palpable as a firm, rounded mass in the vagina, with the abdomen lacking a palpable uterine fundus on bimanual examination.^[2] Diagnosis is primarily clinical, supported by ultrasound if presentation is atypical, and requires immediate recognition to prevent maternal mortality, which can reach 15-20% in untreated cases.^[5] Management prioritizes rapid manual repositioning of the uterus under anesthesia, often with tocolytics like terbutaline or nitroglycerin to facilitate relaxation, followed by uterotonics such as oxytocin to promote contraction.^[4] If manual attempts fail, surgical interventions such as the Huntington procedure (abdominal traction with forceps) or Haultain technique (cervical incision and repositioning) may be necessary, potentially requiring laparotomy or hysterectomy in refractory cases.^[1] Supportive care includes aggressive fluid resuscitation, blood transfusions, and broad-spectrum antibiotics to mitigate infection risks.^[2] With prompt intervention, prognosis is favorable, though recurrence in subsequent pregnancies is possible.^[4]

Definition and Pathophysiology

Definition

Uterine inversion is a rare but life-threatening obstetric condition characterized by the collapse of the uterine fundus into the endometrial cavity, which may result in the uterus turning partially or completely inside out and potentially protruding through the cervix or vagina.^[1] This inversion disrupts normal uterine anatomy, often leading to severe hemorrhage and hypovolemic shock if not promptly addressed.^[1] The condition occurs primarily in the postpartum period, known as puerperal uterine inversion, typically during or shortly after delivery when the uterus fails to contract properly after expulsion of the placenta. Non-puerperal uterine inversion, though even rarer with fewer than 200 cases reported in the literature, can arise outside of childbirth, most commonly associated with uterine pathologies such as benign tumors (e.g., leiomyomas) or malignant neoplasms like leiomyosarcoma, which exert traction on the uterine wall.^[6]^[7] Historically, uterine inversion was first recognized by Hippocrates around 460–370 B.C., with early descriptions in ancient medical texts, and it has since been acknowledged as a critical obstetric emergency in modern medicine, particularly with advancements in understanding its high mortality risk due to associated complications.^[6] Uterine inversion must be differentiated from uterine prolapse, which involves the downward descent of the uterus into the vaginal canal due to weakened pelvic support structures, resulting in an outward protrusion rather than an inward collapse.^[1]

Pathophysiology

Uterine inversion occurs when the fundus of the uterus collapses into the endometrial cavity, often triggered by excessive traction on the umbilical cord or fundal pressure applied during the third stage of labor, particularly if the placenta remains firmly attached or uterine tone is insufficient to maintain its normal configuration.^[1] This mechanism disrupts the physiological process of uterine contraction following delivery, where the myometrium typically contracts to shear off the placenta and restore the uterus to its anteverted position. In cases of strong placental adhesion, such as in placenta accreta, the downward force inverts the uterine wall rather than allowing separation.^[8] A key factor in this process is uterine relaxation or atony in the immediate postpartum period, which reduces the organ's ability to resist inversionary forces; excessive traction or pressure can then propagate the fundus through the cervical ring, especially if compounded by mismanaged third-stage labor.^[1] This often leads to compression of uterine blood vessels, resulting in acute hemorrhage and neurogenic shock from vagal stimulation, where hypotension and bradycardia occur disproportionately to visible blood loss.^[1] In non-puerperal uterine inversion, the pathophysiology differs, typically arising from pathological processes such as submucosal tumors like leiomyomas or, less commonly, malignancies such as leiomyosarcoma, which erode or distend the uterine wall and create localized weakness.^[7] Rapid tumor growth at the fundus, combined with a thin uterine wall or small pedicle, generates traction that inverts the uterus, potentially leading to chronic inversion if undetected. Hemodynamic instability in these cases may manifest as severe anemia from chronic bleeding rather than acute shock.^[7]

Causes and Risk Factors

Causes

Uterine inversion most commonly occurs as a puerperal complication due to mismanagement during the third stage of labor, with excessive traction on the umbilical cord prior to complete placental separation serving as the primary precipitating event.^[1] This traction is particularly likely to trigger inversion when the placenta is fundally attached, leading to the fundus collapsing into the uterine cavity.^[1] Such mismanagement often involves attempts to hasten delivery of the placenta without ensuring adequate uterine contraction.^[9] Iatrogenic factors further contribute to puerperal cases, including overzealous application of fundal pressure on a relaxed uterus and improper timing of uterotonic agents, which can cause sudden and uneven uterine contractions before placental detachment.^[1] Manual removal of a retained placenta has also been implicated as a direct trigger in some instances.^[1] These interventions, when performed prematurely, create the mechanical forces that initiate the inversion process.^[10] Non-puerperal uterine inversion, though rarer and representing about one-sixth of all cases, is typically precipitated by pathological conditions exerting traction on the uterine fundus, such as submucosal fibroids or other benign tumors like myomatous polyps.^[11] Malignant lesions, including endometrial carcinoma or uterine sarcomas, account for a smaller proportion of cases by similarly pulling the fundus inward.^[12] Complications during gynecological procedures, such as hysterectomy, can occasionally lead to inversion through surgical manipulation of the uterus.^[13] Rare precipitating events include idiopathic occurrences in non-pregnant women without identifiable pathology and associations with congenital uterine anomalies that weaken structural integrity.^[11] In puerperal contexts, brief associations exist with features like a short umbilical cord, primiparity, or rapid labor, which may amplify the effects of traction during delivery.^[1]

Risk Factors

Predisposing obstetric risk factors include nulliparity or primigravida status, which may contribute to incomplete cervical dilation or uterine atony during delivery, as well as fetal macrosomia, multiple gestation, and polyhydramnios leading to uterine overdistension.^[1]^[14] Prolonged or rapid labor, short umbilical cord, fundal implantation, placenta previa, and invasive placentation such as placenta accreta further heighten susceptibility by weakening the uterine wall at the implantation site.^[1]^[15] Maternal factors that increase risk encompass uterine structural anomalies like bicornuate uterus, connective tissue disorders such as Ehlers-Danlos or Marfan syndrome, pre-eclampsia, and advanced maternal age over 35 years, all of which can impair uterine integrity or contractility.^[1]^[15]^[14] A history of previous uterine inversion or surgery may also predispose to recurrence due to altered myometrial structure.^[1] High parity has been associated in some cases, potentially through cumulative uterine weakening, though evidence is mixed and not consistently significant.^[15]^[16] Management-related risks during the third stage of labor include the use of uterine relaxants, such as magnesium sulfate for pre-eclampsia, which can promote atony, and improper active management practices in high-parity cases where uterine relaxation is more likely.^[1]^[14] Non-puerperal uterine inversion is primarily linked to large benign uterine tumors like leiomyomata (fibroids) or endometrial polyps, which account for the majority of cases (up to 85%), as well as malignant pathologies such as endometrial carcinoma or uterine sarcoma that erode the uterine wall.^[17]^[18]

Clinical Presentation

Signs and Symptoms

Uterine inversion typically presents acutely in the postpartum period with sudden onset of severe lower abdominal pain and a strong bearing-down sensation, often accompanied by brisk vaginal bleeding that can lead to hemodynamic instability.^[1] The pain is usually described as intense and cramping, reflecting the traumatic inversion of the uterine fundus.^[19] On physical examination, the inverted uterus may appear as a dark red, globular mass protruding through the vaginal introitus, sometimes with the placenta still attached if inversion occurred prior to placental separation.^[2] Abdominal palpation often reveals the absence or irregular shape of the uterine fundus, which is a key clinical clue distinguishing it from other postpartum conditions. Systemic manifestations include shock that is frequently disproportionate to the observed blood loss, resulting from a combination of hypovolemic effects (such as hypotension and tachycardia) and neurogenic shock due to peritoneal stretching and parasympathetic stimulation, which can cause bradycardia and a vasovagal response.^[1] Patients may also experience urinary retention secondary to the inversion. In subacute or chronic cases, where recognition is delayed beyond 24 hours or up to a month postpartum, symptoms are less severe and may include persistent lower abdominal discomfort, irregular vaginal bleeding, and signs of anemia from ongoing blood loss.^[19] Chronic presentations, occurring more than one month after delivery, are rare and often involve edematous or infected uterine tissue leading to prolonged malaise.^[1]

Diagnosis

Diagnosis of uterine inversion relies primarily on clinical evaluation, particularly in the acute puerperal setting, where a high index of suspicion is essential due to its rarity and potential for rapid hemodynamic instability.^[1] During a bimanual examination, the inverted fundus may be palpated as a firm, rounded mass in the lower uterine segment or within the vagina, while the abdominal fundus is notably absent, often described as the "empty uterus" sign.^[1] This physical finding, combined with postpartum hemorrhage and shock out of proportion to visible blood loss, strongly suggests the diagnosis.^[1] If the clinical examination is equivocal, imaging modalities such as ultrasound are employed to confirm uterine inversion. Transabdominal or transvaginal ultrasound typically reveals the absence of the normal uterine fundal contour, with the inverted fundus appearing as a homogeneous, globular mass or target-like structure within the endometrial cavity.^[1] In chronic or non-puerperal cases, magnetic resonance imaging (MRI) provides superior visualization, delineating the inverted uterine walls and identifying underlying pathology such as tumors.^[20] Laboratory tests support the assessment of associated complications, including blood work to evaluate hemoglobin levels for anemia and coagulation studies in cases of hemorrhagic shock.^[1] Differential diagnosis includes conditions like postpartum hemorrhage from atony, uterovaginal prolapse, prolapsed fibroids, or retained placenta, which can mimic the presentation and necessitate careful distinction.^[1] The rarity of uterine inversion poses diagnostic challenges, requiring prompt recognition to avoid delays that exacerbate shock and bleeding.^[1] Recent advances emphasize the utility of point-of-care ultrasound (POCUS) in emergency and low-resource settings, enabling rapid bedside confirmation of abnormal fundal contour and mass, which is particularly valuable where advanced imaging is unavailable.^[21]

Classification

Types

Uterine inversion is classified by degree based on the extent of inversion. First-degree inversion, also known as incomplete, occurs when the uterine fundus inverts into the endometrial cavity but does not extend beyond the internal cervical os.^[14] Second-degree inversion involves the fundus protruding through the cervix into the vaginal canal. Third-degree inversion features the inverted fundus reaching or passing through the introitus into the vagina. Fourth-degree, or total, inversion includes protrusion of the inverted uterus and vaginal walls beyond the perineum, potentially involving the peritoneum.^[14] Classifications by timing distinguish the onset relative to delivery. Acute uterine inversion is diagnosed within 24 hours postpartum and represents the most common presentation. Subacute inversion occurs between 24 hours and 4 weeks postpartum, while chronic inversion develops more than 4 weeks after delivery and is exceedingly rare.^[22] By etiology, uterine inversion is primarily puerperal, occurring in the postpartum period due to obstetric factors such as excessive traction on the umbilical cord or fundal pressure, accounting for approximately 95 percent of cases. Non-puerperal inversion, comprising about 5 percent, arises spontaneously or from underlying pathology like uterine tumors (e.g., leiomyomas or sarcomas) and is not associated with childbirth.^[19] Historical classifications, such as those associated with the Huntington and Haultain methods, primarily served as frameworks for surgical management rather than standalone typologies; the Huntington approach involves abdominal manipulation via round ligaments, while Haultain entails posterior cervical incision to facilitate repositioning.^[1] Recent literature from 2024 has expanded recognition of iatrogenic non-obstetric subtypes within non-puerperal inversion, often linked to gynecologic procedures like dilation and curettage or hysteroscopy, emphasizing distinct diagnostic challenges in non-delivery contexts.^[23]

Complications

Uterine inversion can lead to severe immediate complications, primarily due to massive postpartum hemorrhage resulting from the inability of the inverted uterus to contract effectively. Blood loss can be substantial, often leading to hypovolemic shock, which may be exacerbated by neurogenic shock from vagal stimulation.^[24] If not promptly recognized and managed, these hemodynamic instabilities can progress to multi-organ damage, Sheehan syndrome, and maternal death, with mortality rates reported as high as 15-20% in untreated cases.^[1]^[5] Reproductive sequelae are particularly concerning in chronic or incompletely resolved inversions, where anatomical distortion may result in infertility or recurrent inversion in subsequent pregnancies. Hysterectomy is often necessitated to control persistent bleeding or address associated pathology, occurring in approximately 2.8% of puerperal cases overall but rising to 86.8% in non-puerperal or chronic presentations due to underlying tumors or necrosis.^[25]^[7] Infectious complications arise from exposure of the endometrium and disrupted uterine integrity, leading to endometritis or progression to puerperal sepsis if bacterial ascension occurs. Prophylactic antibiotics are commonly administered post-reduction to mitigate these risks, but untreated cases can result in systemic infection.^[1]^[24] Long-term effects in survivors include chronic pelvic pain and low backache from adhesions or incomplete resolution, as well as anemia secondary to ongoing or recurrent blood loss. In non-puerperal inversions, additional risks involve uterine perforation during attempted manual repositioning and progression of underlying malignancies, such as leiomyosarcoma, which frequently precipitate the inversion.^[26]^[27]^[28]^[1]

Management

Initial Management

Upon recognition of uterine inversion, initial management prioritizes rapid resuscitation to address hypovolemic shock, which is common due to significant hemorrhage. The airway, breathing, and circulation (ABC) approach is essential: secure the airway if compromised, provide supplemental oxygen to support breathing, and establish two large-bore intravenous lines for aggressive fluid resuscitation with crystalloid solutions. Blood products, including packed red blood cells, should be transfused promptly if ongoing bleeding or hemodynamic instability persists, with activation of a massive transfusion protocol as needed. Laboratory evaluation, including complete blood count, coagulation studies, and fibrinogen levels, guides further transfusion requirements.^[19]^[1] Manual repositioning of the uterus is the cornerstone of non-surgical correction and should be attempted immediately after initial stabilization. The Johnson's maneuver involves placing a gloved hand into the vagina, with the palm against the fundus, and applying steady upward pressure along the vaginal axis toward the umbilicus to push the inverted fundus through the cervix and back into its normal position; abdominal assistance may be used simultaneously to support the maneuver. If this fails due to a constriction ring, the O'Sullivan technique—a hydrostatic method—can be employed by sealing the vagina around the cervix with an assistant's hands and infusing 2 to 3 liters of warm saline under pressure (e.g., from a height of 1.5 to 2 meters) to inflate the space and facilitate reduction. These techniques succeed in approximately 80 percent of cases when performed promptly.^[19]^[1]^[29] Pharmacotherapy supports repositioning by promoting uterine relaxation initially, followed by contraction to prevent recurrence. Tocolytics such as terbutaline (0.25 mg subcutaneously or intravenously) or nitroglycerin (50 mcg intravenously, repeatable up to four doses) are administered to relax the uterus and constriction ring, with all ongoing uterotonics discontinued temporarily. Once repositioning is achieved, uterotonics like oxytocin (20 to 40 units in 1 liter of intravenous fluid) are restarted to maintain uterine tone and minimize further bleeding. The placenta must not be removed until the uterus is fully repositioned, as premature extraction can exacerbate hemorrhage by disrupting the uterine blood supply; post-repositioning, it can separate spontaneously or be manually extracted under anesthesia if necessary.^[19]^[1]^[30] A multidisciplinary team approach is critical in emergency settings, involving obstetricians, anesthesiologists, nurses, and operating room staff to coordinate resuscitation, repositioning, and preparation for potential escalation. According to 2025 UpToDate guidelines, immediate activation of this team enhances outcomes by enabling simultaneous interventions and rapid transfer to the operating room if manual methods fail.^[19]^[1]

Surgical Management

Surgical management of uterine inversion is indicated when manual repositioning attempts fail or in cases of subacute or chronic inversion (persisting beyond 24 hours postpartum, with chronic defined as greater than four weeks), often requiring operative intervention to release the constriction ring and restore anatomy.^[1] These procedures aim to minimize hemorrhage, prevent shock, and preserve fertility when possible, though hysterectomy may be necessary in severe or non-puerperal cases.^[19] Abdominal approaches are commonly employed for complete or persistent inversions. The Huntington procedure involves a laparotomy incision, followed by placement of atraumatic clamps (such as Allis or Babcock forceps) on the round ligaments; gentle upward traction is then applied to push the uterine fundus back into position, often aided by tocolysis to relax the uterus.^[1] This method is preferred for acute puerperal inversions when non-surgical methods fail, as it allows direct visualization and manipulation without incising the uterus.^[15] For more resistant or chronic cases, the Haultain procedure is utilized, which entails a posterior incision through the constriction ring at the uterocervical junction to facilitate manual repositioning; the incision is then repaired in layers to restore uterine integrity.^[1] This approach is particularly effective in subacute or chronic inversions where adhesions or fibrosis complicate reduction.^[15] Vaginal surgical interventions are suitable for incomplete inversions, where the fundus has not fully prolapsed beyond the cervix. These may include cervical incisions to release the constriction ring, combined with manual repositioning, and are often performed under anesthesia.^[1] In non-puerperal inversions associated with uterine tumors, such as leiomyomas, vaginal myomectomy can be integrated to remove the inverting mass, followed by uterine repair to prevent recurrence.^[31] Hysterectomy serves as a last resort for uncontrollable postpartum hemorrhage, uterine necrosis, or failed repositioning, particularly in non-puerperal cases where fertility preservation is not a priority.^[1] It is performed via abdominal, vaginal, or combined routes, depending on the clinical scenario, and is associated with significant morbidity but can be life-saving in extremis.^[19] Laparoscopic options have emerged as minimally invasive alternatives for non-emergent or chronic inversions, allowing visualization and reduction through small ports, often incorporating Haultain-like incisions or traction on ligaments.^[32] Case reports demonstrate successful laparoscopic-assisted repairs with reduced recovery time compared to open surgery, though these remain less common in acute hemorrhagic settings.^[33] Postoperative care following surgical correction includes broad-spectrum antibiotics to prevent infection, uterotonics such as oxytocin to promote uterine contraction and avoid recurrence, and close monitoring for hemorrhage, shock, or adhesion formation.^[1] Patients require intensive care observation initially, with imaging if needed to confirm uterine position.^[15]

Epidemiology and Prognosis

Incidence

Uterine inversion is a rare obstetric emergency, with a reported global incidence ranging from 1 in 2,000 to 1 in 20,000 deliveries.^[1] This wide variation reflects differences in definitions, reporting practices, and obstetric care standards across regions. In high-resource settings, such as the United States, the incidence is approximately 2.9 per 10,000 deliveries, or about 1 in 3,448.^[25] The condition is more prevalent in low-resource settings, such as India where the incidence is approximately three times that in the United States, due to suboptimal management of the third stage of labor, such as excessive traction on the umbilical cord or inadequate use of uterotonics.^[1] Non-puerperal uterine inversion, which occurs outside the postpartum period and is often associated with uterine pathology like fibroids or malignancies, is exceedingly rare overall, with fewer than 200 documented cases worldwide.^[18] Incidence trends show a decline in high-income countries, attributed to improved training, widespread adoption of active management of the third stage of labor, and reduced rates of mismanaged deliveries; for example, rates have decreased fourfold following the introduction of such protocols.^[1] Rates remain higher in low-resource regions due to persistent challenges in access to skilled birth attendants and emergency care. As of 2025, continued emphasis on active third-stage management sustains low rates in high-resource settings.^[19] Demographically, uterine inversion predominantly affects women aged 20 to 35 years during labor, often multiparous individuals in rural or underserved areas.^[34]

Outcomes

Uterine inversion carries significant risks for maternal mortality and morbidity, though outcomes have improved markedly with prompt recognition and intervention. Overall maternal mortality rates range from 3% to 15% in reported cases, primarily due to severe hemorrhage and hypovolemic shock if untreated.^[35] In high-resource settings with immediate management, mortality approaches 0%, as evidenced by a large cohort study reporting only 1 death among 2,427 cases (0.04%).^[19] Subacute and chronic presentations are associated with higher mortality due to delayed diagnosis and complications like infection or necrosis.^[1] Historically, mortality exceeded 50% before the 1950s due to limited understanding and management protocols, but rates have declined substantially with advancements in obstetric care.^[15] Morbidity remains a concern, particularly in severe cases, with hysterectomy required in approximately 3% of cases to control intractable hemorrhage or when conservative measures fail.^[25] In a nationwide analysis, postpartum hemorrhage occurred in 37.7% of cases, necessitating blood transfusion in 22.4% and surgical intervention like laparotomy in 6%.^[19] Fertility preservation is achievable in 70-80% of early-managed cases, allowing for subsequent uncomplicated pregnancies, though cesarean delivery may be recommended if prior surgical correction involved the uterine wall.^[10] Long-term implications include potential adhesions or reduced uterine contractility, but many women achieve full recovery without chronic issues when inversion is corrected promptly.^[1] Fetal outcomes are generally favorable in intrapartum inversions, as the condition often manifests postpartum, but emergency cesarean sections in acute scenarios can introduce neonatal risks such as respiratory distress or low Apgar scores.^[1] Key prognostic factors include time to correction, with ideal intervention within 30 minutes minimizing shock and tissue damage, and access to advanced diagnostics like ultrasound, which recent 2025 case reports highlight as improving detection and outcomes in resource-limited settings.^[36] Overall, timely multidisciplinary care significantly enhances survival and quality of life post-event.^[19]

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