The Obstetrician & Gynaecologist 10.1576/toag.11.1.13.27463 www.rcog.org.

uk/togonline 2009;11:13–18 Review

Review Acute inversion

of the uterus
Authors Rita Bhalla / Rekha Wuntakal / Funlayo Odejinmi / Rehan U Khan

Key content:
• Acute uterine inversion is a rare and unpredictable obstetric emergency.
• Mortality and morbidity are reduced by early recognition and management.
• Shock and uterine replacement must be addressed simultaneously.
• The importance of teamwork cannot be overemphasised.
• There is a need for skills and drills training because of the rarity of acute inversion.

Learning objectives:
• To understand the pathophysiology.
• To understand and to be able to evaluate critically the general
management principles.

Ethical issues:
• Management of uterine inversion is guided by a relatively small evidence
base, resulting in treatment modalities being used without proper evaluation.

Keywords manual replacement / postpartum haemorrhage /surgical management

/ tocolysis
Please cite this article as: Bhalla R, Wuntakal R, Odejinmi F, Khan RU. Acute inversion of the uterus. The Obstetrician & Gynaecologist 2009;11:13–18.

Author details
Rita Bhalla MRCOG Rekha Wuntakal MRCOG Funlayo Odejinmi MRCOG Rehan U Khan MRCOG
Senior Specialist Registrar in Obstetrics Specialist Registrar in Obstetrics and Consultant Obstetrician and Gynaecologist Consultant Obstetrician and Gynaecologist
and Gynaecology Gynaecology Department of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology,
Department of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Whipps Cross University Hospital NHS Trust, Royal London Hospital, London, UK
Royal London Hospital, Whitechapel Road, Homerton University Hospital NHS Foundation Whipps Cross Road, Leytonstone,
London E1 1BB, UK Trust, Homerton Row, London E9 6SR, UK London E11 1NR, UK
Email: [email protected]
(corresponding author)

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Review 2009;11:13–18 The Obstetrician & Gynaecologist

Introduction have been as high as 80%.1,8 Abouleish et al.9

Hippocrates (c. 460–377 BC)1 mentioned uterine and Platt et al.,10 however, reported no
inversion, as did Soranus of Ephesus in AD 110,2 associated maternal mortality in a study of 18
but it was not until the 16th century, during the and 28 cases of acute uterine inversion from two
time of Ambroise-Paré, that it was understood.3,4 university-affiliated maternity units. In our
Uterine inversion is defined as ‘the turning inside opinion, the mortality need not be as high as
out of the fundus into the uterine cavity’. Acute quoted, especially in developed nations with
inversion is a rare and serious obstetric appropriate management techniques.
emergency. Women can sink into profound shock
which can prove fatal. Immediate management of Aetiology
shock and manual repositioning of the uterus It is well established that mismanagement of the
both reduce morbidity and mortality. third stage of labour (premature traction on
umbilical cord and fundal pressure before
Incidence and mortality separation of placenta) is the commonest cause of
As with any obstetric complication, the likelihood of acute uterine inversion. This can happen when
a woman of having acute inversion depends on delivery is conducted by an untrained accoucheur,
geographic location; for example, the incidence is a situation more likely to occur in developing
three times higher in India than in the USA.5 Baskett countries, which explains why the incidence in
et al.6 analysed data in a North American unit over India is treble that of the UK. Many other risk
24 years and noted a four-fold decrease in the factors have been cited, including uterine atony,
incidence of acute uterine inversion associated with fundal implantation of a morbidly adherent
vaginal birth after the introduction of active placenta, manual removal of the placenta,
management of the third stage, from 1 in 2304 to 1 precipitate labour, a short umbilical cord, placenta
in 10 044. The perception amongst many praevia and connective tissue disorders (Marfan
obstetricians is that uterine inversion is very rare: it syndrome, Ehlers-Danlos syndrome).5,6,11–17 It must
will occur only once in a decade in most British be emphasised, however, that, in up to 50% of
maternity units (approximately 1:27 902 births).7 cases, no risk factors are identified9 and there is
Baskett et al.,6 however, reported the incidence as no mismanagement of the third stage. This
1:3737, which would suggest occurrence at least condition can, therefore, be unpredictable.
once a year in most units. As it is expected that more
women in the UK will be delivered in the Pathophysiology
community in the future, theoretically, there could There are three possible events that explain the
be an increase in the incidence of uterine inversion, pathophysiology of acute uterine inversion:18
as these women are more likely to have
physiological management of the third stage. • a portion of uterine wall prolapses through
Moreover, time will be spent transferring the the dilated cervix or indents forward
• relaxation of part of the uterine wall
women to hospital if any problems arise. There is, • simultaneous downward traction on the fundus
therefore, a need for training in the management of leading to inversion of the uterus.
acute uterine inversion in all settings and it should
be a part of routine skills and drills teaching. Classification
Various classification schemes describe uterine
Before modern management, mortality rates inversion. For simplicity we categorise uterine
following acute uterine inversion were reported to inversion by severity, as shown in Box 1.16,18–23

Figure 1
Incomplete uterine inversion can be
Clinical presentation and
diagnosed by manual examination.
(Drawn by and reproduced with the
differential diagnosis
kind permission of Bryony Cohen, (See Box 2, Box 3 and Figure 1) The vast majority of
Medical Illustration Department, St
Bartholomew’s Hospital, London,
cases (94%) present with haemorrhage, with or
UK) without shock. It should be noted that, initially,
shock may be neurogenic with signs of bradycardia
and hypotension but, with time, postpartum
haemorrhage will ensue. In a study of 28 cases, Platt
et al.10 described a lower incidence of shock and
haemorrhage (28.5%): this was credited to
awareness, early recognition and appropriate
intervention at their hospital. Therefore, a high index
of suspicion where shock is out of proportion to
blood loss can help in making an early diagnosis and
avoiding haemorrhage.23–26 Those conditions
14 © 2009 Royal College of Obstetricians and Gynaecologists
The Obstetrician & Gynaecologist 2009;11:13–18 Review

presenting with a lump in the vagina or causing

Degree Description Box 1
postpartum collapse need to be excluded. Categories of acute uterine
First (incomplete) The inverted fundus extends to, 16,18–23
inversion by severity
but not beyond, the cervical ring
Management Second (incomplete) The inverted fundus extends
The key to a successful outcome is teamwork, as through the cervical ring but
remains within the vagina
resuscitation and repositioning of the uterus have Third (complete) The inverted fundus extends down
to be undertaken simultaneously. The overall to the introitus
management of acute uterine inversion is Fourth (total) The vagina is also inverted
outlined in an algorithm (Figure 2).

uterine inversion, it is difficult for birth attendants

Treatment of shock to acquire proficiency in this procedure. Therefore,
The basic principles of resuscitation are well there is a role for simulation training.
established and should follow the pattern of a
postpartum haemorrhage drill. The quickest way Hydrostatic methods
to treat neurogenic shock, however, is to replace In 1945 JV O’Sullivan published the first report
the uterus.26,27 of two cases describing hydrostatic replacement
of the uterus following acute uterine inversion.32
Nonsurgical management Although authors have reported successful
Manual replacement repositioning in individual case reports, a
Once the diagnosis is made, uterine replacement literature search failed to yield the success rate of
should be attempted promptly. This is best done the O’Sullivan technique. The World Health
manually, as delay can render replacement Organization33 recommends that if manual
progressively more difficult and increase the risk of replacement fails, hydrostatic methods should be
haemorrhage. In 1949,AB Johnson described the used.
procedure commonly used for manual replacement
of the uterus, now known as the Johnson Before attempting this method, uterine rupture
manoeuvre,28 in nine cases. The principle behind this must be excluded.23 The procedure is performed
is that ‘the uterus has to be lifted into the abdominal in an operating theatre with the woman in the
cavity above the level of the umbilicus before lithotomy position. Warm sterile water or isotonic
repositioning can occur. It is thought that the passive sodium chloride solution is rapidly instilled into
action of uterine ligaments will rectify the uterine the vagina via a rubber tube or intravenous giving
inversion’.28 The chances of immediate reduction are set, while the accoucheur’s hand blocks the
quoted as 43–88%.9,17,24 In Johnson’s description the introitus. The fluid distends the vagina and pushes
whole hand, plus two-thirds of the forearm, is placed the fundus upwards into its natural position by
in the vagina. Holding the fundus in the palm and hydrostatic pressure. The bag of fluid should be
keeping the tips of the fingers at the uterocervical elevated approximately 100–150 cm above the
junction, the fundus is raised above the level of the level of the vagina to ensure sufficient pressure
umbilicus. It may be necessary to apply digital for insufflation. The problem with this method is
pressure constantly, sometimes for several minutes. the difficulty in maintaining a tight seal at the
This places the uterine ligaments under tension. The introitus.32 This can be overcome by the use of a
tension generated relaxes and widens the cervical silastic ventouse cup (Figure 3), although a hand
ring and facilitates the passage of the fundus though may still be necessary to ensure a tight seal.34
the ring. The inversion is, thus, corrected.28 If
repositioning takes place before oedema of the The literature gives little guidance regarding how to
uterus and a contraction ring develops, the procedure use the silicone cup. It is important not to seal the
is relatively easy to perform. As timing is crucial, if cup over the inverted fundus: instead, the cup should
manual replacement fails, performing the hydrostatic be positioned in the direction of the posterior fornix
method in an operating theatre should be considered. to allow vaginal distension. Advocates of the
Once uterine replacement is successful, the uterus
should be held in place for a few minutes and
uterotonics administered to promote contraction of Signs
the uterus and to prevent re-inversion.29,30 Lump in the vagina Box 2
Signs and symptoms of acute
Appropriate antibiotic cover is required to prevent Abdominal tenderness uterine inversion
infection.23 The placenta should only be removed Absence of uterine fundus on abdominal palpation
after repositioning of the uterus and complete Polypoidal red mass in the vagina with placenta
correction of the inversion in order to avoid shock attached Symptoms
and torrential bleeding.31 Severe abdominal pain
Sudden cardiovascular collapse
The main problem surrounding the Johnson Postpartum haemorrhage
manoeuvre is that, because of the rarity of acute

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Review 2009;11:13–18 The Obstetrician & Gynaecologist

Box 3
replacement or use of the hydrostatic method. The
Uterovaginal prolapse
Differential diagnosis of uterine adverse effect of tocolytic-mediated reduction in
inversion Fibroid polyp uterine tone, however, is an aggravation of
Postpartum collapse postpartum haemorrhage, which is especially
Severe uterine atony undesirable in the presence of shock.26,27 Given that
Neurogenic collapse the rate of postpartum haemorrhage is quoted at
Coagulopathy 94%,25 in the presence of acute inversion, the role of
Retained placenta without inversion tocolysis is very controversial. Many drugs have
been used to achieve tocolysis in acute inversion.
These include: magnesium sulphate (4–6 g
ventouse approach believe that a better seal is
achieved but it may prove time consuming to obtain intravenously [IV] over 20 minutes),26 nitroglycerin
a fluid-giving set of appropriate bore to attach to the (100 micrograms IV slowly, achieving uterine
cup inflow. There is no evidence of any particular relaxation in 90 seconds when given sublingually)
method being significantly more likely to correct and terbutaline (0.25 mg IV slowly).26,36,37 Terbutaline
inversion or prevent haemorrhage. and magnesium sulphate take 2 and 10 minutes,
respectively, to be effective.28 Abouleish et al.9
recommended terbutaline as first-line treatment
The possible complications associated with
because of its rapid onset of action, short half-life,
hydrostatic methods are: infection, failure of
ease of use, availability on the labour ward and
the procedure and, theoretically, saline
embolus.1,23 Although as much as 5 litres has familiarity to the obstetrician.
been recommended as the infusion volume,
there have been no reported cases of saline In practice, rather than pursuing the use of
embolus or pulmonary oedema.35 tocolysis on a conscious woman, it will be
necessary to transfer the women to an operating
theatre for general anaesthesia relatively early.
Is there a role for tocolysis?
In the presence of a constriction ring, reduction of The role of general anaesthesia
uterine inversion can be very difficult. Tocolysis If manual replacement fails, general anaesthesia is
has a role in relaxing the uterus before manual required. The advantage of general anaesthesia is

Figure 2
Algorithm of management of acute
uterine inversion

16 © 2009 Royal College of Obstetricians and Gynaecologists

The Obstetrician & Gynaecologist 2009;11:13–18 Review

that, in addition to maternal pain relief, it Figure 3

Hydrostatic method of reduction
promotes uterine relaxation.1,9 In the past, the use with a silastic ventouse cup.
of halothane inhalation was advocated because of (Drawn by and reproduced with the
kind permission of Bryony Cohen,
its uterine relaxation properties.37,38 With the Medical Illustration Department, St
availability of safer anaesthetic agents and the Bartholomew’s Hospital, London,
UK)
risk of severe hypotension with halothane,
however, it is no longer preferred.

Surgical management
The above methods are expected to work in most cases.
The need for surgery is rare. For completeness, some of
the techniques used are outlined below. We believe that
there is no role for vaginal surgery.

Abdominal
Huntingdon’s operation
The abdomen is opened and the inversion site is
third stage of labour. They should also be
exposed. A crater will be noted in the region of the reassured that fertility and reproductive outcome
cervix, with indrawn tubes and round ligaments. are not compromised following surgical
Two Allis forceps are introduced into the crater on correction.5,42
each side and gentle upward traction is exerted on
the forceps, with a further placement of forceps on
the advancing fundus. By doing this, the uterus is Conclusion
pulled out of the constriction ring and restored to The management of acute uterine inversion should
its normal position.39 be incorporated into skills and drills training. As it is
a rare condition, the precise incidence is unknown.
Haultain’s operation In order to record every case in the UK, we
recommend establishing a register.
In this operation the cervical ring is incised
posteriorly with a longitudinal incision. The rest
of the steps are similar to Huntingdon’s method. References
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