Volume 73, Number 7

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2018 Wolters Kluwer Health,
Inc. All rights reserved. CME REVIEW ARTICLE
CHIEF EDITOR'S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of
17
36 AMA PRA Category 1 Credits™ can be earned in 2018. Instructions for how CME credits can be earned appear on the last page
of the Table of Contents.

Uterine Inversion: A Review of a

Life-Threatening Obstetrical Emergency
Michael P. Wendel, MD,* Kelsey L. Shnaekel, MD,* and Everett F. Magann, MD†
*Resident and †Professor, Maternal-Fetal Medicine Fellowship Director, Department of Obstetrics and Gynecology,
University of Arkansas for Medical Sciences, Little Rock, AR
Downloaded from http://journals.lww.com/obgynsurvey by BhDMf5ePHKbH4TTImqenVBhf5K8zlU/3yukil0BNYXW3AtoC9CwHguh1VodSy19u on 08/09/2018

Importance: Uterine inversion is frequently accompanied by postpartum hemorrhage and hypovolemic shock. Mor-
bidity and mortality occur in as many as 41% of cases. Prompt recognition and management are of utmost importance.
Objective: The aim of this review is to describe risk factors, clinical and radiographic diagnostic criteria, and
management of this rare but potentially life-threatening complication of pregnancy.
Evidence Acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on
the number of years searched.
Results: There were 86 articles identified, with 25 being the basis of review. Multiple risk factors for a uterine
inversion have been suggested including a morbidly adherent placenta, short umbilical cord, congenital weak-
ness of the uterine wall or cervix, weakening of the uterine wall at the placental implantation site, fundal implan-
tation of the placenta, uterine tumors, uterine atony, sudden uterine emptying, fetal macrosomia, manual removal
of the placenta, inappropriate fundal pressure, excessive cord traction, and the use of uterotonic agents prior to
placental removal. The diagnosis is almost exclusively clinical, and successful treatment depends on prompt rec-
ognition of the uterine inversion. Treatment options include manual and surgical replacement of the inverted
uterus. There is no consensus regarding mode of delivery in subsequent pregnancies as reinversion in a subse-
quent pregnancy is unpredictable. However, if surgical replacement was required in the index pregnancy and in-
volved an incision into the contractile portion of the uterus, cesarean delivery is a reasonable management option
similar to that offered for a prior classic cesarean section.
Conclusions: Successful treatment is dependent on prompt recognition. Management should include resus-
citation of maternal hypovolemic shock, as well as repositioning of the inverted uterine fundus.
Relevance: Uterine inversion is a rare but potentially life-threatening obstetrical emergency.
Target Audience: Obstetricians and gynecologists, family physicians.
Learning Objectives: After completing this activity, the learner should be better able to evaluate published
literature regarding puerperal uterine inversion, assess its associated comorbidities and risk factors, define clinical
and radiographic diagnostic criteria to assist in prompt recognition and management of this obstetrical emergency,
and propose management options for future pregnancies.

Uterine inversion is an obstetrical complication in
which the uterine fundus collapses into the endometrial
cavity. Overwhelmingly, inversion is a puerperal event,
with only 150 cases of nonpuerperal inversion reported
All authors, faculty, and staff in a position to control the content of
this CME activity and their spouses/life partners (if any) have disclosed
that they have no financial relationships with, or financial interests in,
any commercial organizations pertaining to this educational activity.
Correspondence requests to: Everett F. Magann, MD, University of
Arkansas for the Medical Sciences, 4301 W Markham St, #518, Little
Rock, AR 72205. E-mail: efmagann@uams.edu.
www.obgynsurvey.com | 411
in the literature from 1887 to 2006.1 The condition is
frequently accompanied by postpartum hemorrhage
and hypovolemic shock. Prompt recognition and man-
agement are of utmost importance as morbidity and
mortality of an acute uterine inversion occur in as many
as 41% of cases. Prompt management has all but elim-
inated maternal mortality.2
Inversion is a rare puerperal complication, with a re-
ported incidence ranging from 1 in 20,312 to 1 in
1739 deliveries.3,4 A recent 10-year study in the United
States found 2427 cases in 8,294,279 deliveries from

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

412 Obstetrical and Gynecological Survey
2004 to 2013, or approximately 1 in 3448 deliveries.5
Despite the rarity of a uterine inversion, it remains a
true obstetrical emergency. Early reports estimated the
maternal mortality rates as high as 15%,5 but in more
recent studies, no maternal deaths have been reported
in “high-resource countries” in some time. In contrast,
in “low-income countries,” mortality due to cases of
acute uterine inversion is still a reality.4 Significant
morbidity, however, remains a very real concern. Pa-
tients whose uteri invert following delivery are more
likely to have postpartum hemorrhage and maternal hy-
povolemic shock and require a blood transfusion. In ad-
dition, these patients are at greater risk of requiring
surgical management and/or a hysterectomy, although
fewer than 10% of all cases from 2004 to 2013 required
surgical intervention.5
Uterine inversion is classified both by the timing and
degree of inversion. Inversion can be acute, subacute,
or chronic. If the diagnosis is made within 24 hours,
the inversion is acute. If the diagnosis is made after
4 weeks, it is a chronic inversion, and diagnosis at more
than 24 hours and less than 4 weeks is subacute. Degree
of inversion can be classified from first to fourth (Fig. 1).
First-degree inversion occurs when the corpus or wall of
the uterus extends to the cervix but does not protrude be-
yond the cervical ring. In second-degree inversion, the
corpus passes through the cervical ring but does not
reach the perineum. In third-degree inversion, the fundus
extends to the perineum, and finally, if the vagina inverts
along with the uterus past the perineum, the inversion is
deemed to be a fourth-degree inversion.6
METHODS
PubMed, Web of Science, and CINAHL were searched
using the search terms “inverted uterus” OR “uterine
FIG. 1. Inverted uterus—degrees of inversion.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
inversion” OR “inverted” and “uterus” and “puerperal.”
The search was limited to the English language, and
there were no limitations on the years searched. Two
authors (M.P.W. and K.L.S.) independently reviewed
all of the abstracts and the full articles that discussed
uterine inversion or inverted uterus. In addition, the ref-
erences of the articles were reviewed for any additional
relevant articles. Inclusion criteria included any arti-
cle that discussed risk factors, diagnosis, management,
or complications of the inverted uterus in pregnancy.
Eighty-six abstracts were reviewed, and 25 full-text ar-
ticles were used as the basis of this review (Fig. 2).
RISK FACTORS
The etiology of uterine inversion is not well under-
stood, and in as many as 50% of cases, no precipitating
factor can be identified.7 However, several factors have
been proposed that may increase the risk of inversion;
placenta accreta, short umbilical cord, congenital weak-
ness of the uterine wall or cervix, weakening of the
uterine wall at the placental implantation site, fundal
implantation of the placenta, uterine tumors, uterine
atony, sudden uterine emptying, fetal macrosomia,
manual removal of the placenta, inappropriate fundal
pressure, excessive cord traction, and use of uterotonic
agents prior to placental removal have all been associ-
ated with uterine inversion.2 Coad et al5 also found that
a prolonged labor can also lead to an increased risk of
uterine inversion. In particular, uterine tumors are asso-
ciated with nonpuerperal inversion1; however, this is
beyond the scope of this review.
More recently, some studies have challenged whether
some traditional risk factors really play a role in uterine
inversion. Earlier case reports attributed up to 50% of
cases of uterine inversion to mismanagement of the
 Uterine Inversion • CME Review Article 413

FIG. 2. Flow diagram of literature review.

third stage of labor with Credé fundal pressure, exces- 37.7% of the 2427 inversion cases, and 22.4% of all
sive cord traction, or both, leading to an inverted uterus. cases required a blood transfusion. Maternal hypovole-
More recent studies have hypothesized this is not a mic shock was reported in 39% of cases in Watson and
true risk factor but merely an event that may precipitate colleagues'4 study and in 32% in a study by Brar et al.9
inversion in a uterus prone to do so.5 The paucity of Similarly, Coad and colleagues'5 nationwide cohort
cases despite widespread acceptance of active third-
stage labor management lends credence to this theory.
Primiparity has also long been proposed as a risk factor,
primarily due to the increased incidence of placenta TABLE 1
Risk Factors
fundal implantation in this population.8 However, even
in studies where primiparas represent a large proportion Maternal
• Uterine structural anomalies
of uterine inversions, the percentage of primiparous pa-
• Uterine tumors
tients in the population studied is roughly equivalent to • Connective tissue disorder
multiparas.3,4 In the national cohort by Coad et al,5 fetal • Congenital weakness of uterine wall or cervix
macrosomia was not found to be a statistically signifi- • Weakening of the uterine wall at placenta implantation
cant risk factor despite its historical place among the Placenta
• Fundal placenta
risk factors for uterine inversion (Table 1).
• Morbidly adherent placenta
• Umbilical cord
• Short umbilical cord
DIAGNOSIS Fetus
The diagnosis of uterine inversion is almost exclu- • Fetal macrosomia
Labor
sively a clinical diagnosis. The most common features
• Uterine atony
of inversion are postpartum hemorrhage, hypovolemic • Precipitous labor
shock, and abdominopelvic pain.2 Watson et al4 observed Iatrogenic
that hemorrhage was seen in 94% of cases with an 18- • Inappropriate fundal pressure
case study published in 1980. In Coad and colleagues'5 • Poor management of the third stage of labor
• Manual removal of the placenta
nationwide study, maternal hemorrhage occurred in

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414 Obstetrical and Gynecological Survey
reported a much lower incidence, with only 32 total
cases of shock, which was only 1.3% of all inversion
cases. Despite this small percentage, patients experienc-
ing an inverted uterus were found to be 76.9 times more
likely to experience shock compared with patients with
deliveries not complicated by inversion.6 Early reports
frequently describe shock out of proportion to blood
loss. This was most likely due to either gross underesti-
mation of blood loss or increased vagal tone caused by
stretching of the broad ligament and peritoneal nerves,
as well as pressure on the ovaries as they are pulled into
the inverted uterus.2 However, rapid recognition along
with fluid resuscitation and proper management seems
to have limited the amount of cases that have postpartum
hemorrhage or progress to hypovolemic shock.2,6
In addition to common signs and symptoms, phys-
ical examination findings are key in diagnosing uterine
inversion. The bimanual examination is probably the
most useful physical examination in a situation when
a clinician suspects uterine inversion. Abdominally,
the fundus will not be palpable in the correct anatomic
position, and in patients with a thin abdominal wall,
a cuplike depression indicating the collapsed fundus
may be noted.2 A soft, congested, bleeding mass found
in the vagina is virtually diagnostic, and “if the placenta
is still attached, an error in the diagnosis is impossi-
ble.”2,10 Diagnosis during cesarean section is largely
made by direct visualization of inversion of the fundus
through the uterine incision with either a partially or
completely attached placenta.3
In cases of subacute or chronic inversion or even first-
degree inversions, diagnosis may not be as quickly
apparent. The uterine fundus may be mistaken for a
uterine polyp or prolapsed fibroid.2 In these situations,
ultrasound and magnetic resonance imaging (MRI)
have proven to be effective means of diagnosis. Ultra-
sound can be used both transabdominally or vaginally.
Transabdominally, in the transverse plane, a character-
istic “target sign” can be seen. A hyperechoic fundus
surrounded by a hypoechoic rim created by the space
between the endometrium and vaginal walls creates this
characteristic appearance. In the sagittal plane, a first-
degree inversion may have a Y-shaped endometrium
as the fundus collapses toward the cervix. In second-
degree inversions, the uterus appears as a mirror image
of itself with the 2 serosal edges creating a pseudo en-
dometrial stripe as the entire uterus has inverted into
the vagina through the cervix. Transvaginally, when the
transducer is in contact with the fundus, a similar mir-
rored uterus is seen.11–13
While ultrasonography is the first-line imaging mo-
dality for suspected inversion in either puerperal or non-
puerperal cases, MRI can be a useful adjunctive imaging
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
study. Magnetic resonance imaging is especially useful
in operative planning in cases of inversion caused by
mass lesions. In addition to diagnosis of inversion, MRI
can help to evaluate morphologic changes in the uterus,
origin of potential mass lesions, signal, and contrast
enhancement of potential lesions. Contrast-enhanced
studies are preferred to help fully evaluate masses for
lesions. There are characteristic appearances on both
axial and sagittal views. Axial images will show a sim-
ilar “bull's-eye” or target configuration as on ultrasound
views created by a hyperintense endometrium surrounded
by a second hyperintense rim. Sagittal views will show
a characteristic V-shaped uterine cavity surrounded by
the inverted fundus. Again, MRI is rarely used for ini-
tial diagnosis but is useful for confirmation and delin-
eating the mass lesion from surrounding structures.12,13
TREATMENT
Successful treatment hinges on the ability to quickly
recognize this morbid pregnancy complication. As stated
previously within this article, clinical symptoms such as
hypovolemia and shock, which may seem out of propor-
tion to the actual blood loss, are often the first signs.2,10
Prompt treatment with aggressive fluid resuscitation
and blood transfusion should be initiated. Two large-
bore intravenous lines should be placed, and anesthesia
should be notified to aid in pain control if transition
to the operating room becomes necessary. Additional
staff to assist in the resuscitation should be mobilized.
Uterotonic agents should be stopped, and attempt should
be made to manually replace the uterus. Tocolytic agents
such as terbutaline and magnesium should be availa-
ble but are not required in all cases of inversion.14 There
has been controversy regarding management of the pla-
centa when it is still in place attached to the uterus. Some
authors advocate removal prior to replacement as this de-
creases the bulk of the uterus and may allow for easier
repositioning. Other investigators advocate leaving the
placenta attached in situ with the theory that the attached
placenta may prevent excessive hemorrhage and pre-
vent further exacerbation of maternal shock.2,5,9
Repositioning of the uterus can be accomplished in a
number of ways. Johnson15 was the first to describe
manual replacement of the inverted uterus (Fig. 3). With
the Johnson maneuver, the surgeon's entire hand is posi-
tioned within the vagina, with the tips of the fingers at
the uterocervical junction and the fundus held in the
palm. The uterus is then lifted out of the pelvis and ele-
vated above the level of the umbilicus. This maneuver
causes the uterine ligaments to stretch, which causes the
cervical ring to widen and allows the fundus to move back
through the cervical ring and to its anatomical position.
 Uterine Inversion • CME Review Article
FIG. 3. Inverted uterus—manual method of repair.
Once repositioned, the uterus is held in position for 3 to
5 minutes.2,4,5,10 Henderson and Alles16 described a
slight modification on this by applying ringed forceps
to the cervical ring to allow for countertraction. Another
nonsurgical method includes the O'Sullivan maneuver,
described in 1945, which involves the use of hydro-
static pressure to replace the uterus. The surgeon uses
normal saline hung to gravity with a catheter placed
within the vagina, with the operator's hand used to
block the introitus to prevent escape of fluid. As the
vaginal walls distend, the hydrostatic pressure forces
the fundus upward into its original position. Another im-
portant aspect of management for replacement, whether
conservative and manual or surgical, includes the choice
of anesthesia to maximize both pain control and uterine
and cervical relaxation.2
Attempts at conservative approaches should be the
first and foremost; however, surgeons should not hesi-
tate to pursue surgical management options when con-
servative measures fail. If nonoperative replacement is
not successful, surgical approaches should be utilized.
Surgical approaches for replacement can be categorized
into abdominal versus vaginal approaches. Huntington
et al17 described abdominal replacement of the uterus in
which, after laparotomy, the inversion is identified, Allis
FIG. 4. Inverted uterus—surgical method of repair.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
415
clamps are placed on the uterus at the round ligaments,
and gentle upward traction is applied. The Allis clamps
are replaced and advanced sequentially below the pre-
vious clamps, and this process is repeated until fundus
is replaced (Fig. 4). If this procedure fails to reduce the
inversion, another abdominal surgical approach is the
Haultain procedure, in which a horizontal hysterotomy,
5 to 6 cm in length, is made in the posterior portion of
the lower uterine wall through the cervical ring. The
posterior wall is incised in order to avoid the bladder,
which is usually drawn into the inverted uterine cavity.
By making this incision in the posterior uterine wall
and cervical ring, this increases the size of the opening
and allows easier facilitation of the Huntington proce-
dure. The hysterotomy is closed in usual fashion.2,4,10
A vaginal surgical approach has also been described,
the Spinelli procedure. With this procedure, a trans-
verse incision is made in the anterior vaginal wall above
the anterior cervical lip and includes the anterior uterine
wall. With this, the split uterus is repositioned by apply-
ing upward pressure in the fundus. The anterior uterine
wall is closed in 2 layers from the vaginal approach and
results in a vertical incision similar to that with a classic
cesarean section.8 A few authors have suggested lapa-
roscopic reduction because of benefits such as smaller
416 Obstetrical and Gynecological Survey
incision, less pain, and early recovery; however, this
has been highly scrutinized because of the emergent
nature of inversion. The consensus still remains that,
in the setting of hemodynamic instability, laparotomy
is preferred.1,18
Following replacement, the uterus may become atonic,
especially if tocolytics were used to aid in replacement;
therefore, uterotonics should be used. Historically, oxy-
tocin (Pitocin), ergots, prostaglandins, and fundal mas-
sage have been administered and performed to promote
tonicity. Administration of prophylactic antibiotics after
uterine inversion and replacement remains controver-
sial. A prevailing belief is that the inverted uterus ex-
poses the endometrial surfaces to the vaginal flora and
increases the risk of infection. Two small studies, how-
ever, did not find any benefit to the use of prophylactic
antibiotic administration. Regardless of method of re-
placement, it is important to explore the uterus to rule
out any possibility of uterine rupture, which is a rare
and devastating complication2,4,5,10 (Table 2).
COMPLICATIONS
Several case series have discussed complications as-
sociated with uterine inversion and subsequent uterine
atony resulting in significant postpartum hemorrhage
and shock. Multiple authors describe uterine inversion
during cesarean section.11,19 Several authors have de-
scribed management of subsequent uterine atony with
variations of uterine suturing techniques.20,21 Recurrent
acute reinversion was noted in multiple case reports.
Multiple authors described successful treatment of re-
inversion with intrauterine tamponade balloon to aid
in preservation in position of uterine fundus. It has been
TABLE 2
Management
Supportive
• Call for help, ie, anesthesia, additional staff, experienced physician
• Aggressive fluid resuscitation—2 large-bore intravenous
access lines
• Blood replacement
• Foley placement
• Pain control
• Stop uterotonic medications
Uterine Replacement
• Anesthesia—general
• Tocolytics—magnesium or terbutaline
• Nonsurgical techniques—Johnson, O'Sullivan
• Surgical techniques—Huntington, Haultain, Spinelli
Subsequent Management
• Uterine massage
• Uterotonic medications—Pitocin, methergine (Methergine),
carboprost tromethamine (Hemabate)
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
theorized that placement of balloon conforms to the
contours of the uterus to maintain position.22–26 Many
authors agree regarding management of uterine atony
and continued postpartum hemorrhage. Hysterectomy
may be required if other methods of repositioning and
control of hemorrhage are unsuccessful.
MANAGEMENT OF SUBSEQUENT
PREGNANCIES
Management for subsequent pregnancies is described
throughout the literature. Many sources recommend
delivery in the hospital. Some authors recommended
surgical delivery, whereas others discourage this be-
cause there is no guarantee against recurrence. Regard-
less, most agree that delivery should occur in a facility
with resources for general anesthesia and blood transfu-
sion as necessary.
An additional literature search was performed regard-
ing management of subsequent pregnancies in which
surgical replacement was performed without consen-
sus. It is reasonable to offer cesarean section for those
who required surgical intervention with Haultain or
Spinelli maneuver because of incision into the con-
tractile portion of the uterus similar to classic uterine
incision.27 In addition, this should be performed in the
elective setting with planned delivery. However, no
studies have been done that support this theory, most
likely because of low incidence of uterine inversion as
well as the low incidence of those requiring surgical
intervention.
CONCLUSIONS
Uterine inversion is a rare and potentially life-threatening
complication of pregnancy that occurs during or after
the third stage of labor. There are many suggested risk
factors; however, the predictability of these is un-
known. Uterine inversion is a clinical diagnosis and
should be considered in any patient with symptoms of
hemorrhage, hypovolemic shock, and abdominopelvic
pain, with the physical findings of a soft, congested,
bleeding mass within the vagina on bimanual examina-
tion. Treatment should be prompt and almost intuitive,
with emphasis placed on management of resuscitation
of hypovolemia and replacement of uterine fundus to
its appropriate anatomical position. Recurrence in sub-
sequent pregnancies is unpredictable, and there are no
recommendations regarding the need for surgical deliv-
ery outside routine obstetrical indications. However, if
replacement required surgical correction with incision
within the contractile portion of the uterus, subsequent
delivery with scheduled cesarean section is reasonable,
 Uterine Inversion • CME Review Article
similar to management of those with previous classic
cesarean section.
ACKNOWLEDGMENTS
The authors thank Shelia Thomas, MA (LS), Medical
Research and Clinical Search Services coordinator,
at the University of Arkansas for Medical Sciences
Library for her assistance in their literature search.
The authors also thank Donna Eastham, BA, CRS, for
her help in editing and submitting the manuscript.
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