Acute uterine inversion in a rural African woman: A rare consequence of child birth
Article Outline
Summary
A case study of Ms. TE a 38-year-old Para7+0 with seven living children is presented. Ms. TE had no antenatal care and was rushed to hospital with features of acute incomplete uterine inversion, 90
min after a spontaneous vaginal birth at home. The birth was supported by the second wife of her husband who had no experience in birth attendance. Her third stage of labour was not managed actively. Successful repositioning of the uterus was achieved under anaesthesia in the hospital.
Uninformed mismanagement of third stage of labour was probably the reason for the condition of Ms. TE. Though acute uterine inversion is rare, accessible primary health care services are necessary for safe motherhood and for supporting women to birth safely.
Keywords: Third stage of labour, Vaginal birth, Uterine inversion, Traditional birth attendants, Home birth
Case study
Introduction
This paper presents a case study of a Southern Nigerian woman whose birth experience was complicated with a rare and potentially fatal outcome. This case study provides a salutary warning of the reality that for many women birth is not the normal life event that it could be, and their lives and health face challenges that many would find inconceivable. Ms. TE is a 38-year-old farmer and the first of two wives of their husband. She was a multiparous woman, Para7+0 with seven living children (four males, three females) who had not received any antenatal care. Ms. TE was rushed to a Maternity Hospital in Ogoja, Cross-River State, Southern Nigeria on the 21st day of January 2007 at 0330 with complaint of a mass protruding through the vagina after birth.
Birth and following
Ms. TE had a spontaneous vaginal birth of a live male baby at home about 90min prior to presentation at the hospital. The birth was supported by the second wife who had no prior experience in birth attendance. The woman though not a Traditional Birth Attendant (TBA), said she guided the co-wife through the process. The baby was said to have cried immediately after birth. No drug was administered to Ms. TE during birth or afterwards. There was a delay of about 30min before the placenta was born by uncontrolled cord traction, after which the woman noticed a mass protruding through Ms. TE's introitus. There was associated vaginal bleeding and pain for which she was transferred to the hospital. Ms. TE had an episode of fainting at the hospital gate on disembarking from the motorcycle that transported her and was subsequently carried into the hospital by relatives.
On examination in the hospital, Ms. TE was conscious, alert, and well oriented in time, person, and place. Her pulse was 98 beats/min, with full volume and regular. Her blood pressure was 110/70mmHg and her extremities were warm. Ms. TE's chest was clear on auscultation, and her first and second heart sounds were normal with no murmur. The uterus was not palpable per abdomen. There was no other significant finding on abdominal examination. A dark reddish mass was visible outside the introitus (Fig. 1). There was minimal vaginal bleeding and no obvious perineal lacerations. Any attempt at palpating the mass evoked severe tenderness.
Figure 1.
Anterior view of the inverted uterus.
Diagnosis and management
A diagnosis of acute incomplete uterine inversion was made. Urgent packed cell volume (PCV) estimation was 30%. Ms. TE was resuscitated with intravenous crystalloids, and broad spectrum prophylactic antibiotics were commenced. The mass was manually replaced under general anaesthesia with intravenous ketamine. Intravenous ergometrine 0.5mg was given following the repositioning of the uterus and bimanual uterine compression was maintained till strong uterine contractions were established. Thereafter, the contractions were maintained with infusion syntocinon 40units in 1l of normal saline at 30drops/min, for a period of 24h. Ms. TE was subsequently counselled on family planning and the need for professionally supervised birth for any future pregnancy. Ms. TE consented to the use of her pictures for this case study provided that they were not identifiable. She was discharged home in stable condition on the second postpartum day (23/1/07). On her postnatal visit on the 9th day of March 2007, both mother and baby were healthy—a remarkable and pleasing outcome.
Discussion
Uterine inversion is the prolapse of the fundus to or through the cervix so that the uterus is in effect turned inside out.1 It is acute, when it occurs within 24h of birth,2 and incomplete when the fundus has not prolapsed through the cervix.1 The diagnosis of acute incomplete uterine inversion in Ms. TE was based on the above definitions.
Acute uterine inversion is a rare but potentially life threatening obstetric emergency3, 4 with varying incidences.1, 5, 6 An extensive literature search however did not show any case report or documented incidence rate from Southern Nigeria. The Maternity hospital involved is the only viable public hospital offering primary and secondary health care services to the predominantly poor people of Ogoja and Yala Local Government Areas in the Cross-River State, Southern Nigeria. Despite an annual birth rate of over 500, a review of the hospital's labour ward and theatre records of the preceding 7 years (2000–2006) did not reveal any similar cases.
Acute uterine inversion is unpredictable and the precise cause is unknown.3 As was probably the case for Ms. TE, mismanagement of the third stage of labour has been reported to be the reason in 75% of cases.5 Oxytocics were not administered to Ms. TE after birth, meaning that the management of her third stage of labour was not active. Therefore, it would have been appropriate for the co-wife attendant to observe signs of placental separation before cord traction was applied or more appropriately the placenta should have been delivered by maternal efforts.7 It is not surprising that the usual recommended controlled cord traction technique for the birth of the placenta was not used in this case because of the co-wife attendant's inexperience. It was equally very likely that the traction applied to the umbilical cord was excessive.
Cord traction in the absence of placental separation may lead to uterine inversion. It could have caused a complete inversion if the placenta had been morbidly attached. In this case the inversion was incomplete, probably because the placenta was already separating at the time of the cord traction. It was also possible that her placenta was located in the fundus thereby increasing her predisposition. Why Ms. TE entrusted herself to an inexperienced co-wife as a birth support person is a matter for speculation as she did not proffer any explanation. Having had seven previous normal births at maternity homes, she probably felt assured that she could manage herself with support. Therefore, when her labour started at night, she may have believed that she had the confidence to guide the co-wife through her labour, birth and third stage. Generally, the widespread insecurity of lives together with poor access to good transportation at night has contributed to the reluctance by Nigerians towards seeking hospital care at night except for life threatening situations such as this case. Women are confronted by difficult choices and at a time like this deciding to go to a hospital for what should have been a normal uncomplicated birth was probably too arduous.
Other predisposing factors to acute uterine inversion that were not evident in this woman include placenta accreta, congenital or acquired weakness of the myometrium, uterine anormalies, protracted labour, previous uterine inversion, and/or intrapartum therapy with magnesium sulfate.1
As expected, the diagnosis in this woman was very obvious.1 A recent study5 had reported that majority of cases of acute uterine inversion presented with shock attributable to hypovolaemia in 69% and neurogenic causes in 13% of women. Because there was minimal bleeding and Ms. TE's cardiovascular status was stable at presentation, the fainting attack she had prior to admission was probably neurogenic. Excessive pressure might have been applied to the tender inverted uterus by the woman or her care-givers while disembarking from the motorcycle causing immediate neurogenic shock with subsequent recovery before admission into the labour ward.
As was the case for Ms. TE, treatment of acute uterine inversion involves immediate resuscitation and replacement of the uterus.3 The result of the urgent PCV and her stable cardiovascular status on admission did not warrant blood transfusion, however, fluid replacement with crystalloids was necessary because of Ms. TE's history of blood loss prior to presentation. Moreover, blood transfusion is carried out with great caution in the hospital because Cross-River state has one of the highest HIV/AIDS point sero-prevalence in Nigeria.7, 8, 9 Immediate attempt at repositioning of the uterus is recommended4 but was not possible in this case because of the severe uterine tenderness. If the cervix was constricted at the time of repositioning of the uterus, intravenous salbutamol, which is the only available tocolytic in the hospital, would have been employed because of the absence of an anaesthetist in the locality to administer halothane. For uterine inversion to occur, the uterus must be relaxed therefore, oxytocics were administered to Ms. TE after repositioning of the uterus and bimanual uterine compression was continued till the uterus was well contracted.1 As was done in this case, it is recommended that oxytocics be continued afterwards for at least 24h.1
Other treatment options for acute uterine inversion include hydrostatic correction, and rarely trans-abdominal surgical repositioning of the uterus.10 Abdominal hysterectomy has also been reported as a treatment option in few cases5 but its consequence on future reproductive function must be considered.
Though previous uterine inversion is a predisposition to a repeat occurrence, uncomplicated births are anticipated in subsequent pregnancies9, 11 therefore, Ms. TE was counselled for family planning as well as the need for professionally supervised birth if she decides to conceive in future.
Conclusion
In conclusion, acute uterine inversion is a very rare event in the rural areas of Southern Nigeria with poor distribution of effective maternity services. Though the institution of active management of third stage of labour does not eliminate acute uterine inversion, it has been shown to reduce it markedly.6 Therefore, governments of developing nations at all levels, should work to ensure the provision of accessible, affordable, and effective primary health care centers adequately equipped with health personnel and infrastructure for pregnant women's labour and births where they cannot be safely supported at home by a midwife and TBA. They should also work towards ensuring the safety and security of women's lives and property in their territories, as well as improvements in women's education so that women as the primary carers for the family are healthy and empowered. With these supports in place, women may not have any need or desire to attempt birth without adequate professional supervision and support.
References
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- Federal Ministry of Health Nigeria. 2003 National HIV sero-prevalence sentinel survey: technical report. Abuja: Federal Ministry of Health; 2004. Available at www.nigeria-aids.org/pdf/2003SentinelSurvey.pdf [Accessed March 5, 2007].
- Federal Ministry of Health Nigeria. 2005 National HIV sero-prevalence sentinel survey: process and findings; 2005. Available at http://www.nigeria-aids.org/pdf/2005sentinel.pdf [Accessed March 5, 2007].
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- . Fertility and reproduction following inversion of the uterus. J Indian Med Assoc. 1993;91(6):149–150
PII: S1871-5192(08)00085-1
doi:10.1016/j.wombi.2008.09.006
© 2008 Australian College of Midwives. Published by Elsevier Inc. All rights reserved.
