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Difficulty: HardObstetric Complications

A healthy nulliparous patient at term (3939 weeks gestation) presents in active labor and subsequently delivers a vigorous male infant vaginally. During the third stage of labor, significant umbilical cord traction is applied. Immediately following the delivery of the placenta, the patient develops catastrophic vaginal hemorrhage. Her vital signs rapidly deteriorate, showing a blood pressure of 75/4075/40 mm Hg and a pulse of 138138/min. Palpation of the maternal abdomen reveals that the uterine fundus is entirely unpalpable at the umbilicus. A speculum examination identifies a large, smooth, beefy-red mass extending through the dilated cervix. Intravenous fluid resuscitation and massive transfusion protocols are rapidly initiated for acute complete uterine inversion. Arrange the following definitive management steps in the correct chronological sequence.

  1. 1Discontinue current uterotonic agents and attempt immediate manual repositioning
  2. 2Administer a uterine relaxant such as intravenous nitroglycerin
  3. 3Reattempt manual repositioning of the relaxed uterus
  4. 4Initiate uterotonic therapy to firmly contract the uterus

Answer

The correct sequence for managing acute uterine inversion is to first discontinue uterotonics and attempt immediate manual replacement, then administer a uterine relaxant if initial attempts fail, followed by a reattempt at manual replacement of the relaxed uterus, and finally initiating uterotonic therapy once normal anatomy is restored.
Acute uterine inversion is a life-threatening obstetric emergency characterized by a beefy-red vaginal mass, severe hemorrhage, and an unpalpable abdominal fundus. The immediate goal is to physically replace the uterus. First, any infusing uterotonics must be discontinued, and immediate manual replacement should be attempted. If the cervix has already formed a tight constriction ring, making initial manual replacement unsuccessful, a uterine relaxant (such as intravenous nitroglycerin, terbutaline, or a halogenated anesthetic) must be administered. Once the uterus is relaxed, manual repositioning is reattempted. Finally, after the uterus is confirmed to be in its normal anatomic position, uterotonics (e.g., oxytocin, methylergonovine, carboprost) are administered to firmly contract the uterus, control hemorrhage, and prevent reinversion.

Step-by-Step Solution

1
Identify the complication and underlying pathophysiology
Acute uterine inversion
The patient presents with profound hemorrhagic shock, an absent palpable abdominal fundus, and a beefy-red vaginal mass after umbilical cord traction.
2
Determine the initial definitive intervention
Stop uterotonics and attempt immediate manual replacement
Uterotonics contract the lower uterine segment, making replacement physically impossible. Immediate replacement is the critical first-line therapy before cervical edema and constriction worsen.
3
Select the subsequent medical management for refractory cases
Administer a pharmacological uterine relaxant
If the initial manual attempt fails because the cervix has clamped down around the inverted fundus, pharmacological relaxation (e.g., nitroglycerin, terbutaline) is required.
4
Identify the final corrective and prophylactic actions
Reattempt manual replacement, followed immediately by uterotonic administration
Once the uterus is back in its correct anatomic position, reinitiating uterotonics ensures it remains firmly contracted to halt bleeding and prevent reinversion.

Key Concept

The sequential management of acute uterine inversion requires the immediate discontinuation of uterotonics and prompt manual replacement, followed by pharmacological uterine relaxation if needed, and finally, the administration of uterotonics only after successful repositioning.
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Topics

Obstetric Complications

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