A 32-year-old woman, gravida 2, para 2, experiences sudden, massive vaginal bleeding shortly after a spontaneous vaginal delivery at 39 weeks gestation. The placenta delivered spontaneously 5 minutes ago with gentle cord traction. Her blood pressure is 78/40 mmHg and her pulse is 135/min. On physical examination, the uterine fundus cannot be palpated in the abdomen. Pelvic examination reveals a red, fleshy, globular mass protruding through the external cervical os. Arrange the following management steps in the correct sequential order for this patient's condition.
- 1Discontinue the ongoing oxytocin infusion.
- 2Attempt immediate manual replacement of the uterus.
- 3Administer a uterine relaxing agent (e.g., nitroglycerin) if initial replacement fails.
- 4Restart uterotonic medications (e.g., oxytocin).
Cevap
The correct sequence for managing acute uterine inversion is: 1) Discontinue the ongoing oxytocin infusion, 2) Attempt immediate manual replacement of the uterus, 3) Administer a uterine relaxing agent (e.g., nitroglycerin) if initial replacement fails, and 4) Restart uterotonic medications (e.g., oxytocin) after successful replacement.
Acute uterine inversion is an obstetric emergency presenting with an absent uterine fundus, a vaginal mass, and profound hemorrhagic shock. The first priority in management is to stop all uterotonics (e.g., oxytocin) to prevent the uterus from contracting in the inverted state. Second, prompt manual replacement is attempted by pushing the fundus back up through the cervix. Third, if the uterus is incarcerated by a contracted lower segment and initial replacement fails, uterine relaxants (e.g., nitroglycerin, terbutaline, or general anesthetics) are administered to facilitate replacement. Finally, once normal anatomy is successfully restored, uterotonics must be immediately restarted to ensure the uterus contracts and stays in place, which also serves to halt the hemorrhage.
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Anahtar Kavram
Management Sequence for Acute Uterine Inversion