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Zorluk: Çok zorObstetric Complications

A 28-year-old multiparous patient experiences severe hemorrhage and hypovolemic shock immediately following the vaginal delivery of a 4,100 g4,100\text{ g} neonate. During the third stage of labor, aggressive umbilical cord traction was applied before complete placental separation. Physical examination reveals a firm, round, red mass protruding through the vaginal introitus, and the uterine fundus is no longer palpable in the lower abdomen. Profuse vaginal bleeding is ongoing.

Arrange the following management steps for this obstetric emergency in the correct chronological sequence.

  1. 1Immediate discontinuation of any ongoing uterotonic infusions
  2. 2Administration of a rapidly acting uterine relaxant (e.g., intravenous nitroglycerin)
  3. 3Manual replacement of the uterus by applying steady upward pressure on the prolapsed fundus
  4. 4Initiation of aggressive uterotonic therapy to promote sustained myometrial contraction
  5. 5Exploratory laparotomy utilizing surgical repositioning techniques (e.g., Huntington procedure)

Cevap

The correct sequential management of acute uterine inversion is: 1) Discontinue uterotonics, 2) Administer a uterine relaxant, 3) Perform manual replacement, 4) Restart uterotonic therapy, and 5) Proceed to laparotomy if manual replacement fails.
Acute uterine inversion requires a strict chronological sequence to resolve the mechanical obstruction and prevent life-threatening hemorrhage. The sequence begins by halting any agents that contract the uterus, followed by active relaxation of the myometrium. Once relaxed, the uterus is manually pushed back into position. Only after anatomical restoration is confirmed should contracting agents be administered to secure hemostasis. Surgery is strictly reserved for refractory cases.

Adım Adım Çözüm

1
Discontinue all uterotonics
Prevents further cervical constriction
Avoids trapping the inverted fundus outside the pelvic cavity, which would make reduction impossible.
2
Administer a uterine relaxant (e.g., nitroglycerin or terbutaline)
Relaxes the myometrium and cervical ring
Prepares the anatomical structures to allow the fundus to pass back through the cervix.
3
Perform manual replacement (Johnson maneuver)
Restores normal uterine anatomy
Solves the primary mechanical obstruction by pushing the fundus back into the pelvic cavity.
4
Restart aggressive uterotonic therapy
Contracts the replaced uterus
Maintains the correct anatomical position and achieves hemostasis to stop the life-threatening hemorrhage.
5
Proceed to exploratory laparotomy (Huntington/Haultain procedure)
Surgical correction of the inversion
Provides definitive management if all conservative manual measures are unsuccessful.

Anahtar Kavram

Chronological algorithmic management of acute puerperal uterine inversion

Alternatif Yöntem

If manual replacement fails and surgery is delayed, hydrostatic replacement (O'Sullivan's technique) can be attempted. This involves instilling warm saline into the vagina while blocking the introitus, using fluid pressure to push the fundus upward.
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Obstetric Complications

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