A 27-year-old woman, gravida 1, para 1, experiences a sudden onset of severe vaginal bleeding immediately following the delivery of the placenta. Her blood pressure drops to 80/40 mmHg and heart rate increases to 125/min. On pelvic examination, a purplish, fleshy mass is seen protruding through the vaginal introitus, and the uterine fundus cannot be palpated through the anterior abdominal wall. Arrange the following management steps for this complication in the correct chronological sequence.
- 1Call for additional assistance and initiate aggressive intravenous fluid resuscitation
- 2Attempt immediate manual replacement of the uterus
- 3Administer a uterine relaxant (e.g., nitroglycerin or terbutaline)
- 4Administer uterotonic agents (e.g., oxytocin or methylergonovine)
Cevap
The correct sequence for managing acute uterine inversion is: Call for help and resuscitate, attempt immediate manual replacement, administer a uterine relaxant (if initial replacement fails), and finally administer uterotonic agents.
Acute uterine inversion is a life-threatening obstetric emergency. Management must follow a specific, sequential algorithm to safely correct the inversion and control hemorrhage. First, the team must be assembled and maternal resuscitation initiated. Second, the provider must immediately attempt to manually push the fundus upward through the cervix. Third, if the cervix has already formed a constriction ring around the inverted fundus, a uterine relaxant (such as terbutaline, nitroglycerin, or a halogenated anesthetic) is given to facilitate replacement. Finally, once the uterus is fully reverted to its normal anatomical position, uterotonic drugs (such as oxytocin) are administered to provide a firm, contracted uterus that will resist re-inversion and stop the bleeding. Giving uterotonics before replacement is strictly contraindicated.
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Management algorithm for acute uterine inversion