Re: Inversion of uterus...A rural experience..
From: Charlie Chambers (cchamber@gorge.net)
Mon Jul 1 10:38:08 2002
What's been very effective for me in the past has been IV nitro. Really
relaxes the uterus more than anything else I've tried.
On Monday, July 1, 2002, at 02:33 AM, Dr.Sanjay B.Patil wrote:
> I was summoned as a emergency help in a private nursing home for a
> patient who was just delivered and bled heavily ,ultimately becoming
> pulseless and was in a state of severe haemorrhagic shock. The patient
> was a unregistered fourth gravida who delivered within 15-20 minutes of
> arrival.She had all previous uneventful home deliveries. She had labour
> pains approx.24 hours back. No leaking or bleeding.
> She was accompanied by her neighbour at the time of admission. When
> patient went in shock, she also aptly went home without informing. A
> state existed when nobody was available to take the responsibilty.
>
> However the attending obstetrician gave history of uneventful second
> stage of labor and somewhat prolonged third stage ,i.e. 20 min.
> Possibility of mismanagement of third stage, although a strong contender
> ,was denied by attending accoucher. Immediately after the delivery of
> placenta ,patient complained of severe pain in abdomen and started
> bleeding heavily, which was uncontrolled despite repeating Inj.
> Methergin twice intravenously , followed by Inj.Prostidin. Patient had
> heavy bout of vomiting following this which was attributed to
> Inj.Methergin and/ or Inj.Prostidin and patient started deteriorating.A
> Per vaginum examination done at this point by accoucher made her suspect
> possibility of inversion of uterus.I received the call around one hour
> after delivery.On examination patient was severely pale and was in state
> of severe shock. Patient was immediately shifted to adjacent operation
> theatre and emergency resuscitation efforts were started. Two large
> bore i.v.canula inserted and ringer lactate and haemaccel started.
> Patient meanwhile must have lost 3-4 litres of blood by then. There was
> difficulty in arranging blood from blood bank which was 1 km away from
> hospital and staff of blood bank was reluctant to issue blood without
> replacement .
> In view of this situation and poor and worsening g.c.of patient ,
> attempt of reposition of inversion was made under Ketamine as Boyleís
> aparatus was not available and anaesthetist expressed his limitations.It
> was done by using OíSullivanís method of use of hydrostatic pressure
> .While attempting repositioning a large mass arising out of fundus into
> cavity felt, about 5 by 5cm in size. No pedicle was felt and it
> appeared to be arising out of myometrium.Muscular relaxation obtained
> under this G.A. was of poorest quality.However uterus become
> immediately palpable per abdominally about 24 weeks in size.Bimanual
> massage along with Pitocin drip was started for next 15-20 min .At the
> end on bimanual examination .uterus appeared to be nicely retracted and
> no classical dimpling of uterine wall was felt, making one suspicious of
> fibroid polyp.A attempt of pushing this mass into abdomen was made from
> centre of the mass throughout the procedure but has to be abandoned due
> to great resistance felt from uterine wall and also partly due to fear
> of causing iatrogenic rupture uterus and poor general condition of
> patient.
>
> 12 points of saline and 3 points of Haemaceel were infused within 2
> hours which resulted in improving hydration and general status of
> patient reflected by pulse which was 110/bpm and blood pressure ñ100/70
> mm Hg. After return of little bit sanity with this in the theatre
> ,patient was catheterised and RT aspiration was done. By then patient
> came out of anaesthesia. Relatives became available .Blood was
> arranged. And a detail strategy regarding fluid replacement was chalked
> out. A sonography on settlement of patient next day was advised. I
> then retired from situation leaving management to the concerned nursing
> home. Patient received five points of blood transfusion overnight.
> She was doing well for next five days with complete bed rest with uterus
> getting slowly involuted about 1 cm per day.On fifth day ,i.e. after
> removal of catheter, while passing urine patient experienced mass coming
> out in vagina.Within next 12 hours,the whole uterus was outside the
> perineum i.e. on 6 th P.N.D. The fibroid was not palpable in the
> prolapsed uterus ? disseminated.
> The patient was then shifted to a tertiary care hospital where patient
> underwent abdominal hysterectomy after correction of inversion by
> Spinelliís technique unevenfully with five units of blood being kept as
> a reserve. No fibroid was detectable .The question now arises was it
> really fibroid? It appears that after delivery of placenta ,dimpling of
> fundus must have occurred which with two doses of Inj .Methergin and
> Inj.Prostidin must have resulted into strong contracture of myometrium
> around the prolpased fundus causing its strangulation and must have
> mimicked as a fibroid to the palpating fingers.
> In addition to this the Ketamine anesthesia failed to cause uterus to
> relax resulting into persistence of myometrial contracture ring at the
> neck allowing only Partial repostioning of uterus which helped the
> patient to come out of neurogenic shock and further treatment of
> haemorrhagic shock made her survive.
> The lesson learned here is
> 1.Never try to reposit the inverted uterus without uterine relaxation ,
> producable by halothane, especially when patient has received
> Inj.Methergin and much worse Inj.Prostaglandin.
> 2.Never diagnose rarities.
> 3.No need to take this risk in small setup in absence of Boyleís
> aparatus.
>
> --
> Success come to those who walk towards it.
>
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Charlie Chambers
--
Hood River, OR
cchamber@alumni.rice.edu
"Almost anything you do will seem insignificant but it is very important
that you do it....You must be the change you wish to see in the world"
-- Mahatma Ghandi.
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