Re: Inversion of uterus...A rural experience..
From: art fougner, md (evsono@pipeline.com)
Mon Jul 1 12:42:03 2002
sometimes the old amyl-nitrite "popper" accomplishes this as well.
art
At Mon, 1 Jul 2002, Charlie Chambers wrote:
>
>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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>
--
art fougner, md
ich bin ein New Yorker
