JOURNAL OF GYNECOLOGIC SURGERY

Volume 31, Number 2, 2015

ª Mary Ann Liebert, Inc.
DOI: 10.1089/gyn.2014.0094

Management of Acute and Subacute Puerperal Uterine

Inversion with Intravenous Nitroglycerin

Roopa Malik, MD,1 Viral Sangwan, MD, DM,2 Shaveta Jain, MBBS, MS,1 and Nitin Jain, MBBS, DMRD 3

Abstract

Background: Uterine inversion is an unpredictable entity, with more than one-half of cases reported without
detectible precipitants. Hemorrhage can be rapid and life-threatening, requiring prompt recognition and ag-
gressive management. Cases: Case 1: A 25-year-old female, para 1, with complete uterine inversion presented
as a case of postpartum hemorrhage and this was managed successfully with intravenous (IV) nitroglycerine.
Case 2: A second case involved partial uterine inversion, in a 22-year-old female, para 1, who had a retained
placenta. The inversion was not corrected by anesthesia but was corrected by IV nitroglycerine without any side-
effects. Results: Both cases were treated successfully with the use of IV nitroglycerin. Both women had
postpartum hemorrhage caused by uterine inversion. IV nitroglycerin was found to be effective and was not
associated any adverse effects. Conclusions: General anesthetics are generally used for uterine relaxation in
cases of uterine inversion but these agents are associated with serious side-effects. Nitroglycerin is a useful tool
in the obstetrical armamentarium. Its short duration of action and rapid absorption make it ideal for expeditious
uterine and cervical relaxation. Gynecologists and obstetricians should become familiar with the agents in the
gynecology armamentarium so that major surgery can be prevented in cases like the ones described in this article.
(GYNECOL SURG 31:104)

Introduction sure (BP) of 80 mm Hg and a pulse rate of 136 beats per

minute (BPM). This patient had delivered at home, assisted
A cute inversion of the uterus is a rare—but poten-
tially fatal—obstetrical emergency that can occur in the
third stage of labor. Although the exact cause for this inver-
by an untrained midwife, and had a history of fundal pres-
sure during the second stage of labor. Her placenta was
delivered within 10 minutes of delivery of the neonate by
sion is unclear, active management of the third stage of labor
controlled cord traction, and the length of the umbilical cord
is recommended to avert maternal morbidity and mortality.
was *35 cm. Subsequently, this patient was referred to the
To minimize the hazards of acute puerperal inversion, the
Post Graduate Institute of Medical Sciences (PGIMS) be-
uterus must be repositioned immediately, but manual efforts are
cause she was having uncontrolled postpartum hemorrhag-
often hampered by cervical constriction. To relax the constriction
ing. She reached the casualty department of the PGIMS
ring, halothane is commonly administered, but this weak uterine
following 2 hours of delivery.
relaxant reduces uterine responsiveness to oxytocin and the ergot
On examination, the fundus of her uterus was not palpable
alkaloids. In recent years, intravenous (IV) nitroglycerin has
during an abdominal examination, and a vaginal examination
come to the attention of obstetricians as a potent uterine relaxant.
revealed that all of the inverted uterus was filling the vagina up
This article describes two case reports of puerperal uterine
to the introitus. This patient was diagnosed as having complete
inversion in which manual replacement of the uterus were
uterine inversion. Resuscitation was undertaken. It was de-
facilitated by the use of IV nitroglycerin.
cided to achieve uterine relaxation with IV nitroglycerin, and
50 lg of this agent was administered. IV ketamine was used
Cases for sedation. Complete uterine relaxation was achieved, al-
lowing effortless replacement by the surgeon’s fist. Oxytocin
Case 1
infusion and uterine massage initiated uterine contractions
A 25-year-old female, para 1, was admitted 1.5 hours after within 5 minutes. Gradually the fist was withdrawn. After
delivery of 2600-g neonate. She had a systolic blood pres- adequate blood transfusion this patient recovered normally.

Departments of 1Obstetrics and Gynecology, 2Medicine, and 3Radiology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana,
India.

104
IV NITROGLYCERINE FOR UTERINE INVERSION
Case 2
A 22-year-old female, para 1, was admitted 1 hour after
her delivery because she had a retained placenta. Prior to
presentation, this patient had delivered a 3600-g neonate.
The delivery had been normal, and the neonate was in ex-
cellent condition. This patient had a systolic BP of 76 mm
Hg, a pulse rate of 120 bpm, a hematocrit of 26%, and a
platelet count of 70,000/mm3. Upon manual removal, the
placenta was not adherent to the myometrium. Partial uter-
ine inversion was diagnosed because during the abdomen
examination the fundus of her uterus had not been palpable,
and during a vaginal examination, a tough cervical ring was
palpable through which the fundus could be felt. The um-
bilical cord was average in length (*30 cm). The patient’s
blood loss was *1500 mL; thus, a transfusion was admin-
istered. Manual reposition of the uterus under ketamine
anesthesia was unsuccessful. However, within 90 seconds of
50 lg of IV nitroglycerin, the cervical ring relaxed. The
patient’s uterus was repositioned and held in place until it
became firm with an oxytocin infusion 5 minutes later. At
that point, the surgeon’s hand was gradually withdrawn. The
patient then received 3 units of packed red blood cells and
2 units of platelet-rich plasma. She was discharged on the
fifth postpartum day.
Results
Both cases were treated successfully with the use of IV
nitroglycerin. Surgeons were able to reposition these pa-
tient’s uteri manually, thus, avoiding the need for surgical
intervention.
Discussion
Uterine inversion occurs when the uterine fundus pro-
lapses within the endometrial cavity. Uterine inversion is an
unpredictable entity with more than one-half of cases re-
ported without detectible precipitants. Hemorrhage can be
rapid and life-threatening, requiring prompt recognition and
aggressive management. The incidence of uterine inversion
varies, depending upon the patient’s geographic location and
varies from 1:5000 to 1:6407 following vaginal birth. The
maternal mortality is as high as 15%.1
Puerperal uterine inversion has been classified as first
degree, in which the fundus has inverted but has not passed
through the cervix; second degree, in which the inverted fundus
has passed through the cervix into the vagina; and third degree,
in which the fundus is inverted and is outside the vulva.2 In-
version has also been classified as acute when it has occurred
without contraction of the cervix, subacute when the cervix
has contracted, and chronic when > 4 weeks have elapsed.3
Uterine inversion can occur in both obstetrical (puerperal)
and gynecologic (nonpuerperal) settings. Uterine inversion
has been linked to a number of etiologic factors, although
there may be no obvious cause. Factors associated with
puerperal uterine inversion are multiparity, fundal location
of the placenta, an abnormally adherent placenta, a uterine
structural anomaly, uterine atony, a short umbilical cord,
antepartum use of tocolysis such as magnesium sulfate,
precipitate labor, and poor management of third stage of
labor because of premature cord traction prior to placental
separation.4
105
The diagnosis of uterine inversion is usually clinical.
When there is complete inversion, the diagnosis is made
most easily by palpating the inverted fundus at the external
cervical os or vaginal introitus. Profuse bleeding, absence of
the uterine fundus, or an obvious defect of the fundus noted
on abdominal examination, as well as evidence of shock
with severe hypotension will provide the clinician with
further diagnostic clues.
Treatment modalities involve immediate repositioning of
the uterus (the Johnson maneuver),5 use of tocolytics, and
replacement of lost fluid. In some patients, contraction of
the cervical ring around the uterus renders repositioning of
inverted uteri difficult.1 In 10%–15% of patients, general
anesthesia is required to allow repositioning of the uterus.2
What is rarer still is that laparotomy, with traction or in-
cision of the contracted ring, has been used in refractory
cases.
Treatment of uterine inversion consists of manual ma-
nipulation of the uterus and the use of pharmacologic agents
to assist in uterine relaxation for achieving correction (e.g.,
tocolytics, such as MgSO4, terbutalin). Furthermore, agents
are then given to cause uterine contraction to prevent re-
inversion and to decrease blood loss. If these methods fail,
surgical intervention might be necessary. The two most
commonly used procedures are the Huntington6 and Haul-
tain7 procedures.
At the PGIMS, general anesthesia (halothane) is used to
induce uterine relaxation. Halothane is cardio-depressant
and is associated with hypotension. In addition, halothane
increases aspiration of gastric contents especially during
pregnancy.8,9 However, nitroglycerin does not produce these
side-effects. Thus, nitroglycerin is ideal for treating inver-
sion of the uterus, because of this agent’s powerful uterine-
relaxant effect and short plasma half-life (*2 minutes). With
a low dose of nitroglycerin, the degree and duration of uterine
relaxation can be controlled easily without maternal side-
effects. In this way, the significant risk of needing general
anesthesia may circumvented.8
First synthesized in 1846, nitroglycerin has been used in
many ways in medicine. Obstetrical use of nitroglycerin
dates back to the late 1800s. Since that time it has been used
successfully for treating internal podalic version, retained
placenta, and breech delivery.10 Nitroglycerine’s usefulness
in the obstetrical field lies in its ability to relax smooth
muscle within the cervix and uterus. Nitroglycerine, a nitric
oxide donor and potent smooth-muscle relaxant, acts on
smooth muscle by elevating cyclic guanosine monopho-
sphate. Uterine relaxation occurs within 30–95 seconds, and
the medication has a half-life of 1–3 minutes.
This short duration of action makes nitroglycerin useful at
times when the prolonged effects of tocolytics might be he-
modynamically disadvantageous to the patient. Nitroglycerin
can be administered by various non-IV routes (lingual, sub-
lingual, intranasal, intrabuccal, oral, and topical) or can be
given through IV infusion. Although nitroglycerin can cause
hypotension and headache, therapeutic doses are generally
well-tolerated.
The data on using IV nitroglycerin for treating uterine
inversion suggests infusing doses ranging from 50 lg to
200 lg, with success noted at all dosing levels.11 The current
authors have corrected uterine inversion successfully at a
minimum dose of 50 lg without any side-effects.
106
Conclusions
Nitroglycerin is a useful tool in the obstetrical arma-
mentarium. Its short duration of action and rapid absorption
make it ideal for expeditious uterine and cervical relaxation.
Disclosure Statement
No competing financial conflicts exist.
References
1. Soleymani MH, Pilsniak A, Reginald PW. Recurrent uter-
ine inversion: A novel treatment approach using SOS Bakri
balloon. Br J Obstet Gynecol 2009;116:999.
2. Watson P, Besch N, Watson A. Management of acute and
subacute puerperal inversion of uterus. Obstet Gynecol
1980;55:12.
3. Kitchin J, Thiagaraja H, May H, Thornton W. Puerperal
inversion of the uterus. Am J Obstet Gynecol 1975;123:51.
4. Achanna S, Mohamed Z, Krishnan M. Puerperal uterine
inversion: A report of four cases. J Obstet Gynecol Res
2006;32:341.
5. Johnson A. A new concept in the replacement of the in-
verted uterus and a report of nine cases. Am J Obstet
Gynaecol 1949;57:557.
MALIK ET AL.
6. Huntington JL. Abdominal reposition in acute inversion of
the puerperal uterus. Am J Obstet Gynaecol 1928;15:34.
7. Haultain F. The treatment of chronic uterine inversion by
uterine hysterotomy. BMJ 1901;2:974.
8. Beringer RM, Patteril M. Puerperal uterine inversion and
shock. Br J Anaesth 2004;92:439.
9. Abouleish E, Ali V, Joumaa B, Lopez M, Gupta D. An-
aesthetic management of acute puerperal uterine inversion.
Br J Anaesth 1995;75:486.
10. Altabef KM, Spencer JT, Zinberg S. Intravenous nitro-
glycerin for uterine relaxation of an inverted uterus. Am J
Obstet Gynecol 1992;166:1237.
11. Dufour P, Vinatier D, Puech F. The use of intravenous
nitroglycerin for cervico-uterine relaxation: A review of the
literature. Arch Gynecol Obstet 1997;261:1.
Address correspondence to:
Nitin Jain, MBBS, DMRD
House No. 629, Sector 14,
Rohtak, Haryana 124001
India
E-mail: logindrnitin@gmail.com
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