Open Access

Case report
Puerperal uterine inversion managed by the uterine balloon tamponade

Mariétou Thiam1,2,&, Mouhamadou Mansour Niang3,4, Lamine Gueye1,2, Fatou Rachel Sarr1,2, Marie Edouard Faye Dieme4, Mamadou
Lamine Cisse1,2

1
Thies University , Faculty of Health Sciences , Thiès , Senegal, 2Service of Obstetrics and Gynecology Regional Hospital Thiès, Senegal,
3
Department of Obstetrics and Gynecology Institute of Social Hygiene in Dakar, Senegal, 4Cheikh Anta Diop University of Dakar, Dakar, Senegal

&
Corresponding author: Mariétou Thiam, Thies University, Faculty of Health Sciences , Thiès , Senegal

Key words: Uterine inversion, postpartum hemorrhage, uterine balloon tamponade

Received: 14/09/2015 - Accepted: 25/11/2015 - Published: 03/12/2015

Abstract
The uterine inversion is a rare and severe puerperal complication. Uncontrolled cord traction and uterine expression are the common causes
described.We report a case of uterine inversion stage III caused by poor management of the third stage of labor. It was about a 20 years old
primigravida referred in our unit for postpartum hemorrhage due to uterine atony. After manual reduction of the uterus, the use of intra uterine
balloon tamponade helped to stop the hemorrhage. The uterine inversion is a rare complication that may cause maternel death. The diagnosis is
clinical and its management must be immediate to avoid maternal complications.

Pan African Medical Journal. 2015; 22:331 doi:10.11604/pamj.2015.22.331.7823

This article is available online at: http://www.panafrican-med-journal.com/content/article/22/331/full/

© Mariétou Thiam et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)

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Introduction pelvic pain and cardiovascular collapse which are the main warning
signs. The uterine inversion stage III is visible from the perineal
inspection with a fundus externalized to the vulva as a fleshy mass
Acute puerperal uterine inversion is the penetration into the uterine
bloody. The treatment must be immediate and based on three main
cavity of the uterus bottom. This is a rare and serious obstetrical
points: correction of cardiovascular collapse, intra-abdominal
complication because it can impact badly the maternal prognosis.
replacement of the uterus and uterine atony correction. Literature
We report a case of acute puerperal uterine inversion occurred after
data recommends first a manual reduction by simply reversing taxis
a vaginal delivery complicated by major postpartum hemorrhage
which consists to push the fundus in order to replace it or the
and managed with the uterine balloon tamponade.
Johnson's method which consists of a pressure on the vaginal cul-
de-sac by vaginal fingers and the bottom by the palm of the hand.
[1] In case of failure of the manual repositioning, other methods are
Patient and observation described: - hydrostatic methods which consist in filling the vagina
with saline in sealing the vagina either manually (O´Sullivan) or by
A 20 years old primigravida, without particular medical and surgical using a suction cup (Ogueh) [1,3, 5] - the uterine packing [3] -
history was admitted in our unit for cardiovascular collapse due to surgical correction by high way by the Huntington technique or
postpartum hemorrhage. She had a normal delivery an hour earlier Haultain or vaginally with the technique of Spinelli [1] -
in another health center. The newborn was a female weighting 2700 hysterectomy hemostasis remains the gold standard in case of
g with a Apgar score 10/10 in the fifth minute. The delivery was persistent bleeding but is exceptionnel [6]. More recently the use of
made by a matron with active management of the third stage of balloons such as Rusch or Bakri have been described in the
labor (AMTSL) using intramuscular injection of 5 IU of Oxytocin literature as the re-inversion prevention method within two hours
followed by uncontrolled cord traction causing the uterine inversion. following initial reintegration [4,7-10]. They are associated with
One hour after the delivery, when she arrived in our unit, the fewer complications (infection and necrosis uterine) compared to
examination revealed cardiovascular collapse with blood pressure at uterine sutures. In our case, despite uterine massage and Oxytocin
5/2 and stunning pulse. The gynecological examination revealed a infusion, there was a persistent atony. The use of intrauterine
uterine inversion stage III with the placenta adhering to the fundus balloon tamponade allowed us to stop the bleeding and prevent
(Figure 1). The requested laboratory tests showed a blood Rhesus uterine re-inversion. This balloon, easy to use and low cost, has the
group B positive; a prothrombin rate 79,7; an hemoglobin rate 6 g / advantage of being available in our resource-limited countries.
dl and a platelets rate 211000 / mm3. The patient was urgently Whatever the technique used, antibiotic therapy should be
transferred to the operating room. After general anesthesia, the systematic to avoid the risk of postpartum endometritis.
uterus was replaced in his anatomical position simply by taxis
without difficulty. The clinical examination after uterine reintegration
revealed uterine atony with persistent bleeding despite the uterine Conclusion
massage and intravenous (IV) Oxytocin. At this moment, we took
the decision to place the uterine ballon tamponade. The balloon
The uterine inversion is a rare obstetric emergency. The strict
device include a catheter, a condom and a 60 ml syringe (Figure
respect of the steps of AMTSL would avoid this serious obstetrical
2). Once the condom is attached to the catheter and introduced into
complication. The use of intrauterine balloon tamponade is used to
the uterine cavity, after we start inflating the condom with
stop bleeding related to uterine atony and prevent the re-inversion.
physiological saline up to 700 cc. The patient had received
antibiotics (2 g of cefazolin IV), blood transfusion (1500 ml) and
plasma transfusion (1000 ml). The uterine balloon tamponade was
removed 8 hours later and after, the clinical examination showed Competing interests
that there was no bleeding and the uterus was well retracted. We
administered 10 IU of Oxytocin IV, continued the antibiotic orally None of the authors have a relationship with companies that may
during 7 days. The patient stayed 5 days at the hospital without any have a financial interest in the information contained in the paper
complications. A month later, the gyneacological examination and Authors'.
the pelvic ultrasound was normal (Figure 3).

Authors’ contributions
Discussion
All authors contributed equally to this study.
The puerperal uterine inversion is a rare and serious obstetric
emergency. Its frequency is about 1/2000 deliveries in the USA and
1/20 000 deliveries in Europe [1]. Maternal death can occur in 15% Figures
of cases [2]. Some iatrogenic etiologic factors have been described:
excessive traction on the umbilical cord before placental abruption,
Figure 1: Uterine inversion stage III with the placenta adhering to
uterine expression and the sudden stop of the Oxytocin infusion
the fundus
[3,4]. Primiparity, short umbilical cord and fast or long labor are also
Figure 2: The balloon device include a catheter, a condom and a
associated with this complication [1]. In our case, the risk factors
60 ml syringe
was a forced traction on the cord while the placenta was not
Figure 3: Pelvic ultrasound normal
detached from the myometrium and the delivery performed by
unqualified personnel. With the introduction of AMTSL, the incidence
of uterine inversion may increase if the obstetrician does not respect
the conditions of the directed delivery including controlled cord
traction and proscription of uterine expression to prevent this
complication. The diagnosis is primarily clinical with hemorrhage,

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Figure 1: Uterine inversion stage III with the placenta adhering to the fundus

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Figure 2: The balloon device include a catheter, a condom
and a 60 ml syringe

Figure 3: Pelvic ultrasound normal

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