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INTRODUCTION

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Uterine inversion is a rare complication of the third stage of labor but is potentially life-threatening. Although largely preventable, some occurrences are unavoidable. Prompt recognition and management are critical to reduce maternal morbidity and mortality rates, mainly due to hemorrhage.

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CLASSIFICATION

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The classification systems of uterine inversion are based on either the duration or magnitude of the inversion. Criteria are found in Table 31-1, and examples are seen in Figures 31-1 and 31-2 (Kitchin, 1975; Livingston, 2007; Pauleta, 2010; Watson, 1980; You, 2006). Most are acute and second- or third-degree inversions (Baskett, 2002; Brar, 1989; Dali, 1997; Morini, 1994; Platt, 1981; Shah-Hosseini, 1989; Witteveen, 2013).

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Table Graphic Jump Location
TABLE 31-1.Classification Systems of Uterine Inversion
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FIGURE 31-1

Complete uterine inversion. The uterus is completely prolapsed and the placenta is still attached to the fundus. (Reproduced with permission from Cunningham FG, Leveno KL, Bloom SL, et al (eds): Hemorrhage. In Williams Obstetrics, 24th ed. New York, McGraw-Hill Education, 2014.)

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FIGURE 31-2

Depiction of uterine inversion from an abdominal perspective. The inverted fundus appears as a "dimple" with the fallopian tubes and round ligaments drawn into the inversion. The bladder and ovaries rim the top of the "dimple."

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INCIDENCE

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The reported incidence of uterine inversion varies widely, which may be due to differences in definition, patient populations, and awareness and recognition. The reported incidence ranges from 1 in 500 to 1 in more than 57,000 deliveries (Baskett, 2002; Bunke, 1965; Das, 1940; Hostetler, 2000; Morini, 1994; Shah-Hosseini, 1989; Watson, 1980; Witteveen, 2013). Two single-institution reports that analyzed long epochs cite incidences of 1 in 1860 during cesarean delivery, 1 in 3737 during vaginal delivery, and 1 in 6403 in all delivery settings (Baskett, 2002; Shah-Hosseini, 1989). In a nationwide population-based study, the incidence was 1 in 20,000 vaginal births (Witteveen, 2013).

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Previously, uterine inversion during cesarean delivery was considered rare (Chatzistamatiou, 2014; Witteveen, 2013). However, in one series, the incidence of inversion during cesarean delivery was actually twice that associated with vaginal delivery (Baskett, 2002). As one explanation, management of third-stage labor during cesarean delivery has varied over time and ranged from immediate manual extraction of the placenta to cord traction to promote ...

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