Displacement of the uterus

Dr ; sahar anwar rizk

The uterus has central position in the pelvic The ternal os is at the level of the ischial spine It is ante verted & ante flexed Anteverted ;angle between axis of the cervic and vertical axis of female . Ante flexed ;angle between Axis of the uterine body and Axis of the cervix

Retroversion of the uterus ; it mean that the axis of the cervix become behind the vertical axis of femal body . Retoflexion; axis of the uterine body become behind the ais
of female body .

DEGREE First ;axis of the cervix is behind the vertical axis of female but the fundus is above the promontory .
Second ;the fundus is below the promontory
but still above the external os .

Third ; the fundus is below the external os

Causes of RVF ; Acquired during L&D; 1-Bearing down 2- Forceps delivery 3-breach extraction before fully dilatation During puerperium ; No kegles ex No sims position heavy uterus; fibroid , subinvolution Lax ligament ; pregnancy Adhesion ; inflammation

symptoms
Pain 1. Low backache 2. Dysmenorrheal 3. Dysparunia 4. Dyschasia 5. Mid cyclic pain 6. Menstrual disturbance ;polymenorrhea 7. Leucorrhea

Signs
1.

2.
3.

Cervix is displaced Fundus in dougls pouch Absent of the uterus interiorly

4. Acute anterior angulation of the vagina 5. The cervix positioned well behind the pubic symphysis 6. A soft, smooth, nontender mass filling the cul-de-sac

investigation

PV Examination -----fied or mobile uterus Hystrography---- position of the uterus Double pessary test

complication
1.

Kinking of the uterine vessels---------congestion of utters-- dysmenorrhea ,abortion menorrhagia Congestion of the ovary polymenorrhra , anovulation ,mid cyclic pain

2.

3.

Infertility
anovulation, cervix away from seminal pool

Uterine prolapse Prolapse of tube & ovaries

Management

1.

2.

Prophylactic During labor ,avoid bearing down , breach extraction before full dilatation of the cervix During puerperium , sleeping in semis position empty of bladder , Hodge pessary

Management Possible therapies for retroversion or incarceration include the following: Bladder drainage by indwelling catheter
Patient positioning exercises (eg, intermittent knee-chest or all-fours positioning, sleeping prone) Manipulation of the uterus into its usual anatomic position, with or without tocolysis or anesthesia

Colonoscopic manipulation of the uterine fundus under anesthesia

Surgical exploration and replacement (almost never indicated) Specialized and rarely attempted techniques of replacement (eg, employment of a mercury-filled Voorhees bag in the vagina, amniocentesis with manipulation)

Prolapse of the Uterus

Prolapse of the uterus refers to the downward displacement of the vagina and uterus. The word prolapse is derived from the latin procidere which means with effect to fall. The uterus is held in position by adequate ligaments Besides, it has the support of the muscular structures of vagina and all other local tissues and muscles. Due to the laxity of support by muscles, tissue and ligaments, the uterus sags downwards.


1. 2.

Types of uterine prolapse; True uterine prolapse False uterine prolapse DEGREE First degree ;external os lies behind ischial spine but inside the introitus Second degree ; external os lies outeside the introitus but the fundus is inside the introitus Third degree,fundus lies outside the introitus (procedentia )

Vaginal prolapse

Cystocoele ; bulge of bladder into anterior vaginal wall Urethrocoele ; bulge of post wall of urethra into vaginal wall Rectocoele ; bulge of anterior wall of rectum into post vaginal wall Prolapse of post vaginal wall; bulge of lower posterior vaginal wall of into lumen of vagina Hernia of Dougls pouch ; bulge of loop of intestine into upper part of post vaginal wall Vault prolapse ; bulge of the scare of TAH

causes
1.

2.

Congenital Congenital prolapse ---at birth Virginal prolapse -----before marriage Acquired Labor 1-Bearing down 2- Forceps delivery 3-breach extraction before fully dilatation 4- large head without episiotomy 5-traction on cord 6-prolonged labour, an interference in the delivery by inexpert people,

1.

During puerperium ; No kegles ex No sims position lack of exercise and bodily weakness lack of proper rest and diet in postnatal periods, repeated deliveries and manual work. heavy uterus; fibroid , sub involution Lax ligament ; pregnancy Menopausal atrophy ----decrease of estrogen

 1. 2.

3.
4. 1. 2.

3.

Increase in intra abdominal pressure; Abdominal mass Ascitis Chronic cough Chronic constipation Heavy uterus tumors of the uterus, Pregnancy Subinvolution

symptoms

She feels a sense of fullness in the region of the bladder and rectum. dragging discomfort in the lower abdomen, low backache, heavy menses and milk vaginal discharge . increase in the frequency of urination and the patient feels difficulty in total emptying of the bladder. burning sensation due to infection. sexual

The woman may experience difficulty in passing stools and complete evacuation of bowels. These symptoms become more pronounced before and during menstruation. The condition may also result in difficulty in normal sexual intercourse and sometimes sterility.

Complications

1.
2. 3. 1. 2. 3.

Cystocoele ; Cystitis Pyelonephrinits Kinking of the tube Uterine prolapse Keratinisation of the Decubital ulcer Kinking of the tube

1. 2. 3. 1.

2.

prevention good antenatal care in pregnancy, proper management and timely intervention during delivery, Empty of bladder &rectum Avoid bearing down Avoid piston technique in placental delivery good postnatal care with proper rest, correct diet and appropriate exercise so as to strengthen the pelvic musculature. sleeping in semis position empty of bladder , Hodge pessary ,avoid early ambulation

Uterine inversion may occur immediately postpartum or, much less frequently, during the puerperium. Inversions are usually described as acute (<30 d after delivery) or chronic (>30 d after delivery).

Uterine inversion

Degree

In first-degree inversion, the inverted wall extends to but not through the cervix. In second-degree inversion, the inverted wall protrudes through the cervix but remains within the vagina. In third-degree inversion, the inverted fundus extends outside the vagina. In fourth degree or total inversion, both the vagina and uterus are inverted.

Possible etiology Reported associations for uterine inversion include the following: Idiopathic Excessive cord traction or a short umbilical cord Cred (fundal) pressure Placenta accreta or increta or percreta Fundal implantation of the placenta Chronic endometritis Fetal macrosomia Trials of vaginal birth following cesarean delivery Myometrial weakness Precipitate labor drugs, including magnesium sulfate

S&S

The classic observations include postpartum hemorrhage, the sudden appearance of a vaginal mass, and varying degrees of cardiovascular collapseall usually occurring in the immediate puerperium. The postpartum hemorrhage is usually the most striking of the symptoms and initially commands the attention of the clinician. In other cases, the sudden and disconcerting protrusion of a large, dark red, polypoid mass through the vagina either accompanying or following the placenta is noted. The characteristic appearance of the inverted uterus either retained within the vagina or protruding externally is both surprising and startling and usually immediately establishes the correct diagnosis

Management Following uterine inversion, prompt treatment of hemorrhage and shock is vital in limiting maternal morbidity and the risk of mortality. Hypotension and hypovolemia require aggressive fluid resuscitation. The general principles of treatment follow the (STAR) protocol

 1.

2.

3. 4. 5. 6.

7.

Shock Initiate fluid resuscitation with 2 large-bore intravenous lines. Promptly administer 1 or more liters of an isotonic salt solution such as lactated Ringer parenterally. Submit specimens to the laboratory for possible transfusion and for determination of baseline values of hemoglobin (Hgb), hematocrit (Hct), and coagulation factors. Insert a Foley catheter. Immediately summon an anesthesiologist. Treat aggressively Order appropriate surgical equipment and assistants to ready the operating room for a possible laparotomy. Administer tocolytics to promote uterine relaxation. These may include nitroglycerin , or magnesium sulfate at 4-6 g IV over 20 minutes.

Attempt prompt uterine replacement. First, proceed with a trial of simple manual replacement. If this is unsuccessful, promptly perform a laparotomy for a surgical replacement At laparotomy, general anesthesia employing a uterine relaxing agent is best,

It is important that the part of the uterus that came out last (the part closest to the cervix) goes in first. Figure P-52 Manual replacement of the inverted uterus

Repair
Suture birth canal lacerations and any surgical incisions in cervix or vagina. Perform uterine massage (after replacement). Administer uterotonics. These may include methyl ergonovine maleate (Methergine 0.2

Surgical techniques If 2 or more attempts at manual replacement are unsuccessful, surgery is indicated. An abdominal approach for uterine replacement is favored. A vaginal technique has also been described but has few adherents. In the vaginal procedure, the bladder is dissected from the cervix, and the anterior lip of the cervix and the anterior wall of the uterus are incised to the extent necessary to permit replacement.

POST-PROCEDURE CARE Once the inversion is corrected, infuse oxytocin 20 units in 500 mL IV fluids (normal saline or Ringers lactate) at 10 drops per minute: - If haemorrhage is suspected, increase the infusion rate to 60 drops per minute; - If the uterus does not contract after oxytocin, give ergometrine 0.2 mg or prostaglandins (Table S-8). Give a single dose of prophylactic antibiotics after correcting the inverted uterus: - ampicillin 2 g IV PLUS metronidazole 500 mg IV; - OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.