Uterine Inversion 

 

 

Considerations

 

  • Emergency situation

  • Postpartum hemorrhage with need for massive transfusion

  • Facilitation of uterine reduction: tocolytics (nitroglycerin, volatile anesthetics)

  • Treatment of uterine atony after reduction (medical & surgical)

  • Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)

 

 

Goals & Conflicts

 

  • RSI in the setting of a patient in hypovolemic shock

  • Safely manage airway avoiding aspiration & hypoxemia

  • Aggressive fluid resuscitation

  • Close communication with obstetrician during titration of tocolytic therapy

 

 

Management

 

  • Confirm diagnosis: postpartum hemorrhage, hypovolemic shock, mass in introitus/vagina

  • Mobilize resources, obstetrician STAT, establish management plan:

    • To OR for definitive treatment

    • Assemble skilled help

    • Notify blood bank, prepare for massive transfusion

  • Begin fluid resuscitation, large bore IV access, rapid transfuser, blood products to OR

  • Tocolytic therapy: nitroglycerin 100-400 mcg IV boluses (chase with phenylephrine boluses), volatile anesthesia following RSI (low dose or no ketamine)

  • Followed by uterotonic therapy:

    • Oxytocin 40 units per 1 L crystalloid or duratocin 100mcg IV slow push

    • Ergonovine 0.2mg IM & 0.2mg IV slow push

    • Carboprost (hemabate) 0.25mg IM or intramyometrial

    • Misoprostol 800-1200mcg rectal

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