Uterine Inversion: Symptoms, Types, Causes and Treatment

Uterine inversion is a rare but potentially life-threatening condition that can occur during or after childbirth, or rarely, outside the context of pregnancy. Its recognition and timely management are crucial for patient survival and long-term health. This article provides a comprehensive overview of the symptoms, types, causes, and treatment options for uterine inversion, drawing on recent case studies and reviews from the medical literature.

Symptoms of Uterine Inversion

Uterine inversion often presents as a dramatic and distressing clinical scenario. Recognizing the symptoms promptly can make the difference between life and death, especially in acute cases. Symptoms may vary depending on the type and timing of inversion, but certain hallmark features can guide diagnosis.

Symptom	Description	Severity	Source(s)
Vaginal Bleeding	Sudden, profuse bleeding, sometimes massive	Severe, life-threatening	1,2,3,8,11
Abdominal Pain	Acute and severe lower abdominal pain	Moderate to severe	1,2,3,13
Shock	Hypotension, tachycardia, altered consciousness	Can be profound	8,11,12
Vaginal Mass	Protruding, soft or rubbery mass in the vagina	Variable	1,2,4,10
Anemia	Resulting from ongoing blood loss	Mild to severe	2,9
Infertility	May be a delayed symptom in chronic cases	Variable	2

Table 1: Key Symptoms

Acute vs. Chronic Presentation

• Acute Inversion: Presents within 24 hours of delivery, with dramatic symptoms—sudden hemorrhage, shock, and visible or palpable mass protruding from the vagina 8,11.
• Chronic Inversion: Develops over weeks to years, often after an initially missed or mismanaged acute episode. Symptoms may be subtler, including persistent vaginal bleeding, pelvic pain, anemia, and sometimes a sensation of a mass 1,2,3.

Symptom Breakdown

Vaginal Bleeding and Shock

The most striking feature is heavy vaginal bleeding, which can lead to hypovolemic shock. The degree of shock may be disproportionate to the volume of blood loss due to neurogenic mechanisms triggered by the inversion 8,11,12.

Pain and Physical Findings

Acute, severe lower abdominal pain is common. On examination, a soft, bleeding mass may be seen or felt protruding through the cervix or vagina. Sometimes, the uterine fundus is not palpable abdominally, a key diagnostic clue 1,4,10.

Anemia and Chronic Symptoms

In chronic cases, ongoing blood loss leads to anemia and symptoms like fatigue, pallor, and secondary infertility 2,9.

Associated Signs

• Hypotension and tachycardia
• Pallor
• Failure to palpate the uterine fundus abdominally
• Cervical ring palpable behind the mass 1,2

Types of Uterine Inversion

Uterine inversion is classified based on the timing, completeness, and degree of the inversion. Understanding these distinctions is essential for diagnosis and management.

Type	Timing/Onset	Description	Source(s)
Acute	<24 hours postpartum	Sudden inversion, severe symptoms	3,8,11
Subacute	24 hours–4 weeks	Intermediate onset, partial cervical contraction	3
Chronic	>4 weeks postpartum	Delayed symptoms, often subtle	1,2,3
Puerperal	Related to childbirth	Most common, during/after delivery	8,11
Non-puerperal	Unrelated to childbirth	Associated with tumors, rare	4,5,6,7,9,10,13
Incomplete	Any	Fundus inverts but does not extend past cervix	12
Complete	Any	Fundus passes through cervix, possibly into vagina	12,10
Total	Any	Uterus and vagina both prolapse	12

Table 2: Types of Uterine Inversion

Timing-Based Classification

• Acute Inversion: Occurs within 24 hours after delivery; most dangerous due to rapid hemorrhage and shock 3,8,11.
• Subacute Inversion: Presents between 24 hours and four weeks postpartum. Symptoms may be less dramatic but still serious 3.
• Chronic Inversion: Develops more than four weeks after the initial event. Presents with persistent or intermittent symptoms, often leading to delayed diagnosis 1,2,3.

Etiology-Based Classification

• Puerperal Inversion: Directly related to childbirth, accounting for the vast majority of cases 8,11.
• Non-puerperal Inversion: Occurs unrelated to pregnancy or delivery, often due to uterine tumors, and is much rarer 4,5,6,7,9,10,13.

Degree of Inversion

• Incomplete Inversion (First-degree): The uterine fundus descends but remains above the cervical os 12.
• Complete Inversion (Second/Third-degree): The fundus passes through the cervix, possibly protruding into or through the vaginal canal 12,10.
• Total Inversion: Both the uterus and vaginal walls are inverted and protrude externally 12.

Causes of Uterine Inversion

Uterine inversion is multifactorial, with causes varying depending on whether the inversion is puerperal or non-puerperal. Recognizing these risk factors is vital for prevention and early intervention.

Cause/Risk Factor	Description	Frequency/Significance	Source(s)
Excessive Cord Traction	Pulling the umbilical cord before placental separation	Common in puerperal cases	8,11,12
Fundal Pressure	Inappropriate manual pressure on uterine fundus	Common in puerperal cases	8,12
Uterine Atony	Lack of uterine muscle tone post-delivery	Increases risk	8,11
Placenta Accreta	Abnormal placental adherence	Associated risk	8,12
Fundal Placenta	Placenta implants on uterine fundus	Predisposes inversion	8,12
Uterine Tumors	Submucosal leiomyomas, sarcomas, polyps	Major cause in non-puerperal cases	4,5,7,9,10,13
Malignancy	Uterine cancer (e.g., sarcoma)	Notable in older women	4,7,9
Congenital Weakness	Inherent weakness of uterine wall	Rare	8
Idiopathic	No identifiable cause	Some non-puerperal cases	7,9

Table 3: Causes and Risk Factors

Puerperal (Obstetric) Causes

• Excessive Cord Traction: Premature pulling on the umbilical cord before the placenta has separated from the uterine wall can invert the uterus, especially if the placenta is fundally located 8,11,12.
• Fundal Pressure (Credé Maneuver): Aggressive pushing on the uterine fundus during attempts to deliver the placenta can precipitate inversion 8,12.
• Uterine Atony: When the uterus fails to contract effectively after delivery, it is more susceptible to inversion 8,11.
• Morbidly Adherent Placenta: Conditions like placenta accreta increase the risk of inversion due to abnormal placental attachment 8,12.
• Other Factors: Short umbilical cord, rapid uterine emptying, multiparity, or use of uterotonic agents before placental delivery 8.

Non-Puerperal (Gynecological) Causes

• Uterine Tumors: The most common cause in non-puerperal cases is a submucosal leiomyoma (fibroid) located at the fundus. The tumor acts as a mass that pulls the uterine lining downward, causing inversion 4,5,7,9,10,13.
• Malignancy: Uterine sarcomas and other cancers can also precipitate inversion, especially in postmenopausal women 4,7,9.
• Other Masses: Polyps or other benign tumors may occasionally be implicated 7.
• Idiopathic: In a minority of cases, no cause is identified 7,9.

Risk Factors

• Multiparity (multiple previous pregnancies)
• Abnormal placental implantation
• Previous uterine surgery or trauma
• Congenital anomalies of the uterus 8

Treatment of Uterine Inversion

Treatment of uterine inversion is a true medical emergency. The primary goals are to stabilize the patient, control hemorrhage, and restore normal uterine anatomy. The approach depends on the type, chronicity, and underlying cause.

Step/Method	Description	Indication	Source(s)
Resuscitation	IV fluids, blood transfusion, shock management	All cases, especially acute	2,8,11
Manual Reposition	Johnson maneuver (pushing fundus back via vagina)	First-line for acute cases	1,8,11,12
Tocolytics	Medications to relax uterus (e.g., nitroglycerin)	If manual fails due to uterine tone	11,12
Hydrostatic Methods	Use of saline or fluid pressure to reinvert	Alternative to manual	3,11
Surgical Reposition	Haultain, Huntington, or other procedures	If manual/hydrostatic fails or in chronic cases	1,2,3,7,13
Hysterectomy	Removal of uterus	Persistent inversion, malignancy, or non-puerperal cases	4,7,9,10,13
Treat Underlying Cause	Tumor removal, oncologic care	Non-puerperal inversion	4,7,13

Table 4: Treatment Modalities

Initial Stabilization

Immediate priorities are to:

• Control hemorrhage
• Restore blood volume with IV fluids and blood products
• Monitor vital signs and correct shock 2,8,11

Non-Surgical Repositioning

Manual Reposition (Johnson Maneuver)

• The first attempt should be manual repositioning by pushing the uterine fundus upward through the vagina. This is most successful in acute cases before cervical ring contraction 1,8,11,12.
• Tocolytic agents (e.g., magnesium sulfate, terbutaline, intravenous nitroglycerin) or general anesthesia may be used to relax the uterus and facilitate reposition 11,12.

Hydrostatic Reposition

• Hydrostatic methods involve infusing saline into the vagina under pressure to push the uterus back into place. This may be tried if manual attempts fail 3,11.

Surgical Management

• Haultain Procedure: An abdominal approach involving incision of the constricting cervical ring to allow repositioning. Particularly useful in chronic or resistant cases 1,2,3,7,13.
• Huntington Procedure: Involves gradual traction on the inverted fundus via abdominal route 7.
• Vaginal Approaches: Some chronic inversions may be corrected via vaginal surgery, particularly when the inversion is partial 1,7.

Hysterectomy

• Indicated when:
  • The uterus cannot be restored,
  • There is associated malignancy,
  • The patient is postmenopausal or has completed childbearing 4,7,9,10,13.
• Often performed in non-puerperal inversions due to tumor involvement.

Follow-up and Prognosis

• With prompt treatment, prognosis is good and future fertility can be preserved in many cases 2.
• In non-puerperal cases, removal of the underlying tumor is essential and may require oncologic follow-up 4,7.

Conclusion

Uterine inversion, though rare, is a critical diagnosis that requires immediate attention. Key points to remember include:

• Symptoms: Sudden vaginal bleeding, shock, abdominal pain, and a vaginal mass are hallmark features. Chronic cases may present with anemia or infertility.
• Types: Classified by timing (acute, subacute, chronic), etiology (puerperal vs. non-puerperal), and degree (incomplete, complete, total).
• Causes: In puerperal cases, obstetric maneuvers and uterine atony are major factors; in non-puerperal cases, uterine tumors (especially fibroids) are most common.
• Treatment: Rapid stabilization, manual or surgical reposition, and management of underlying causes are essential. Fertility can often be preserved with timely intervention.

Summary of Main Points:

• Uterine inversion is rare but life-threatening, especially in the postpartum period.
• Acute recognition and management save lives.
• Non-puerperal inversion, though rare, is most often due to tumors and may require hysterectomy.
• Multidisciplinary care and individualized treatment plans are key for optimal outcomes.

By understanding the symptoms, types, causes, and treatments of uterine inversion, healthcare providers and patients alike can better navigate this challenging and urgent medical condition.