Altaf Bashir  ( Department of Obstetrics and Gynaecology, Allied Hospital, Punjab Medical College, Faisalabad. )

Acute inversion of the uterus is rare, the incidence being 1 in 23000¹. If not detected and treated immediately, it may prove fatal^2,3. Instant replacement within a few seconds of its occurrence without any anaesthesia, except if already being used for conduct of the delivery, is desired to prevent the patient going into shock⁴. The longer the treatment is deferred, the more difficult it becomes to correct the inversion because of the tightening of the cervical ring. If the inversion cannot be corrected by vaginal manipulation, surgical intervention becomes imperative. Successful replacement 24 hours after delivery is rarely recorded. In the case reported here, the patient presented, after a lapse of 24 hours and manual replacement was performed easily under anaesthesia.

A 30 years old (grand multipara) Gravida 8 Para 8, 6 alive, two infant deaths, with history of home delivery 24 hours back was admitted as an emergency with acute complete inversion of uterus. Patient had all previous home deliveries conducted by traditional birth attendant without any obstetric complication during pregnancies, labour and deliveries. Delivery was spontaneous but the placenta was retained for over half an hour and then removed manually by the TBA. The placental removal was followed by moderate postpartum haemorrhage. The patient had felt severe lower abdominal pain and collapsed. She was taken to a local clinic where the shock was treated symptomatically. The patient continued to bleedvaginallyand complained of a strongbearing down sensation. The diagnosis was missed until some hours later when a reddish mass appeared at the vulva after the patient visited the toilet. She was then transferred to the District Headquarter Hospital, Faisalabad. She was not in shock but was pyrexial (99°F). The haemoglobin was 7.9gm%. The fundus of the uterus could not be felt on abdominal palpation. A reddish turgid mass bleed­ing to touch was present at the vulva. Complete inversion of the uterus was confirmed on pelvic examination. The inverted mass was cleaned and reduced into the vagina. An intravenous line was secured and two unit of blood infused and other fluids were transfused. Antibiotic cover was estab­lished. The patient was then transferred to the operation theatre and manual replacement was attempted under general anaesthesia. The method described by Johnson⁵ was used. The entire hand was placed in the vagina with the tips of the fmgers at the uterocervical junction and the fundus of the uterusin thepahnof thehand. The uteruswaslifted up to make the ligaments tense. Pressure was then exerted first to widen the cervical ring and then to pushthe fundus throughit. The uteruswassuccess­fully replaced with slight haemorrhage during the 322 procedure. Postoperative recovery was unevent­ful. She was transfused 2 more units of blood to correct the anaemia. She was discharged home on the fifth postoperative day in a satisfactory condi­tion.

Of the various causes of the acute inversion of the uterus, inexperience of the personnel per­forming the delivery appears to be an important factor⁶ . If an untrained person inverts the uterus treatment is also delayed, thus increasing the mortality rate appreciably. Acute inversion of the uterus can be replaced either by manipulation or by hydrostatic pressure as described by O\'Sullivan⁷ . Both these methods are perhaps equally effective in replacing the inversion. Ian Donald described a case of acute inversion where replacement was attempted 4 hours after the accident. Manual replacement failed in that case but hydraulic pressure was successful⁵. The efficiency of both methods decreases with lapse of time because closure and tightening of the cervical ring causes the prolapsed fundus to become oedeniatous. In the case reported here manual replace­ment was accomplished 24 hours after delivery. It is suggested that in cases of acute inversion of the uterus where treatment is delayed an attempt at manual replacement must be made before resort­ing to surgical intervention.

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