Acute postpartumuterine inversion with haemorrhagic shock: laparoscopic reduction: a new method of management

Abstract

Sir, While this case report is interesting and there are very nice laparoscopic images to illustrate the inverted uterus, I was disturbed by several features of the report. Nobody can have much experience in this rare complication, however, with 35 years of obstetric practice, 25 years as a consultant, I have never found hydrostatic reduction of an inverted uterus to fail. Yet, this well-established technique was never even attempted, but only referred to in the discussion. There is no explanation why an attempt at hydrostatic reduction was not made. As described by Calder,1 as a youngster I scoffed at the concept when I first heard of the method. However, in practice I soon found that with uterine relaxation and patience, the uterine inversion is silently reduced under the hydrostatic pressure. WHO2 recommends that if manual reduction fails, then the hydrostatic method should be used. In hospital practice, we would favour the use of the hydrostatic method as the primary method. Any attempt at reduction of a complete inversion needs to be combined with some form of uterine relaxation and adequate analgesia. I was also puzzled by the details of the case report regarding haemorrhage. At the time of uterine inversion, there was a massive haemorrhage. This is not the time to attempt reduction. There is no description of continued bleeding, and this conforms to my experience that once the uterus is inverted and well contracted there is relatively little bleeding. Her collapse may well have been partly due to a vasovagal response associated with the attempt at reduction and the presence of the inversion itself. This is supported by the fact that she appears to have been given colloids only as there is no mention of a blood transfusion. It appears that there was rather quick resort to a completely unconventional although innovative management. We cannot accept that laparoscopic reduction can be any more likely to be successful than manual reduction, and much less effective than hydrostatic reduction. j References