Acute Inversion Research Articles

Acute postpartum uterine inversion with haemorrhagic shock: laparoscopic reduction: a new method of management?

Acute postpartum uterine inversion with haemorrhagic shock: laparoscopic reduction: a new method of management?

Inversión uterina puerperal. Análisis de un caso y revisión de la literatura médica

Acute puerperal uterine inversion is an uncommon but serious complication occurring in the third stage of labor. This event is associated with significant blood loss and neurogenic shock. We report a case of spontaneous grade III uterine inversion during the third stage of labor in a 36-year-old primipara. Manual manipulation was immediately attempted to reverse the inversion. Predisposing factors and the approaches used to correct uterine inversion are reviewed.

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

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

Assessment of acute ankle sprain with os subfibularein children

Children commonly present with acute inversion injuries of the ankle. Radiographs occasionally show small fragments under the tip of the lateral malleolus. The purpose of our study was to clarify their origin. A prospective standardized clinical examination and a magnetic resonance imaging were carried out. Among the 116 included patients, seven of them showed an os subfibulare. They presented more pains on the lateral ankle area than the other children. We found also more injuries on the anterior talofibular ligament. The os subfibulare could be secondary to an accessory ossification but the lateral area of the ankle would be likely to be injured.

The effect of three degrees of elevation on swelling in acute inversion ankle sprains

The use of elevation is a central tenant in the treatment of acute soft tissue injuries, the most appropriate degree of elevation for swelling reduction is yet to be established The aim of this study was to determine the acute effect different degrees of limb elevation on the amount of swelling present in patients with acute first and second degree anterior Talo-fibular ligament sprains. Thirty patients with a diagnosed grade 1 or 2 anterior Talo-fibular ligament (ATFL) sprains (injuries 24 to a maximum 72 h old) participated in the study. Subjects were randomly allocated to one of three groups, either 0°, 20° or 60° elevation. Each subject was elevated to the group angle for 30 min, following 30 min elevation the patients undertook two sets of 20 repetitions full (available) range dorsi to plantar flexion at 0° elevation. Volumetric measurement of the foot and ankle (water displacement method) and girth measurement of ankle (using a tape measure) were made pre-elevation, post-elevation and post-exercise. MANCOVA analysis revealed a significant effect for treatment on post elevation girth and volume measurements ( p < 0.0001 ) and post exercise girth and volume measurements ( p < 0.0001 ). Post-hoc stepwise comparisons revealed post-elevation and post-exercise volume and girth measurements to show a significantly greater reduction in 60° vs. 20° ( p < 0.0001 ), 60° vs. 0° ( p < 0.0001 ) and 20° vs. 0° ( p < 0.003 ). The results of this study would indicate that in acute ATFL sprains 60° of limb elevation provides the most effective acute means of swelling reduction.

Commentary: Acute postpartum uterine inversion with haemorrhagic shock

Commentary: Acute postpartum uterine inversion with haemorrhagic shock

Surgical management of subacute puerperal uterine inversion

Puerperal uterine inversion is rare, but represents an obstetric emergency. Prompt recognition of the condition will enable immediate repositioning of the uterus before it becomes incarcerated by a constriction ring, which may necessitate surgical intervention. Acute puerperal inversion presents with shock, vaginal bleeding and pain. In its classical form, the absence of the uterine fundus upon abdominal palpation and the surgeon’s inability to either visualize or palpate the cervix upon pelvic examination is the most obvious clue [1]. Sometimes, the presentation is not classical, and we present a case to illustrate the need for a high index of suspicion for acute uterine inversion in all cases of postpartum collapse despite its rarity. A 34-year old primapara woman was referred to the Ladoke Akintola University of Technology

Uterine rhabdomyosarcoma presenting as acute inversion in an adolescent

Uterine rhabdomyosarcoma presenting as acute inversion in an adolescent

Hydrostatic reduction of acute uterine inversion

Acute uterine inversion is a rare emergency (1:551 to 1:19998 deliveries). O’Sullivan described replacing the inverted uterus using hydrostatic pressures. The challenge in O’Sullivan’s method is in developing a water seal. Ogueh described the use of silastic ventouse cup for a partial inversion case. Fluid leakage still required blocking by the operator’s palm at the introitus. Technique modification resulted in a successful reduction of a total uterine inversion case. A 32-year-old Para 2 woman with a history of uterine evacuation for retained placenta had an uneventful antenatal course in her third pregnancy in 2004. She delivered vaginally a 3412-g boy at 39 weeks’ gestation. The third stage was actively managed. There was difficulty in delivering the placenta which was fundal in location. Prompt diagnosis of acute uterine inversion was made when a “large mass” was delivered. The patient was pale but hemodynamically stable. Manual separation of the placenta succeeded but manual reduction of the inverted uterus failed. An emergency code was activated. She was transferred to the operating theatre for reduction under general anesthesia. (authors)

Acute complete non-puerperal uterine inversion

Acute complete non-puerperal uterine inversion

Uterine inversion and concomitant perforation following manual removal of placenta

A life-threatening puerperal uterine perforation and an acute uterine inversion can both be caused by placenta accreta but seldom together. A 22-year-old woman gravida 2 presented in labor to the emergency unit of the Gynecology and Obstetrics Department at 30 weeks of pregnancy with preterm premature rupture of membranes breech presentation thick meconium-stained liqueur and nonlocalization of fetal heart sounds confirmed by ultrasound. Placenta was fundal approaching the right lateral wall. A dead fetus weighing 1000 g was delivered but not the placenta. The patient was taken to the operating room for manual removal of the retained placenta (MRP). Under anesthesia a cleavage was felt toward the lower edge of the placenta and separation was attempted. The placenta was delivered with a fleshy piece of tissue attached possibly myometrium. The patient immediately went into shock. Per-vaginum examination revealed an acute incomplete inversion of the uterus with suspicion of a big rent. Laparotomy was immediately performed with infusion of blood. After uterine reposition per vaginum via the Johnson maneuver a 5 cm x 4 cm fundal perforation was discovered. Subtotal hysterectomy was performed hemostasis was secured and the patient was discharged on the 10th day. A histopathologic evaluation revealed placenta accreta. (excerpt)

Maternal and Perinatal Outcome of Massive Postpartum Hemorrage: A Review of 33 Cases

Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. We evaluated maternal and perinatal outcome of primary massive postpartum hemorrhage. In a restrospective case analysis of 33 women with intractable postpartum hemorrhage initially managed either by hysterectomy or a conservative approach in a tertiary referral center between January 1, 1991 to December 30, 1998, we reviewed the procedures used as a primary or secondary attempt to arrest the hemorrhage. Medical and surgical measures were successful in controlling hemorrhage in 21 (63.6%) of the 33 women. Hemorrhage was successfully arrested by conservative surgery in 13 cases, and by medical management in 8 cases. Emergency hysterectomy was performed in 12 cases (0.7 per 1000 deliveries) No maternal deaths occurred, but there were 2 early neonatal deaths (6.1 %). Atony of the uterus was the main cause of hemorrhage (n=15). Genital tract laceration was associated with a worse prognosis, but the time lapse between delivery and surgery appears to be the main prognostic factor. Uterine atony and morbid adherent placenta are major causes of massive obstetric hemorrhage. In our series, morbidity was high, but there was no mortality. Obstetricians should identify women at risk which is especially associated with a prior cesarean delivery, a current placenta previa and high parity. Early intervention and proper procedure could minimize the complications.

Surgical management of chronic lateral ankle instability in adolescents.

Chronic lateral ankle instability in adolescents is an infrequent result of either an acute or recurrent ankle inversion injury. The majority of these patients improve with nonoperative management. Numerous surgical interventions have been proposed when nonoperative management is ineffective. Since 1979, 12 adolescents, all girls, have undergone surgical treatment of chronic lateral ankle instability at a major pediatric center. The average age at the time of surgery was 14 years and 3 months. Questionnaires were sent to each patient to assess subjective long-term outcome. Follow-up ranged from 1 year and 5 months to 8 years and 5 months (average 3 years and 1 month). The Watson-Jones technique was performed in six, the Evans in four, the Chrisman-Snook in one, and the Brostrom in one. At most recent follow-up, 11 adolescents had a stable ankle, 9 had a full range of ankle and subtalar motion, and 6 had returned to all activities.

A Pulmonary Syndrome in Patients with Acute Myelomonocytic Leukemia and Inversion of Chromosome 16

Different subtypes of acute myelogenous leukemia have distinct clinical presentations and courses. The specific clinical and molecular aspects of these leukemias have helped modify and create specific strategies for their management. We observed an increased incidence of pulmonary complications in patients with acute myelomonocytic leukemias (AMML) with inversion of chromosome 16 [inv(16)] irrespective of the presence of hyperleukocytosis. We reviewed patient records available over a period of 12 years at The Cleveland Clinic Foundation of patients with AMML with inv(16) and compared the incidence of pulmonary complications to a matched control group of patients with AMML but without inv(16).We found an increased incidence of pulmonary complications in the AMML with inv(16) group when compared to the control group. Two of these patients demonstrated brochiolitis obliterans with organizing pneumonia (BOOP) on lung biopsy. No specific etiology for the pulmonary complications was identified. These findings represent the first observation of an association between WHO-AMML with inv(16) [FAB-AML M4 with inv(16)] with a pulmonary syndrome at presentation. BOOP should be suspected in these cases. A larger prospective study to evaluate this association is warranted.

Een willekeurige controletest van passieve translatoire gewrichtsmobilisering bij acute inversieverstuikingen van de enkel

A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains [Physical Therapy 2001;81(4):984-94]

Inversion of uterus during cesarean section

Acute inversion of the uterus is a rare complication during cesarean section. We describe one such case in which diagnosis was made immediately and reversion was performed within few minutes. A high index of suspicion and prompt management can prevent further complications.

Emergencies in operative obstetrics

Among all the emergency situations which may arise across the field of obstetrics and gynaecology, there are a small number which call for urgent practical steps to be taken in order to safeguard the life of the mother or the baby or both. The three such complications dealt with in this chapter consist of one prior to delivery—prolapse of the umbilical cord; one during delivery—shoulder dystocia; one following delivery—acute inversion of the uterus. All of the above require prompt action by well-trained staff and may involve the active and efficient co-operation of a range of different health care professionals. It is critically important that staff are fully aware of the procedures to be followed and the chain of command which will ensure that they are followed as efficiently and successfully as possible.

Hydrostatic replacement of acute inversion of the uterus can cause acute pulmonary oedema by intrauterine fluid intravasation

Hydrostatic replacement of acute inversion of the uterus can cause acute pulmonary oedema by intrauterine fluid intravasation

Magnetic Resonance assessment of inversion ankle injuries in children

A cohort of ten children with X-ray negative inversion ankle injuries were studied using Magnetic Resonance Imaging. The images obtained were scored on six pathological criteria. Despite all ten having normal plain radiographs, 50 per cent were found to have direct evidence of growth plate injury. Seventy per cent of the cohort had periosteal elevation including all those with evidence of growth plate injury. This study supports previous work which suggested that children with ‘X-ray’ negative acute inversion ankle injuries who exhibited the clinical signs of injury to their lower fibular growth plate most probably have an undisplaced Salter-Harris Type 1 fracture of this structure, despite normal radiographs.

Effect of Orthotics on Postural Sway Following Inversion Ankle Sprain

Orthotic devices have been shown to successfully modify selected aspects of lower extremity mechanics and enhance foot stability during the support phase of running. It was hypothesized that orthotic intervention would relieve excessive strain on the ankle ligaments and reduce postural sway, especially in subjects with acute ankle sprains. The primary purpose of this study was to determine if orthotics would reduce postural sway in injured and uninjured subjects. Thirteen subjects with acute inversion ankle sprain and 12 uninjured subjects were assessed for postural sway on the Balance System under two treatment conditions (orthotic and nonorthotic) and four platform movements. A three-factor repeated measures analysis of variance revealed a significant group X treatment interaction, suggesting that postural sway with orthotic intervention improved significantly more in injured subjects than in uninjured subjects. A significant platform movement X treatment interaction, furthermore, revealed that postural sway for the four movement conditions was dependent upon treatment (orthotic vs. no orthotic). Tukey post hoc analysis revealed that orthotic intervention significantly reduced postural sway when the platform moved in the medial/lateral plane and inversion/eversion plane. This research suggests that custom-fit orthotics may restrict undesirable motion at the foot and ankle and enhance joint mechanoreceptors to detect perturbations and provide structural support for detecting and controlling postural sway in ankle-injured subjects.