Uterine inversion: an anesthetic emergency

A case of complete uterine inversion, in a 27-year-old woman after delivery of her third child, is reported. Because of lack of placental separation after 40 min. manual removal was carried out under general anaesthesia (midazolam, ketamine, alfentanil). The placenta was quickly and easily removed, but followed immediately by protrusion of the uterine fundus at the vulva. Simultaneous, blood pressure became unmeasurable, and the patient became cyanosed. The uterus remained impossible to replace until anaesthesia had been deepened. The patient remained shocked despite intravenous fluids and catecholamines. As soon as the uterus was replaced, blood pressure rose to 80 mmHg. The patient was extubated 50 minutes later, blood pressure being 105/80 mmHg. Acute and subacute puerperal uterine inversion is a rare obstetrical emergency (1 in 20,000 deliveries) with a 15% mortality rate. Immediate recognition and early treatment to relax the cervico-uterine junction, should ensure rapid replacement of the uterus.