Accepted Manuscript

Title: Puerperal uterine inversion from two viewpoints: Its

recurrence at the next pregnancy and
“unavoidable”-procedure-associated inversion

Authors: Rie Usui, Chikako Yoshida, Takahiro Yoshiba, Miki

Yokoyama, Shigeki Matsubara

PII: S0301-2115(17)30219-1
DOI: http://dx.doi.org/doi:10.1016/j.ejogrb.2017.04.044
Reference: EURO 9887

To appear in: EURO

Received date: 26-4-2017

Please cite this article as: Usui Rie, Yoshida Chikako, Yoshiba Takahiro,
Yokoyama Miki, Matsubara Shigeki.Puerperal uterine inversion from two viewpoints:
Its recurrence at the next pregnancy and “unavoidable”-procedure-associated
inversion.European Journal of Obstetrics and Gynecology and Reproductive Biology
http://dx.doi.org/10.1016/j.ejogrb.2017.04.044

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Letter to the Editor (Brief Communication)

Puerperal uterine inversion from two viewpoints: Its recurrence at the next
pregnancy and “unavoidable”-procedure-associated inversion

Rie Usui, Chikako Yoshida, Takahiro Yoshiba, Miki Yokoyama, Shigeki Matsubara

Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan

Correspondence: Shigeki Matsubara, MD, PhD

Professor, Department of Obstetrics and Gynecology, Jichi Medical University
3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
Tel.: +81-285-58-7376 Fax: +81-285-44-7411 E-mail: matsushi@jichi.ac.jp

E-mail addresses of co-authors:

Rie Usui: satori@jichi.ac.jp
Chikako Yoshida: r0861cy@jichi.ac.jp
Takahiro Yoshiba: 97100ty@jichi.ac.jp
Miki Yokoyama: r1353ym@jichi.ac.jp

Rie Usui, Chikako Yoshida, Takahiro Yoshiba, Miki Yokoyama, Shigeki Matsubara＊
Department of Obstetrics and Gynecology
Jichi Medical University, 3311-1 Shimotsuke, Tochigi 329-0498, Japan

＊
Corresponding author at:
Department of Obstetrics and Gynecology, Jichi Medical University
Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
Tel.: +81-285-58-7376; fax: +81-285-44-7411,
E-mail address: matsushi@jichi.ac.jp (S. Matsubara).
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Dear Editor,

Puerperal uterine inversion usually occurs unexpectedly [1], which may be one reason

why inversion is often associated with a poor outcome. We report that inversion may

recur at the next pregnancy, and it may occur in association with an “unavoidable”

procedure.

A 28-year-old 1-parous woman vaginally delivered her second term infant. Her first

delivery was complicated by uterine inversion, requiring manual repositioning, with total

bleeding of 3,050 mL. Pan-hypopituitarism manifested, necessitating steroid/thyroid

replacement thereafter. She became pregnant again.

Twenty minutes after infant delivery, the placenta remained undelivered and massive

bleeding (1,900 mL) occurred, with a blood pressure of 60/0 mmHg. The uterus was

floppy and ultrasound revealed that a half of the placenta had separated and the remaining

half was un-separated. Manual placental removal was attempted; however, the

un-separated placenta was difficult to separate. The first author, a specialist, cautiously

attempted to separate the un-separated placenta, with almost entire placenta being

removed: partial placenta accreta (no increta/percreta) was suggested. Bleeding

continued and the uterine fundus was difficult to discern. Ultrasound revealed incomplete

uterine inversion, and manual repositioning was performed. The uterus was repositioned,

with a Bakri balloon being placed both to prevent acute inversion recurrence

(re-inversion) and achieve hemostasis. Uterotonics were administered appropriately.

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Hemostasis was achieved without re-inversion. The measured total bleeding amount was

9,590 mL. Red blood cells (28 units), fresh frozen plasma (10 units), and platelet

concentrates (20 units) were transfused and her condition was stabilized. On day 5 after

delivery, moderate bleeding occurred and grey-scale/color ultrasound revealed a small

part (4 x 2 cm) of the placenta with abundant flow attached to the uterine wall.

Diagnosing this condition as placenta accreta partially remaining in utero with bleeding,

bilateral uterine arterial embolization was performed with hemostasis. She had no

sequelae.

This case highlights two important issues. Firstly, inversion can recur at the next

pregnancy. Inversion sometimes recurs soon after repositioning [1], namely, re-inversion.

Reports showed that intrauterine balloon placement [1, 2], holding the cervix (closing the

anterior-posterior cervix by forceps) [3], or their combination [4] was employed to

prevent re-inversion. The Bakri balloon may have prevented re-inversion in this case. The

present case suggests that uterine inversion may also recur at the next pregnancy.

Inversion has been reported to occur in 1/5,000-6,407 deliveries [1]. Its consecutive

(twice) occurrence is estimated to be 1/25-41 million deliveries and incidental occurrence

twice is unlikely. Actually, we encountered another case in which both re-inversion and

next-pregnancy-inversion occurred [5]. Inversion occurred, for which abdominal

repositioning was performed with success, and then re-inversion occurred, for which

uterine compression suture was performed [5]. Interestingly, she developed inversion at

her next pregnancy.

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Secondly, some inversion may be caused by an “unavoidable” procedure. In this case,

there was no alternative but to perform manual placental removal/separation since half of

the placenta had already been separated, with massive bleeding occurring. Another

strategy may be: only the partially separated placenta is removed, with accreta placenta

remaining in utero, with the Bakri balloon inserted, thereby attempting hemostasis [2].

This strategy may be exceptional. Although whether inversion was caused solely by

manual placental separation is unclear, inversion may have been at least associated with

this “unavoidable” procedure.

Inversion may recur at the next pregnancy. Placenta accreta with partial placental

separation, requiring manual placental removal/separation, may cause inversion.

Inversion usually occurs unexpectedly. However, it may be prudent to anticipate its

occurrence and prepare for it when: i) a woman with prior inversion is delivering, or ii)

performing manual separation for suspected placenta accreta (especially with the placenta

partially separated). This suggestion is solely based on our limited experience. Data

accumulation is needed.

Word count 600 (limit 600)

Financial support: None.

Source of funding: None
Patient anonymity: Preserved
Informed consent: Obtained
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Conflict of interest: None

Conflicts of interest statement:

The authors declare no conflicts of interest regarding this study.
Patient anonymity: Preserved.

Contributions:
RU, CY, TY, MY, and SM treated the patients, identified the significance, wrote and
edited the manuscript.

References
[1] Soleymani Majd H, Pilsniak A, Reginald PW. Recurrent uterine inversion: a novel
treatment approach using SOS Bakri balloon. BJOG 2009;116:999-1001.

[2] Ida A, Ito K, Kubota Y, Nosaka M, Kato H, Tsuji Y. Successful reduction of acute
puerperal uterine inversion with the use of a bakri postpartum balloon. Case Rep Obstet
Gynecol 2015;2015:424891.

[3] Matsubara S. "Holding the cervix" technique: prophylaxis for acute recurrent uterine
inversion. Arch Gynecol Obstet 2013;288:463-5.

[4] Matsubara S. Combination of an intrauterine balloon and the "holding the cervix"
technique for hemostasis of postpartum hemorrhage and for prophylaxis of acute
recurrent uterine inversion. Acta Obstet Gynecol Scand 2014;93:314-5.

[5] Matsubara S, Yano H, Taneichi A, Suzuki M. Uterine compression suture against

impending recurrence of uterine inversion immediately after laparotomy repositioning. J
Obstet Gynaecol Res 2009;35:819-23.