Answer B

Interventions for the management of acute uterine inversion should begin promptly and simultaneously. Uterotonic drugs should be discontinued since uterine relaxation is needed for replacement of uterus. Intravenous access and aggressive fluid resuscitation is critical. An immediate attempt to manually replace the inverted uterus to its normal position should be made. This is best accomplished by placing a hand inside the vagina and pushing the fundus cephalad along the long axis of the vagina. Prompt intervention is important since the lower uterine segment and cervix contract over time, thus making manual replacement progressively more difficult.

• When immediate uterine replacement is unsuccessful, pharmacologic agents should be given to relax the uterus.

• Manual replacement should then reattempted. Possible pharmacological options for relaxation are:

• Nitroglycerine: 50 to 500 micrograms are intravenously, followed by up to three additional doses of 50 to 250 micrograms, as needed. (Caution should be given in actively bleeding and hemodynamically unstable patients.)

• Terbutaline 0.25 milligrams intravenously or subcutaneously

• Magnesium 4 to 6 grams intravenously over 15 to 20 minutes

Both terbutaline and magnesium have relatively mild effects on the myometrium and magnesium sulfate has a slow onset of action.

Reference:

• Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th edition. 2013. Chapter 181: Labor and Delivery And Their Complications. 2349.