Use of nitroglycerin spray in uterine inversion.

Uterine inversion is an infrequent obstetric emer~ gency, occurring in 1 in 2000 to 1 in 2500 obstetric patients. Uterine inversion, so named because the uterus turns inside out, has been associated with multiparity, placenta accreta, short umbilical cord, and a fundal placenta. The degree of inversion is described as ranging from first-degree (incomplete) inversion, in which the corpus extends to the cervix but not beyond the cervical ring, to third-degree (complete) inversion, where the inverted uterus extends to the perineum. The additional term totol uterine inversion describes prolapse of the vagina along with the uterus. Excessive cord traction in the third stage of labor and fundal pressure (Crede maneuver) have been implicated in its cause. Even so, uterine inversion is an unpredictable entity with more than one half of cases reported without detectible precipitants. Hemorrhage can be rapid and life-threatening, requiring prompt recognition and aggressive management. Accompanying hypotension is common and often exceeds what might be expected from concomitant blood loss, further complicating the clinical presentation. Treatment modalities involve immediate replacement of the uterus (Johnson maneuver), use of tocolytics, and replacement of lost fluid. In some patients, contraction of the cervical ring around the uterus renders replacement of the inversion difficult. l In 10% to 15 % of patients general anesthesia is required to allow replacement of the uterus. Rarer still, laparotomy with traction or incision of the contracted ring has been used in refractory cases. Several authors have suggested a role for intravenous nitroglycerin in treatment of uterine inversion.3s A recent search of the literature, however, did not find oral forms of nitroglycerin described as being used for the same purpose. I describe a case of uterine inversion with cervical entrapment of the