Title:   Uterine inversion associated Neurogenic Shock, does it exist?

Author: Janos Dancso consultant

Scunthorpe General Hospital

Introduction:

     Neurogenic shock (NS) term is accepted in both traumatology and neurology. The traditional obstetric opinion that the degree of shock associated with uterine inversion (UI) is out of proportion of the blood loss. NS associated with Uterine Inversion (NS-UI) was suggested for the quickly progressing shock. A retrospective study of Beringer concluded that the degree of shock was proportional with measured but not the estimated blood loss. The objective of this paper is to review the evidence regarding NS-UI.  Specifically clinical signs, observations with NS-UI and compared those with the NS caused by neurogenic injury above than Th6 spinal cord.

Method:

 Literature review conducted with the key words: uterine inversion, neurogenic shock, 3rd stage complications. This identified 45 relevant original articles which were stratified according to the opinion of the authors from the NS-UI.  NS-UI suggested in 5, the possibility in 7, excluded in 12 articles. Further 21 article discussed UI without reference to NS.

Results:

12/45 of articles considered presence or possibility of NS-UI. 33/45 of the article did not consider or could not confirm NS-UI. There was no reference to NS-UI without significant bleeding. The articles with NS-UI rarely documented observations, symptoms and signs. 

I compared the NS characteristics from patients after high spinal cord injury with the NS-UI obstetric patients

                                             NS after trauma>T6                               Observed with UI and suggested NS

History and Cause             Central nervous damage                          Acute puerperal uterine inversion

 Pathophysiology              Loss of sympathetic tone                          Increased parasympathetic tone

                                           Decreased vascular resistance                  Haemorrhage, hypovolaemic shock

Clinical effects

Blood pressure                         Hypotension                                                Hypotension

Heart rate                           Bradycardia, pulse rate<60                     Tachycardia, very rarely bradycardia

Skin                                             Warm, pink, dry                                            Pale and wet                       

Core temperature                       36.0 C or lower                                                normal

Sympathetic NS

Compensation                               Missing                                                             present

Recovery time                                 weeks                                                      Soon after volume/Hb restored

Full recovery                             Life-time card                                              Usually within hours-days

Treatment

Safe body position                            Yes                                                                no

Inotrope                                      Dopamine, norepinephrine                                    no

Vasopressin, ADH                          Ephedrine                                                          no

Fluid resuscitation                         Cautious                                                            Rapid

Atropine                                          Sometimes                                                        no

Transfusion                                         No                                                                yes.

   

 

Conclusion:

The review could not confirm evidence of NS-UI. The observations suggest haemorrhagic instead of a neurogenic shock. A false diagnosis can delay the correct treatment, have further risks for the patient, mislead learning opportunities and have legal implications.