Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report

Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report Hong Zhang, Zhe-Xia Hu, Jing-Ru Zhang, Hui Du, Tian-hong Gao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8471314/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Apr, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 13 You are reading this latest preprint version Abstract Background Puerperal uterine inversion is a rare obstetric emergency that could be life-threatening.This article presents a typical case of puerperal uterine inversion. Images are provided in this paper to visually demonstrate the clinical manifestations, aiming to assist in the rapid clinical recognition and management of such cases. Case presentation: A 35-year-old woman (gravida 2, para 1) was admitted to the hospital for full-term pregnancy. During the placental expulsion stage postpartum, acute uterine inversion accompanied by postpartum hemorrhage occurred. We promptly recognized the condition and successfully performed manual repositioning within 7 minutes. Conclusion Early identification and timely reduction are the cornerstones of managing acute puerperal uterine inversion. Puerperal Uterine inversion Postpartum hemorrhage Reposition Figures Figure 1 Background Puerperal uterine inversion is defined as the prolapse of the uterine fundus into the uterine cavity, cervical canal, or even the vagina after delivery, which can result in postpartum hemorrhage, shock, and ultimately, death. It is a rare obstetric emergency with an incidence of 0.5–4 per 10,000 deliveries [ 1 – 5 ] . Early diagnosis and prompt treatment are of vital importance. This article reports a case of acute uterine inversion after delivery and reviews the relevant literature. Case presentation The patient was a 35-year-old gravida 2, para 1 (G2P1) pregnant woman who had undergone a full-term vaginal delivery 1 year and 5 months prior. She was admitted due to intermittent lower abdominal pain for half a day at 39⁺⁴ weeks of gestation in her second pregnancy. No abnormalities were noted during prenatal check-ups, and she denied a history of uterine fibroids. Her baseline characteristics included a height of 167 cm, pre-pregnancy weight of 60 kg, with a body mass index (BMI) of 21.51 kg/m², and total gestational weight gain of 14 kg. Physical examination findings: blood pressure (BP) 90/64 mmHg, flaccid abdominal wall. Vaginal examination revealed a cervical canal length of 0.5 cm, midline position, soft consistency, cephalic presentation at station−2.5, with an estimated fetal weight of 3000 g. Ultrasound indicated an anterior placenta. Blood routine examination showed hemoglobin (HB) 121 g/L. Spontaneous labor onset occurred after admission, and epidural labor analgesia was administered. A female neonate weighing 3495 g was delivered vaginally at 15:00 on June 25, 2025, with a single loop of umbilical cord around the neck. The first stage of labor lasted 7 h 15 min, and the second stage 15 min. Post-delivery, 10 U of oxytocin was intramuscularly injected, and 10 U of oxytocin was intravenously infused to enhance uterine contraction. Controlled cord traction was performed at 15:27 to assist placental delivery, and the placenta was expelled slowly from the vaginal introitus at 15: 28, resulting in a third stage of labor of 28 min. Gross inspection revealed a "giant" placenta, with visible lower, left, and right edges, but the upper edge was deeply embedded in the vagina and not visible (Fig. 1 ). Exploration along the placenta into the vagina identified a 13 cm × 10 cm solid, hard mass. Gentle separation of partial placental tissue exposed the underlying endometrium with acute bleeding, and the uterine contour was impalpable in the lower abdomen. The patient remained conscious without complaints of lower abdominal pain, with BP 96/67 mmHg and pulse (P) 92 beats/min. Initial suspicion of uterine inversion was raised. An emergency rescue protocol was initiated immediately, with the following measures taken: blood products were prepared, two intravenous accesses were established, oxytocin infusion was discontinued, and 1.5 g of cefuroxime sodium was intravenously administered to prevent infection. We performed the first uterine repositioning but failed due to spastic contractions of the lower uterine segment and cervix. With severe vaginal bleeding, the patient was urgently transferred to the operating room for general anesthesia, followed by a second attempt at Johnson’s manual reduction. Successful reduction was achieved 7 minutes after the onset of inversion. Post-reduction, 10 U of oxytocin was intravenously infused and 250 µg of carboprost tromethamine was intramuscularly injected to maintain uterine tone. After 20 minutes of observation, the uterine contour was distinct with no active vaginal bleeding, and follow-up ultrasound confirmed an anteverted uterus. Total blood loss reached 1330 mL within 17 minutes after placental expulsion, with BP dropping to 76/50 mmHg and P rising to 99 beats/min. For severe postpartum hemorrhage, 4 units of red blood cells were transfused. There was no recurrence of uterine inversion or secondary infection. One day after delivery, the hemoglobin (HB) was 112 g/L. Three days after delivery, the patient recovered well and was discharged as planned. Discussion and conclusion Risk factors for puerperal uterine inversion include excessive cord traction before placental expulsion in the third stage of labor, fundal placental implantation, placental adhesion, placenta accreta spectrum disorders, postpartum uterine atony, short umbilical cord, manual placental removal, abrupt reduction in intrauterine pressure, and intrapartum magnesium sulfate administration [ 1 – 3 , 6 , 7 ] . Liang et al. [ 5 ] analyzed 10 cases of postpartum uterine inversion and found that 5 cases involved cord traction before placental separation. Scholars recommend delaying cord traction until signs of placental separation appear to reduce inversion risk [ 1 , 3 , 5 ] . Acute uterine inversion is classified by the extent of inversion [ 1 , 5 ] : 1st degree: the fundus is within the endometrial cavity; 2nd degree: the fundus protrudes through the cervical; 3rd degree: the fundus protrudes to or beyond the introitus; 4th degree: both the uterus and vagina are inverted. The present case, with a history of full-term vaginal delivery 1 year and 5 months prior, presented with abdominal wall laxity on admission and uterine atony post-fetal delivery. Inversion occurred during third-stage cord traction, consistent with a typical case of acute grade 3 postpartum uterine inversion. Patients with uterine inversion may present with vaginal masses, postpartum hemorrhage (PPH), abdominal pain in some patients, and shock in severe cases. The PPH rate is reported as 37.7%–86.7% with blood loss ranging from 200 mL to 2600 mL, and the shock rate is 39%–47% [ 2 , 5 ] . Mortality varies significantly by regional healthcare capacity: Witteveen et al. (Netherlands) reported 15 consecutive successful resuscitations [ 2 ] , Coad et al. (United States) documented a mortality rate of 0.04% [ 1 ] , and Dwivedi et al. (India) noted an 18.18% mortality rate [ 6 ] . On physical examination, the normal uterine contour is absent on abdominal palpation, while vaginal examination reveals a concave uterine fundus or even a prolapsed solid mass. If clinical examination fails to confirm the diagnosis, ultrasonography is indicated, with magnetic resonance imaging (MRI) as an adjunct if necessary [ 8 ] . Ultrasonographic features include the absence of a rounded uterine fundus on the sagittal plane, with the fundus invaginating into the uterine cavity to form a "Y-shape". In advanced inversion, the uterus may appear as a self-mirror image, when complete inversion into the vagina occurs, the two serosal edges form a pseud endometrial stripe [ 9 ] . The cornerstones of management are early diagnosis, aggressive resuscitation, and expeditious uterine repositioning. Resuscitation entails establishing adequate intravenous access, fluid resuscitation, and blood transfusion. The blood transfusion rate is reported as 22.4%–47.5% [ 1 , 3 ] , rising to 70.4% for cases following vaginal delivery [ 3 ] . Concurrently with resuscitation, uterotonic agents should be discontinued, and manual repositioning performed under adequate anesthesia. The success rate of manual repositioning ranges from 80% to 100%, influenced by the duration of inversion, anesthesia status, and the manual replacement technique used [ 1 , 3 , 5 ] . Prolonged inversion increases the risk of failure due to uterine contraction-induced lower uterine segment spasm and cervical retraction. Baskett et al. [ 3 ] reported 27 cases successfully repositioned within 45 minutes, while Liang et al. [ 5 ] and Michalska et al. [ 10 ] each documented 1 case of failure at 30 minutes and 40 minutes post-inversion, respectively. General anesthesia is required in 81.5%–93% of manual repositioning procedures [ 2 , 3 ] . Uterine relaxants such as terbutaline, nitroglycerin, and magnesium sulfate may facilitate repositioning [ 3 , 4 , 6 ] . The Johnson maneuver is the currently preferred manual technique: fingers are placed at the cervico-uterine junction, the inverted fundus is cupped in the operator’s palm, and gentle upward pressure is applied into the vagina and uterine cavity [ 4 , 9 ] . If manual repositioning fails, hydrostatic reduction and surgical interventions can be attempted. Surgeries such as the Huntington procedure, Haultain procedure, Spinelli procedure, and Robinson procedure have all been reported in the literature [ 6 , 7 , 9 ] . Post-repositioning management includes uterotonic therapy and anti-infective treatment to prevent recurrence and secondary infection [ 4 , 9 ] . Intrauterine balloon tamponade has also been proposed for recurrence prevention [ 2 , 9 ]. Hysterectomy is indicated for complications such as disseminated intravascular coagulation (DIC), hemodynamic instability, or severe infection, with a reported rate of 2.8% [ 1 ] . A key management controversy concerns inversion occurring before placental detachment. Most authors advocate prioritizing uterine repositioning over placental removal to avoid exacerbating hemorrhage [ 2 , 4 , 9 ] , while others argue that prior placental detachment improves the feasibility of manual repositioning [ 11 ] . In the present case, placental detachment preceded repositioning, although bleeding increased, the reduced uterine size facilitated repositioning, which was successful 7 minutes post-inversion. For clinicians encountering this rare condition for the first time, placental detachment aids diagnosis and eliminates obstructions to repositioning. The authors propose that, in cases of unexplained vaginal masses with a relaxed cervical os and stable vital signs, partial placental detachment may be performed to confirm the diagnosis. Once uterine inversion is confirmed, rapid induction of general anesthesia supports successful manual repositioning. Given the rarity of this disease, there remain controversies surrounding its treatment to date. This constitutes a limitation of the present study, which warrants further investigation in subsequent research. In summary, acute postpartum uterine inversion is a rare obstetric emergency. Clinicians should maintain a high index of suspicion for this condition in patients presenting with persistent PPH, shock, abdominal pain, and a vaginal mass to avoid delaying optimal management. Declarations Acknowledgements The authors thank the patient for her recognition and support. Authors’ contributions Data curation: Hong Zhang, Zhe-Xia Hu, Jing-Ru Zhang. Resources: Hong Zhang, Zhe-Xia Hu, Jing-Ru Zhang. Writing – original draft: Hong Zhang, Zhe-Xia Hu. Writing – review & editing: Hui Du, Tian-hong Gao. Funding Shijiazhuang City Science and Technology Research and Development Program Project, Grant/Award Number: No.201460573. Availability of data and materials All the relevant data are included in the case report. Reasonable requests for any additional data can be obtained by contacting the corresponding author. Declarations Ethics approval and consent to participate The patient described in this case report provided informed consent. An ethics board review was not needed. All procedures performed involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinkideclaration and its later amendments or comparable ethical standards. Consent for publication Written informed consent was obtained from the patient to publish the accompanying images and information. Competing interests The authors declare no conflicts of interest, financial or otherwise. References Coad SL, Dahlgren LS, Hutcheon JA. Risks and consequences of puerperal uterine inversion in the United States, 2004 through 2013. Am J Obstet Gynecol. 2017;217(3):e3771–377. .e6 . Witteveen T, van Stralen G, Zwart J, van Roosmalen J. Puerperal uterine inversion in the Netherlands: a nationwide cohort study. Acta Obstet Gynecol Scand. 2013;92(3):334–7. Baskett TF. Acute uterine inversion: a review of 40 cases. J Obstet Gynaecol Can. 2002;24(12):953–6. Evensen A, Anderson JM, Fontaine P. Postpartum hemorrhage: prevention and treatment. Am Fam Physician. 2017;95(7):442–9. Liang Z, He J. Clinical Analysis of 10 Cases of Puerperal Uterine Inversion. Chin J Obstet Gynecol. 2017;52(9):623–5. Dwivedi S, Gupta N, Mishra A, Pande S, Lal P. Uterine inversion: a shocking aftermath of mismanaged third stage of labour. Int J Reprod Contracept Obstet Gynecol. 2013;2(3):292–5. Agrawal H, Chafale S. A case series on uterine inversion: diagnostic and surgical considerations. Int J Reprod Contracept Obstet Gynecol. 2025;14(10):3521–5. Zaki-Metias KM, Hosseiny M, Behzadi F, Balthazar P. Uterine Inversion Radiographics. 2023;43(6):e230004. Felis S, Carrucciu F, De Simone A. Acute puerperal uterine inversion. Am J Med Clin Res Rev. 2023;02(12):01–9. Michalska M, Bojar I, Borycki J, Zięba B, Brandl S, Kołaciński R, Samulak D. Postnatal inversion of the uterus-management in specific cases. Ann Agr Env Med. 2020;27(4):717–20. Gao Q, Jiang H, Jia M, Xiong J. Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report. Medicine(Baltimore).2024; 103༈17༉:e37986. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Apr, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 20 Jan, 2026 Reviews received at journal 18 Jan, 2026 Reviews received at journal 17 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviews received at journal 16 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers invited by journal 15 Jan, 2026 Editor assigned by journal 15 Jan, 2026 Editor invited by journal 07 Jan, 2026 Submission checks completed at journal 07 Jan, 2026 First submitted to journal 07 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8471314","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":576446216,"identity":"e8440707-c449-4ee9-a85e-3a54783595fb","order_by":0,"name":"Hong Zhang","email":"","orcid":"","institution":"Shijiazhuang No.4 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Zhang","suffix":""},{"id":576446217,"identity":"a1568a62-e21a-4ec9-9093-10271211c13a","order_by":1,"name":"Zhe-Xia Hu","email":"","orcid":"","institution":"Shijiazhuang No.4 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09:36:19","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40228,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8471314/v1/32fc20b74054b9c8bff762af.html"},{"id":100666347,"identity":"9275e3ea-dce4-4d50-891d-7a59c544cc32","added_by":"auto","created_at":"2026-01-20 09:37:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":329377,"visible":true,"origin":"","legend":"\u003cp\u003eThe placenta and inverted uterus were expelled simultaneously through the vaginal orifice.\u003cbr\u003e\n The region indicated by the arrow showed marked bulging, with the inverted uterus positioned posteriorly.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8471314/v1/be47cbd6e329dc5d673ef13f.png"},{"id":107487365,"identity":"eb11eb78-ee60-4ee6-8338-5a8b84b45f75","added_by":"auto","created_at":"2026-04-22 02:41:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":518192,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8471314/v1/eb524438-376b-44cf-aa99-832c1bc3f63a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003ePuerperal uterine inversion is defined as the prolapse of the uterine fundus into the uterine cavity, cervical canal, or even the vagina after delivery, which can result in postpartum hemorrhage, shock, and ultimately, death. It is a rare obstetric emergency with an incidence of 0.5\u0026ndash;4 per 10,000 deliveries\u003csup\u003e[\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Early diagnosis and prompt treatment are of vital importance. This article reports a case of acute uterine inversion after delivery and reviews the relevant literature.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient was a 35-year-old gravida 2, para 1 (G2P1) pregnant woman who had undergone a full-term vaginal delivery 1 year and 5 months prior. She was admitted due to intermittent lower abdominal pain for half a day at 39⁺⁴ weeks of gestation in her second pregnancy. No abnormalities were noted during prenatal check-ups, and she denied a history of uterine fibroids. Her baseline characteristics included a height of 167 cm, pre-pregnancy weight of 60 kg, with a body mass index (BMI) of 21.51 kg/m², and total gestational weight gain of 14 kg. Physical examination findings: blood pressure (BP) 90/64 mmHg, flaccid abdominal wall. Vaginal examination revealed a cervical canal length of 0.5 cm, midline position, soft consistency, cephalic presentation at station−2.5, with an estimated fetal weight of 3000 g. Ultrasound indicated an anterior placenta. Blood routine examination showed hemoglobin (HB) 121 g/L.\u003c/p\u003e \u003cp\u003eSpontaneous labor onset occurred after admission, and epidural labor analgesia was administered. A female neonate weighing 3495 g was delivered vaginally at 15:00 on June 25, 2025, with a single loop of umbilical cord around the neck. The first stage of labor lasted 7 h 15 min, and the second stage 15 min. Post-delivery, 10 U of oxytocin was intramuscularly injected, and 10 U of oxytocin was intravenously infused to enhance uterine contraction. Controlled cord traction was performed at 15:27 to assist placental delivery, and the placenta was expelled slowly from the vaginal introitus at 15: 28, resulting in a third stage of labor of 28 min. Gross inspection revealed a \"giant\" placenta, with visible lower, left, and right edges, but the upper edge was deeply embedded in the vagina and not visible (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Exploration along the placenta into the vagina identified a 13 cm × 10 cm solid, hard mass. Gentle separation of partial placental tissue exposed the underlying endometrium with acute bleeding, and the uterine contour was impalpable in the lower abdomen. The patient remained conscious without complaints of lower abdominal pain, with BP 96/67 mmHg and pulse (P) 92 beats/min. Initial suspicion of uterine inversion was raised.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAn emergency rescue protocol was initiated immediately, with the following measures taken: blood products were prepared, two intravenous accesses were established, oxytocin infusion was discontinued, and 1.5 g of cefuroxime sodium was intravenously administered to prevent infection. We performed the first uterine repositioning but failed due to spastic contractions of the lower uterine segment and cervix. With severe vaginal bleeding, the patient was urgently transferred to the operating room for general anesthesia, followed by a second attempt at Johnson’s manual reduction. Successful reduction was achieved 7 minutes after the onset of inversion. Post-reduction, 10 U of oxytocin was intravenously infused and 250 µg of carboprost tromethamine was intramuscularly injected to maintain uterine tone. After 20 minutes of observation, the uterine contour was distinct with no active vaginal bleeding, and follow-up ultrasound confirmed an anteverted uterus. Total blood loss reached 1330 mL within 17 minutes after placental expulsion, with BP dropping to 76/50 mmHg and P rising to 99 beats/min. For severe postpartum hemorrhage, 4 units of red blood cells were transfused. There was no recurrence of uterine inversion or secondary infection. One day after delivery, the hemoglobin (HB) was 112 g/L. Three days after delivery, the patient recovered well and was discharged as planned.\u003c/p\u003e "},{"header":"Discussion and conclusion","content":"\u003cp\u003eRisk factors for puerperal uterine inversion include excessive cord traction before placental expulsion in the third stage of labor, fundal placental implantation, placental adhesion, placenta accreta spectrum disorders, postpartum uterine atony, short umbilical cord, manual placental removal, abrupt reduction in intrauterine pressure, and intrapartum magnesium sulfate administration\u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Liang et al.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e analyzed 10 cases of postpartum uterine inversion and found that 5 cases involved cord traction before placental separation. Scholars recommend delaying cord traction until signs of placental separation appear to reduce inversion risk\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Acute uterine inversion is classified by the extent of inversion\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e: 1st degree: the fundus is within the endometrial cavity; 2nd degree: the fundus protrudes through the cervical; 3rd degree: the fundus protrudes to or beyond the introitus; 4th degree: both the uterus and vagina are inverted.\u003c/p\u003e\u003cp\u003eThe present case, with a history of full-term vaginal delivery 1 year and 5 months prior, presented with abdominal wall laxity on admission and uterine atony post-fetal delivery. Inversion occurred during third-stage cord traction, consistent with a typical case of acute grade 3 postpartum uterine inversion.\u003c/p\u003e\u003cp\u003ePatients with uterine inversion may present with vaginal masses, postpartum hemorrhage (PPH), abdominal pain in some patients, and shock in severe cases. The PPH rate is reported as 37.7%–86.7% with blood loss ranging from 200 mL to 2600 mL, and the shock rate is 39%–47%\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Mortality varies significantly by regional healthcare capacity: Witteveen et al. (Netherlands) reported 15 consecutive successful resuscitations\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, Coad et al. (United States) documented a mortality rate of 0.04%\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, and Dwivedi et al. (India) noted an 18.18% mortality rate\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. On physical examination, the normal uterine contour is absent on abdominal palpation, while vaginal examination reveals a concave uterine fundus or even a prolapsed solid mass. If clinical examination fails to confirm the diagnosis, ultrasonography is indicated, with magnetic resonance imaging (MRI) as an adjunct if necessary\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Ultrasonographic features include the absence of a rounded uterine fundus on the sagittal plane, with the fundus invaginating into the uterine cavity to form a \"Y-shape\". In advanced inversion, the uterus may appear as a self-mirror image, when complete inversion into the vagina occurs, the two serosal edges form a pseud endometrial stripe\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe cornerstones of management are early diagnosis, aggressive resuscitation, and expeditious uterine repositioning. Resuscitation entails establishing adequate intravenous access, fluid resuscitation, and blood transfusion. The blood transfusion rate is reported as 22.4%–47.5%\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e, rising to 70.4% for cases following vaginal delivery\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Concurrently with resuscitation, uterotonic agents should be discontinued, and manual repositioning performed under adequate anesthesia. The success rate of manual repositioning ranges from 80% to 100%, influenced by the duration of inversion, anesthesia status, and the manual replacement technique used\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Prolonged inversion increases the risk of failure due to uterine contraction-induced lower uterine segment spasm and cervical retraction. Baskett et al.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e reported 27 cases successfully repositioned within 45 minutes, while Liang et al.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e and Michalska et al.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e each documented 1 case of failure at 30 minutes and 40 minutes post-inversion, respectively. General anesthesia is required in 81.5%–93% of manual repositioning procedures\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Uterine relaxants such as terbutaline, nitroglycerin, and magnesium sulfate may facilitate repositioning\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. The Johnson maneuver is the currently preferred manual technique: fingers are placed at the cervico-uterine junction, the inverted fundus is cupped in the operator’s palm, and gentle upward pressure is applied into the vagina and uterine cavity\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. If manual repositioning fails, hydrostatic reduction and surgical interventions can be attempted. Surgeries such as the Huntington procedure, Haultain procedure, Spinelli procedure, and Robinson procedure have all been reported in the literature\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Post-repositioning management includes uterotonic therapy and anti-infective treatment to prevent recurrence and secondary infection\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Intrauterine balloon tamponade has also been proposed for recurrence prevention\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e]. Hysterectomy is indicated for complications such as disseminated intravascular coagulation (DIC), hemodynamic instability, or severe infection, with a reported rate of 2.8%\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA key management controversy concerns inversion occurring before placental detachment. Most authors advocate prioritizing uterine repositioning over placental removal to avoid exacerbating hemorrhage\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, while others argue that prior placental detachment improves the feasibility of manual repositioning \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In the present case, placental detachment preceded repositioning, although bleeding increased, the reduced uterine size facilitated repositioning, which was successful 7 minutes post-inversion. For clinicians encountering this rare condition for the first time, placental detachment aids diagnosis and eliminates obstructions to repositioning. The authors propose that, in cases of unexplained vaginal masses with a relaxed cervical os and stable vital signs, partial placental detachment may be performed to confirm the diagnosis. Once uterine inversion is confirmed, rapid induction of general anesthesia supports successful manual repositioning.\u003c/p\u003e\u003cp\u003eGiven the rarity of this disease, there remain controversies surrounding its treatment to date. This constitutes a limitation of the present study, which warrants further investigation in subsequent research. In summary, acute postpartum uterine inversion is a rare obstetric emergency. Clinicians should maintain a high index of suspicion for this condition in patients presenting with persistent PPH, shock, abdominal pain, and a vaginal mass to avoid delaying optimal management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the patient for her recognition and support.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData curation: Hong Zhang, Zhe-Xia Hu, Jing-Ru Zhang.\u003c/p\u003e\n\u003cp\u003eResources: Hong Zhang, Zhe-Xia Hu, Jing-Ru Zhang.\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: Hong Zhang, Zhe-Xia Hu.\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Hui Du, Tian-hong Gao.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShijiazhuang City Science and Technology Research and Development Program Project, Grant/Award Number: No.201460573.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the relevant data are included in the case report. Reasonable requests for any additional data can be obtained by contacting the corresponding author.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient described in this case report provided informed consent. An ethics board review was not needed. All procedures performed involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinkideclaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient to publish the accompanying images and information. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest, financial or otherwise.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCoad SL, Dahlgren LS, Hutcheon JA. Risks and consequences of puerperal uterine inversion in the United States, 2004 through 2013. Am J Obstet Gynecol. 2017;217(3):e3771\u0026ndash;377. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e6\u003c/span\u003e\u003cspan address=\"http://.e6\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWitteveen T, van Stralen G, Zwart J, van Roosmalen J. Puerperal uterine inversion in the Netherlands: a nationwide cohort study. Acta Obstet Gynecol Scand. 2013;92(3):334\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaskett TF. Acute uterine inversion: a review of 40 cases. J Obstet Gynaecol Can. 2002;24(12):953\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvensen A, Anderson JM, Fontaine P. Postpartum hemorrhage: prevention and treatment. Am Fam Physician. 2017;95(7):442\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang Z, He J. Clinical Analysis of 10 Cases of Puerperal Uterine Inversion. Chin J Obstet Gynecol. 2017;52(9):623\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDwivedi S, Gupta N, Mishra A, Pande S, Lal P. Uterine inversion: a shocking aftermath of mismanaged third stage of labour. Int J Reprod Contracept Obstet Gynecol. 2013;2(3):292\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgrawal H, Chafale S. A case series on uterine inversion: diagnostic and surgical considerations. Int J Reprod Contracept Obstet Gynecol. 2025;14(10):3521\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaki-Metias KM, Hosseiny M, Behzadi F, Balthazar P. Uterine Inversion Radiographics. 2023;43(6):e230004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelis S, Carrucciu F, De Simone A. Acute puerperal uterine inversion. Am J Med Clin Res Rev. 2023;02(12):01\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichalska M, Bojar I, Borycki J, Zięba B, Brandl S, Kołaciński R, Samulak D. Postnatal inversion of the uterus-management in specific cases. Ann Agr Env Med. 2020;27(4):717\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao Q, Jiang H, Jia M, Xiong J. Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report. Medicine(Baltimore).2024; 103༈17༉:e37986.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Puerperal, Uterine inversion, Postpartum hemorrhage, Reposition","lastPublishedDoi":"10.21203/rs.3.rs-8471314/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8471314/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePuerperal uterine inversion is a rare obstetric emergency that could be life-threatening.This article presents a typical case of puerperal uterine inversion. Images are provided in this paper to visually demonstrate the clinical manifestations, aiming to assist in the rapid clinical recognition and management of such cases.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 35-year-old woman (gravida 2, para 1) was admitted to the hospital for full-term pregnancy. During the placental expulsion stage postpartum, acute uterine inversion accompanied by postpartum hemorrhage occurred. We promptly recognized the condition and successfully performed manual repositioning within 7 minutes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eEarly identification and timely reduction are the cornerstones of managing acute puerperal uterine inversion.\u003c/p\u003e","manuscriptTitle":"Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 08:39:29","doi":"10.21203/rs.3.rs-8471314/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-20T11:15:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T01:21:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-18T03:52:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33957593173730617789151265949052178680","date":"2026-01-18T03:22:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67763548476534276123530578584233099445","date":"2026-01-17T11:52:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-16T16:46:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70500526739709142109770152687681140850","date":"2026-01-16T02:23:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294502898450212789011248376114062605643","date":"2026-01-15T12:29:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-15T11:39:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-15T11:27:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-07T11:15:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T08:35:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-01-07T08:24:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be77abf2-6f64-47d7-8d03-be841113dc07","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:11:06+00:00","versionOfRecord":{"articleIdentity":"rs-8471314","link":"https://doi.org/10.1186/s12884-026-09125-x","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2026-04-18 15:57:13","publishedOnDateReadable":"April 18th, 2026"},"versionCreatedAt":"2026-01-20 08:39:29","video":"","vorDoi":"10.1186/s12884-026-09125-x","vorDoiUrl":"https://doi.org/10.1186/s12884-026-09125-x","workflowStages":[]},"version":"v1","identity":"rs-8471314","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8471314","identity":"rs-8471314","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}