Accepted Manuscript

Risks and consequences of puerperal uterine inversion in the United States,

2004-2013

Sarah L. Coad, MD., Leanne S. Dahlgren, MD., Jennifer A. Hutcheon, PhD

PII: S0002-9378(17)30627-0
DOI: 10.1016/j.ajog.2017.05.018
Reference: YMOB 11665

To appear in: American Journal of Obstetrics and Gynecology

Received Date: 2 March 2017

Revised Date: 1 May 2017
Accepted Date: 7 May 2017

Please cite this article as: Coad SL, Dahlgren LS, Hutcheon JA, Risks and consequences of puerperal
uterine inversion in the United States, 2004-2013, American Journal of Obstetrics and Gynecology
(2017), doi: 10.1016/j.ajog.2017.05.018.

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 ACCEPTED MANUSCRIPT
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Risks and consequences of puerperal uterine inversion

in the United States, 2004-2013

Sarah L. COAD1, MD., Leanne S. DAHLGREN1, MD., Jennifer A. HUTCHEON1,

PhD.

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1
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology
at the University of British Columbia, Vancouver, BC, Canada.

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The authors report no conflict of interest.

Presented at the 37th Annual Pregnancy Meeting of the Society for Maternal-
Fetal Medicine, Las Vegas, NV, Jan. 23-28, 2017.

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Corresponding author:
Dr. Sarah Coad

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C420-4500 Oak Street
Vancouver, BC, Canada V6H 2N9
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Phone: 604-877-6000 x2367
Fax: 604-875-2725
Email: scoad2@cw.bc.ca
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Word Counts:
1) Abstract: 302 words
2) Main text: 2498 words
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Condensation:

Using Nationwide Inpatient Sample data, the incidence, temporal trends, risk
factors and outcomes in women with acute puerperal uterine inversion are
estimated.

Short version of the article title:

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Risks and consequences of uterine inversion

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Structured abstract:

Background: Puerperal uterine inversion is a rare, potentially life-threatening

obstetrical emergency. The current literature consists of small case series and a

single nationwide study from Europe with only 15 cases.

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Objective: We aimed to define the incidence, temporal trends and outcomes in

women with uterine inversion using a nationally representative United States

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(US) cohort.

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Study Design: We used the Nationwide Inpatient Sample, a 20% sample of US
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hospital admissions, to identify all deliveries from 2004 to 2013. ICD-9 diagnosis

codes were used to identify cases of uterine inversion and associated adverse
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outcomes (maternal death, blood transfusion, maternal shock, need for surgical
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correction and length of hospital stay). The incidence of uterine inversion overall
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and for each year of the study period was calculated with 95% confidence

intervals (CI). The case fatality and incidence of other adverse outcomes among
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women with a uterine inversion were also estimated.

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Results: Among 8,294,279 deliveries in 2004-2013, there were 2427 cases of

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puerperal uterine inversion, corresponding to an incidence of 2.9 per 10,000

deliveries (95% CI: 2.8-3.0). There was one maternal death in our cohort (4.1 per

10,000 events). No change in the incidence of uterine inversion over the study

period was detected. Among women with a uterine inversion, 37.7% (95% CI:
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35.8%-39.6%) had an associated postpartum hemorrhage, 22.4% (95% CI:

20.7%-24.0%) received a blood transfusion and 6.0% (95% CI: 5.1%-7.0%)

required surgical management. Only 2.8% (95% CI: 2.1%-3.5%) underwent a

hysterectomy. The median length of hospital stay was 3 days.

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Conclusions: The present study provides the largest population-based results on

puerperal uterine inversion to date and highlights the high likelihood of adverse

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maternal outcomes associated with the condition. The results inform the

optimization of clinical management, by preparing for possible postpartum

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hemorrhage, need for blood products and surgical management in the rare event
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of uterine inversion.
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Words/Phrases for indexing:

Uterine inversion; Inversion, Uterine; Inversion of Uterus; Uterus Inversion

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Postpartum hemorrhage
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Puerperal disorders
Obstetric labor complications
Placenta accreta/complications
Blood transfusion
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Delivery, obstetric
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INTRODUCTION
Acute, puerperal uterine inversion is a rare but life-threatening obstetrical

emergency. Unless rapidly recognized and managed appropriately, the

associated bleeding may be substantial. The severity of uterine inversion

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typically depends on the extent of fundal protrusion, which can be classified into

four degrees. First degree (incomplete) uterine inversion occurs when the fundus

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is inverted, but remains within the endometrial cavity. With progressive fundal

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prolapse, second through fourth degree uterine inversion are defined as follows:

fundal protrusion through the cervical os (second degree), to the level of the

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vaginal introitus (third degree) and, the most catastrophic, total inversion of both
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the uterus and vagina through the introitus (fourth degree).
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Maternal mortality secondary to uterine inversion in older series is as high as

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15%,1 although more recent reports suggest that this is much lower, particularly
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in developed nations.2 Multiple risk factors have been reported including fundal

placental implantation, vigorous fundal pressure, excessive umbilical cord

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traction prior to placental separation in the third stage of labor and placenta

accrete syndromes.3 However, in about half of cases, no precipitating factors can

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be identified.4
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Despite the high risk of severe maternal morbidity associated with uterine

inversion, there are major gaps in our understanding of its incidence, temporal

trends and risk factors. The current literature consists of only of small single-

center case series5-8 and a single nationwide study from the Netherlands with
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only 15 cases of uterine inversion.2 Not surprisingly, estimates of the incidence of

puerperal uterine inversion vary widely, ranging from 1 in 2,0007 to 1 in 20,000

births.2 There are no population-based data examining how the incidence of

uterine inversion has changed over time. This is despite the introduction and

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wide adoption of practice guidelines in the mid to late 2000s 9-11 advocating the

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active management of the third stage of labor to prevent postpartum

hemorrhage. These protocols all include controlled umbilical cord traction to

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hasten delivery of the placenta, which may increase the risk of uterine inversion.

There are also no contemporary population-based data from North America on

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the morbidity and mortality associated with uterine inversion. In this study, we
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aimed to define the incidence, temporal trends, risk factors and outcomes in

women with puerperal uterine inversion using a large, nationally representative

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United States (US) cohort.

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METHODS
We used the Nationwide Inpatient Sample database to identify all deliveries in

the United States from 2004 to 2013, inclusive.12 The Nationwide Inpatient
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Sample is the largest sample of all-payer hospitalizations in the United States.

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The database contains information abstracted from approximately 8 million

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patient hospitalizations per year and comprises a stratified sampling frame of

20% of all US hospital discharges. Delivery hospitalizations were identified using

the algorithm described previously by Kuklina et al.13 Cases of uterine inversion

were identified using International Classification of Diseases, 9th Revision (ICD-

9) code 665.2. Race is classified in the Nationwide Inpatient Sample as white,

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black, Hispanic, Asian or Pacific Islander, Native American, or other. Nine states

did not report race data therefore it is missing in 20% of the sample. These

women were classified in the ‘other’ category. Primary payment information was

classified as Medicaid, private, self-pay and other/missing.

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Risk factors for puerperal uterine inversion were also identified using ICD-9

diagnostic and procedure codes (see Appendix 1). These included abnormal

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placentation (retained and/or abnormally adherent placenta), fetal macrosomia

(birth weight equal to or greater than 4500 grams), grand multiparity, multiple

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gestation, prolonged labor and mode of delivery (cesarean or vaginal).
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Demographic data including maternal age in years, race and primary payer (as

an indicator of socioeconomic status) were also abstracted.

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Within our identified cases, we used both ICD-9 diagnostic and procedure codes
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(see Appendix 1) to ascertain associated adverse maternal outcomes. These

included: maternal death, blood transfusion (including the use of packed red
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blood cells, platelets or other blood products), maternal distress (maternal shock

during or following labor and delivery, as well as maternal hypotension), need for
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surgical correction (defined as need for surgical correction of inverted uterus,

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exploratory laparotomy, or hysterectomy) and length of hospital stay (days).

Descriptive characteristics of the study population were summarized using

means with standard deviation and counts with percentages. In agreement with
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NIS data use requirements, all cells with counts less than 10 were suppressed.

The incidence of uterine inversion overall and for each year of the study period

was calculated with 95% confidence intervals (CI). The case fatality and

incidence of other adverse outcomes and risk factors among women with a

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uterine inversion were estimated with 95% CI. Median length of hospital stay

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among women with uterine inversion was estimated using quantile regression.

Multivariable logistic regression was used to estimate the independent

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association of risk factors with uterine inversion, which are reported as crude and

adjusted odds ratios (ORs). Adjusted models controlled for all other risk factors

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examined in the study. We similarly estimated the increased odds of maternal
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mortality and other adverse outcomes among women with uterine inversion

compared with those who did not experience a uterine inversion.

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Our hospital ethics board waived ethical review because the data are publicly
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available. Statistical analyses were conducted using Stata SE version 13

(College Station, TX).

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RESULTS
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Among 8,294,279 deliveries in 2004-2013, there were 2427 cases of puerperal

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uterine inversion identified, corresponding to an incidence of 2.9 per 10,000

deliveries (95% CI: 2.8-3.0). There was one maternal death among women with a

uterine inversion (4.1 per 10,000). The incidence of uterine inversion appeared
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stable over the study period, based on the overlap in 95% confidence intervals

for the annual rates (Figure 1).

Table 1 summarizes the demographic characteristics and other risk factors for

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uterine inversion. The mean age of women who experienced a uterine inversion

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was 27.0 years old (±5.9 years), which is 0.7 years lower than those women who

did not (adjusted OR of 0.97 per year increase in maternal age [95% CI: 0.97-

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0.98]). The rate of abnormal placentation was significantly higher in women with

a uterine inversion (6.3% vs. 0.5%), with an adjusted OR of 13.6 (95% CI: 11.5-

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16.1). Other risk significant risk factors included prolonged labor (adjusted odds
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ratio of 1.58 (95% CI: 1.12-2.25) and severe pre-eclampsia (adjusted OR 2.43

(95% CI: 1.98-2.98)). When compared to vaginal delivery, cesarean section was
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not protective for uterine inversion. Fetal macrosomia and grand multiparity were
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not found to be statistically significant risk factors. Multifetal pregnancy was

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protective with an adjusted odds ratio of 0.17 (95% CI: 0.07-0.37), although these

numbers were small with fewer than 10 cases of uterine inversion among women
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with a multifetal pregnancy.

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In Table 2, the key obstetrical outcomes of women who had a uterine inversion
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are summarized. Among women with a uterine inversion, 37.7% (95% CI: 35.8%-

39.6%) had an associated postpartum hemorrhage and 22.4% (95% CI: 20.7%-

24.0%) received a blood transfusion. Six (6) percent (95% CI: 5.1%-7.0%) of

uterine inversions required surgical management, however, only 2.8% (95% CI:
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2.1%-3.5%) necessitated a hysterectomy. These risks were 17 to 106-fold more

common in women with uterine inversion compared with women without an

inversion. The median length of hospital stay in women with a uterine inversion

was 3.1 days compared with 2.6 days among women with no inversion.

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COMMENT

The present study included over 8 million delivery records between 2004 and

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2013 contained in the national-representative NIS database. Within this robust

cohort, the incidence of puerperal uterine inversion was 2.9 per 10,000 deliveries

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(95% CI: 2.8-3.0). Reassuringly, there was only 1 maternal death among the
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identified cases of uterine inversion, but women with uterine inversion were more

likely to have a postpartum hemorrhage requiring transfusion, and suffer from

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hypotension and shock. It is reassuring that less than 10% of patients with
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uterine inversion required a laparotomy and surgical correction. With timely

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recognition and prompt intervention to immediately replace the inverted uterus

most, if not all cases should be managed without the need for a laparotomy.
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The strongest risk factor for uterine inversion was abnormal placentation (aOR
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13.6; 95% CI: 11.5-16.1). Women with prolonged labor were also found to be at
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higher risk for uterine inversion (aOR 1.58; 95% CI: 1.12-2.25). This is likely

related to uterine muscle exhaustion leading to uterine atony in third stage of

labor. However, other well accepted risk factors for uterine atony such as fetal

macrosomia and multifetal pregnancy were not found to be statistically significant

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risk factors and interestingly, multifetal pregnancy was found to be protective for

uterine inversion. The etiology leading to uterine atony is different in these factors

(uterine over-distention) and perhaps is more easily overcome with the

administration of prophylactic uterotonics reducing the risk of uterine inversion.

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The increased risk of uterine inversion in patients with severe pre-eclampsia was

an unexpected finding. It is possible that patients with pre-eclampsia also have

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other risk factors for postpartum hemorrhage, leading to more careful evaluation

of the uterine contour during the third stage of labour and therefore increased

diagnosis of uterine inversion.

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It is unknown whether mode of delivery affects the risk of uterine inversion. The
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majority of the existing literature reports only on uterine inversion at the time of
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vaginal delivery, and excludes those cases that occur at the time of Caesarean
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section. Interestingly, in the one small case series7 that did include events at the

time of Caesarean section, the incidence of uterine inversion was twice as high
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during Caesarean section (1 in 1860 vs. 1 in 3737 deliveries). However, theses

cases seemed to be less severe as they were all managed with immediate fundal
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replacement under the existing regional anesthesia and although the rate of
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postpartum hemorrhage was 37.5%, none required a blood transfusion. No

difference in the incidence of uterine inversion was found between the two

modes of delivery in our study (aOR for Caesarean section compared to vaginal

delivery was 0.98 [0.89-1.07]). During Caesarean delivery, the uterine contour is
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directly visualized and the cavity often explored following delivery of the placenta.

This could potentially identify more and less severe events.

The current literature on uterine inversion is extremely limited with multiple case

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reports, a few small case series5-8 and only one other cohort studies.2 Baskett7

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conducted a retrospective chart review over a twenty-four year period at a single

Canadian hospital and described forty cases of uterine inversion among 125,081

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births. The calculated incidence of 2.7/10,000 deliveries in his study closely

matches the incidence in our cohort. In his small series, he reported a higher rate

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of post-partum hemorrhage (65%) and blood transfusion (47%) than our
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contemporary cohort. Of the 27 cases of uterine inversion following vaginal

delivery, all were replaced manually, without the need for surgical intervention.
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Risk factors identified were manual removal of the placenta and cesarean
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section. Baskett7 reported no increased risk with nulliparity, classically

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considered to be a risk factor, but not evaluated in our study due to lack of data.
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Witteveen, et al,2 published the only other nationwide cohort study examining

puerperal uterine inversion in the Netherlands. The group reported on fifteen

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cases identified within the LEMMoN cohort, a cohort specifically intended to

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assess severe maternal morbidity related to pregnancy and childbirth. Only

patients who met pre-specified criteria for severe acute maternal morbidity were

included. The incidence of uterine inversion was calculated to be 0.5/10,000

deliveries. This is likely an underestimated true incidence of uterine inversion in

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their population, given the strict inclusion criteria for their cohort. Our study

suggests that acute uterine inversion may vary considerably in severity, perhaps

due to differences in recognition and management. Although no statistical

analysis was performed in the Dutch study, the described risk factors and

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maternal adverse outcomes identified match closely with our study. Additionally,

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they reported no difference in risk of uterine inversion between nulliparous and

multiparous patients and no maternal deaths.

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Multiple authorities have cautioned against the routine practice of controlled cord

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traction prior to clinical signs of placental separation in the third stage of labor to
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prevent inversion of the uterus. Deneux-Tharaux et al.14 conducted a randomized

controlled trial to assess the impact of controlled cord traction on the incidence of
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postpartum hemorrhage in a high resource setting. This study followed the

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introduction and wide adoption of the active management of the third stage of
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labor, to prevent postpartum hemorrhage, which includes controlled cord traction.

While the incidence of postpartum hemorrhage did not differ between the
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controlled cord traction arm (9.8%) and standard placenta expulsion arm

(10.3%), controlled cord traction did decrease the overall length of the third stage
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of labor by 15 minutes and the need for manual removal of the placenta. No
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uterine inversion occurred in either arm, although the study was not powered to

assess this outcome. Despite the increase in use of controlled cord traction

during the study period, no increase in uterine inversion was observed in our

study.
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The present study is the only large, contemporary population-based study on

acute puerperal uterine inversion. The NIS database comprises information

extracted from hospital discharge summaries, which may be subject to coding

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errors. The accuracy of the code for uterine inversion is unknown. Additionally,

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under-diagnosis by obstetrical providers is possible if, at the time of vaginal

delivery, the event was mild (first degree inversion). This would lead to an

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underestimation of the true incidence, although clinically significant events would

likely be reported. However, the NIS data have been used extensively for

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research, are regularly reviewed for completeness, and are compared with other
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national data sources of hospital care such as the National Hospital Discharge

Survey to maintain database quality.15,16 Additionally, several studies examining

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the accuracy of obstetrical diagnoses and procedures in hospital discharge data

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using medical record audits have demonstrated that these data, overall are
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coded with reasonable sensitivity and specificity.17-19 Furthermore, our estimate

of incidence of uterine inversion agrees closely with that of the largest hospital
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based study that reviewed all cases of uterine inversion.7 Despite this, the NIS

database has not been specifically validated for our outcome. As uterine
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inversion is a rare event, obtaining a sufficient number of cases in a validation

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study would be extremely challenging. As a result, we cannot rule out the

possibility that coding bias within the database has lead to over- or

underestimation of rates in our study.

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Limitations in the NIS dataset meant that some potential risk factors for puerperal

uterine inversion that would have given useful clinical information could not be

examined. These included gravidity and parity, placenta location, labor

augmentation, precipitous delivery, and uterine anomalies. Furthermore, if

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maternal outcomes could have been stratified by the severity of uterine inversion,

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this would have provided additional clinically relevant results, but as there is only

one ICD-9 code for uterine inversion that does not specify the degree of

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inversion, this analysis could not be performed. Nevertheless, the present study

confirms some of the classic risk factors associated with uterine inversion

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including abnormal placentation and prolonged labor. In addition, it highlights the
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high likelihood of adverse maternal outcomes associated with acute uterine

inversion. The results inform the optimization of clinical management, by

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immediately preparing for possible postpartum hemorrhage, need for blood

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products and surgical management upon diagnosis.

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ACKNOWLEDGEMENT(S)

None

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REFERENCES

1. Das P. Inversion of the uterus. Br J Obstet Gynaecol 1940;47:525–48.

2. 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;92:334–337.

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3. Cunningham FG, Leveno KJ, Bloom SL, et al. eds. Williams Obstetrics.
New York, NY: McGraw-Hill Education; 2014:787-788.
4. Adesiyun AG. Septic postpartum uterine inversion. Singapore Med J

RI
2007;48:943.
5. Shah-Hosseini R, Evrard JR. Puerperal uterine inversion. Obstet Gynecol
1989;73:567-70.

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6. Watson B, Besch N, Bowes WA. Management of acute and subacute
puerperal inversion of the uterus. Obstet Gynaecol 1980;55:12-16.

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7. Baskett TF. Acute uterine inversion: a review of 40 cases. J Obstet
Gynaecol Can 2002;24:953.
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8. Dali SM, Rajbhandari S, Shrestha S. Puerperal inversion of the uterus in
Nepal: case reports and review of literature. J Obstet Gynaecol Res
1997;23:319.
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9. Leduc D, Senikas V, Lalonde, AB. Active Management of the Third Stage

of Labour: Prevention and Treatment of Postpartum Hemorrhage. JOGC
2009;10:980–993.
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10. Managing complications of pregnancy and childbirth: a guide for midwives

and doctors. Geneva: World Health Organization, United Nations
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Population Fund, United Nations Children’s Fund and The World Bank;
2003. Available at:
http://apps.who.int/iris/bitstream/10665/43972/1/9241545879_eng.pdf.
Accessed January 30, 2017.
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11. Management of the third stage of labour to prevent post-partum

haemorrhage (joint statement). The Hague and London: International
Confederation of Midwives and International Federation of Gynaecology
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and Obstetrics; 2003. Available at:

http://www.internationalmidwives.org/assets/uploads/documents/FIGO/PP
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H%20Joint%20Statement.pdf. Accessed January 30, 2017.

12. Agency for Healthcare Research and Quality. HCUP Nation-wide Inpatient
Sample (NIS). Healthcare cost and utilization project (HCUP). 2004-2013.
Agency for Healthcare Research and Quality. Available at:
http://www.hcup-us.ahrq.gov/niso-verview.jsp. Accessed: June 14, 2016.
13. Kuklina EV, Whiteman MK, Hillis SD, et al. An enhanced method for
identifying obstetric deliveries: implications for estimating maternal
morbidity. Matern Child Health J 2008;12:469–77.
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14. Deneux-Tharaux C, Sentilhes L, Maillard F, et al. Effect of routine

controlled cord traction as part of the active management of the third stage
of labour on postpartum haemorrhage: multicentre randomised controlled
trial (TRACOR). BMJ 2013;346:f1541.
15. Healthcare Cost and Utilization Project. HCUP quality control procedures.
2014. Available at: www.hcup-us.ahrq.gov/db/quality.jsp.

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16. Healthcare Cost and Utilization Project. HCUP NIS related reports. 2014.
Available at: www.hcup-us.ahrq.gov/db/nation/nis/nisrelatedreports.jsp.
17. Yasmeen S, Romano PS, Schembri ME, Keyzer JM, Gilbert WM.

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Accuracy of obstetric diagnoses and procedures in hospital discharge
data. AJOG 2006;194:992–1001.

SC
18. Lain SJ, Roberts CL, Hadfield RM, Bell JC, Morris JM. How accurate is
the reporting of obstetric haemorrhage in hospital discharge data? A
validation study. ANZJOG 2008;48:481–484.
19. Lydon-Rochelle MT, Holt VL, Cardenas V, et al. The reporting of pre-

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existing maternal medical conditions and complications of pregnancy on
birth certificates and in hospital discharge data. AJOG 2005;193:125–34.
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Table 1: Risk factors for uterine inversion in the Nationwide Inpatient Sample, 2004-2013.
Risk Factor No Uterine Inversion Uterine Inversion Unadjusted odds Adjusted odds ratio*
N=8,291,852 N=2427 ratio (95% CI) (95% CI)

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N (%) or mean± SD N (%) or mean± SD
Race:

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White 3,562,083 (43.0) 1,071 (44.1) Reference Reference
Black 924,146 (11.1) 174 (7.2) 0.62 (0.53-0.74) 0.61 (0.52-0.72)
Hispanic 1,599,519 (19.3) 512 (21.1) 1.06 (0.96-1.18) 1.06 (0.95-1.19)

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Other/Missing 2,206,104 (26.6) 670 (27.6) 1.01 (0.92-1.11) 0.99 (0.90-1.09)
Primary payer:
Private 4,196,575 (50.6) 1,234 (50.8) Reference Reference

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Medicaid 3,575,536 (43.1) 1,053 (43.4) 1.00 (0.922-1.09) 0.91 (0.82-1.00)

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Self-Pay 266,399 (3.2) 73 (3.0) 0.93 (0.74-1.18) 0.94 (0.74-1.20)
Other/Missing 253,342 (3.1) 67 (2.8) 0.90 (0.70-1.15) 0.85 (0.67-1.09)
Age in years at admission 27.7 ±6.1 27.0 ±5.9 0.98 (0.97-0.99) 0.97 (0.97-0.98)

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Abnormal placentation 41,340 (0.50) 153 (6.30) 13.4 (11.4-15.8) 13.6 (11.5-16.1)
Mode of delivery:

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Vaginal 5,610,128 (67.66) 1,691 (69.67) reference reference
Cesarean 2,681,724 (32.34) 736 (30.33) 0.91 (0.84-0.99) 0.98 (0.89-1.07)

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Multiple pregnancy 121,749 (1.47) <10 (<1.0) 0.17 (0.07-0.37) 0.17 (0.07-0.37)
Fetal macrosomia 214,814 (2.59) 67 (2.76) 1.07 (0.84-1.36) 1.11 (0.88-1.43)
Prolonged labor 66,520 (0.80) 32 (1.32) 1.65 (1.17-2.34) 1.58 (1.12-2.25)
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Grand multiparity 51,102 (0.62) <10 (<1.0) 0.60 (0.31-1.16) 0.62 (0.31-1.26)
Severe pre-eclampsia 156,767 (1.89) 102 (4.2) 2.28 (1.87-2.78) 2.43 (1.98-2.98)
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*Adjusted for other risk factors listed in the table

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Table 2: Maternal outcomes among women with and without a uterine inversion in the Nationwide Inpatient Sample, 2004-
2013.
Outcome No Uterine Inversion Uterine Inversion Odds Ratio (95% CI)

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N=8,291,852 N=2427
N (%) N (%)

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Post-partum 237,730 (2.87) 915 (37.7) 20.5 (18.9-22.3)
Hemorrhage

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Transfusion 79,468 (0.96) 543 (22.4) 29.8 (27.1-32.8)
Maternal Shock 1,440 (0.02) 32 (1.3) 76.9 (54.1-109.4)
Maternal Hypotension 10,335 (0.12) 51 (2.1) 17.2 (13.0-22.7)

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Laparotomy 812 (0.01) 25 (6.0) 106.3 (71.2-158.5)

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Hysterectomy 7,296 (0.09) 68 (2.8) 32.7 (25.7-41.7)

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FIGURE LEGEND:

Figure 1. Incidence of uterine inversion in the Nationwide Inpatient sample, 2004-2013.

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APPENDIX: Additional Information

This file includes the ICD-9 diagnostic and procedure codes used to identify the exposure and outcome variables.

PT
Description ICD-9 code ICD-9 procedure

RI
Abnormal placentation 667
Macrosomia 656.6

SC
Elderly primigravida 659.5
Grand multiparity 659.4
Multiple Gestation 651

U
Mode of delivery:

AN
SVD V30
Caesarean section 669.7 74.1
Prolonged Labour 662, 662.0, 662.2

M
Postpartum Hemorrhage 666, 666.0, 666.1, 666.2,
666.3

D
Blood Transfusion 99.0
Of Packed cells 99.04

TE
Of platelets 99.05
Of other blood 99.06, 99.07
products
EP
Surgical Intervention
Surgical correction 75.93
C

of inverted uterus
Exploratory 54.11
AC

laparotomy 68.3, 68.4, 68.6, 68.8

Hysterectomy
Maternal Distress 669.0
Shock during or 669.1
following labour
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and delivery
Maternal 669.2
Hypotension

PT
RI
U SC
AN
M
D
TE
EP
C
AC
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4
Uterine Inversions per 10,000 deliveries
3.5

PT
3

RI
2.5

SC
2

U
2004 2006 2008 2010 2012 2014
Calendar Year
AN
Risk 95% Confidence Inverval
M
D
TE
C EP
AC