The frequency of uterine inversion reported in the literature is highly variable. It would be 1/100,000 in Europa and 1/2000 in United States [1] [2] [4] . The variability of the frequency can be explained by the unusualness of this pathology. In Côte d’Ivoire, there is no data on this pathology. Two conditions are necessary for the occurrence of a uterine inversion: uterine hypotonia and sufficient cervical dilatation [5] . The puerperal uterine inversion (IUP) of obstetric origin in 85% to 95% of cases [1] [6] , committed life-threatening maternal and requires a fast support. It is described 4 anatomical stages of increasing severity [7] . The stage I contain the uterine background in cup without reaching the cervical orifice. At the stage II, the uterine substance crosses the cervical orifice. At the stage

III, the uterus is exteriorized out of the vagina. At the stage IV; the vaginal walls are involved in the turnaround. Classically, IUP occurs mainly in the primiparous and young women [5] , as was the case in the first clinical observation. Fürst estimated that, into the primiparous group, uterus atone is more common due to a longer labor. According to him the placental insertion fundic site is more common [2] . In our observation, dangerous maneuvers such as excessive traction on the cord or the exaggerated uterine expression may have contributed to the occurrence of the IUP [1] . In the literature, other factors of risk are found: a fast delivery, a short umbilical cord, abnormal placental traction and uterine inertia [1] [2] [3] .

In contrast, no puerperal uterine inversion (IUNP) affects older women, at least 45 years. This type of uterine inversion is most often associated with benign tumors of the uterus [8] [9] [10] . But as it is observed in young patients of childbearing age, a malignant tumor of the uterus is usually the cause. Authors such as De Vries [11] and Lupovitch [12] had reported cases. Unlike the classical case, the patient was young (28 years) and the newfound cause was benign uterine fibroid) in our second clinical case.

The pathophysiology of the IUNP is not yet understood. In the literature, several theories have been mentioned: a thin uterine wall, a location of the tumor to the uterine substance, a pediculated tumor, a dilation of the cervix by distension of the uterine cavity and abrupt expulsion from the tumor of the vagina [9] [13] . In our observation, the basis of implantation of the tumor was wide and located in the bottom of the uterus. Like etiology, Das found 87% of fibroids, 7% of sarcomas and 6% of carcinomas [14] . Two classifications have been proposed for the IUNP: partial or complete and acute or chronic depending on the mode of occurrence [15] [16] .

Puerperal uterine inversion (IUP) diagnosis is clinical, during delivery or immediately after, in front of three main signs that are hemorrhage, shock, and pelvic pain [1] [2] [3] . The intensity of the state of shock is not proportional to the extent of the bleeding and it can even proceed, due to an etiology not hypovolemic also neurogenetic. Indeed, the aspiration of the uterine substance through the uterine cervix caused a stretch of nervous nets of the peritoneum and the broad ligaments, as well as a compression of the ovaries [17] [18] . The treatment of IUP provides to the understanding of the physiopathology which require the correction of shock pass by the reduction of inversion associated with the recovery medical [19] . In this case, many lost times were observed before admission of the patient in our unit care. This a negative factor in the management. That was in relation with a lack of ambulance to evacuate rapidly the patients to other maternity more competent.

In the incomplete forms of the IUNP, the contribution of imagery is essential for an accurate diagnosis, for example the pelvic ultrasound and Imaging by Magnetic Resonance (MRI) [11] [12] [13] . In our Observation No. 2, the reversal was complete and easy clinical diagnosis. Indeed, the acute IUNP is characterized by a very intensive pain and more abundant menorrhagia unlike chronic forms where there is also the pelvic pain, vaginal, minimal menorrhagia. At first, it can be difficult to differentiate the IUNP to a large polyp given birth by the uterine cervix, bloody and purulent. A careful inspection will highlight the tubal orifice, the uterine cervix and the characteristic dead end [8] [9] [10] . Concerning etiologies, sub-mucosal myoma are founded in 70% to 85% of cases according to the literature [14] [15] [16] . In 15% to 30% of cases, malignant tumors were founded, mainly the uterine sarcomas. Less frequents etiologies of uterine inversion were endometrial cancer or mullerians tumors [13] [16] .

Support of IUP needs multidisciplinary actions, involving obstetrician and anesthetist. It is an emergency. Multidisciplinary treatment allows improving significantly the mother’s prognosis. It combines a medical resuscitation aimed at correcting the shock, a quick manual reduction and antibiotic injection [20] [21] . If all methods of manual reduction fail, surgery is necessary and different techniques have been described [1] [2] [22] . Oboro [23] reported four surgical techniques: intervention by vaginal route so-called “Spinelli” which consists of a total anterior median colpohysterotomy. Laparotomy known as “Huntington technique” which consists of a light pull and continues on the round ligaments while another person trying a manual reduction vaginally; Haughty procedure which consists of a posterior median hysterotomy, facilitating the replacement of the uterus by the method of Huntington and hysterectomy as a last resort. In our case, a hysterectomy for IUP was performed after attempts failed and manual and surgical reduction before the severe hypovolemic shock, which was hardly compensated for by the 3 units globular.

Hysterectomy can be done vaginally or through high according to the habits of the operator, but also according to the conditions surgical [1] [24] . Some teams offer the laparoscopic surgery [25]. The IUP are associated with significant morbidity and maternal mortality: blood and infectious (postpartum endometritis) [5] . Immediate of IUP acute diagnosis followed to process would avoid hysterectomy [1] [4] .

Several assumptions have been described in the literature in the IUNP: a conservative treatment in early forms. When there is no desire of pregnancy, or when the uterine inversion is the 3rd or 4th degree, hysterectomy remains the treatment of choice [8] [9] [10] . In the complete IUNP through abdominal hysterectomy was once the intervention of reference. Teams practice more in addition to vaginal hysterectomies [26] . Indeed, after a careful repositioning of the uterus in its anatomical position, a vaginal hysterectomy ends the procedure.

Laparoscopy and vaginal association seems to be a good alternative, to confirm the diagnosis, to assess the degree of ischemia of the annexes and the vagina, and hemostasis surgical of the uterus by laparoscopy by controlling the uterine pedicle from her origin [26] [27] . In general, the prognosis of uterine inversion is related to the precocity of diagnosis. Furthermore, obstetric prognosis is reserved for patients who have received conservative treatment, because risk of recurrence [1] [2] [5] .