Incarcerated uterus

Incarcerated Uterus: Compression and anterior displacement of bladder into abdominal cavity with compression of rectum. Most common presenting symptoms is urinary retention.

Background

  • Retroverted uterus is a normal variant (up to 20% of the population).
  • During pregnancy, a retroverted uterus spontaneously flips to become anteverted at 14-16 weeks gestation age.
  • Incarcerated uterus = impregnated retroverted uterus that is unable to spontaneously revert because the fundus is wedged below the sacral promontory.
  • Growth of uterus during pregnancy in retroverted position leads to compression of pelvic organs leading to symptomatology.

Clinical Features

History

PMH

  • Posterior and/or fundal fibroids
  • Endometriosis, adhesive disease (prior surgery, peritonitis, PID)
  • Prior history of incarcerated uterus

Bimanual Exam

  • ACOG Recommendation: All women with second trimester urinary retention should have a pelvic exam performed at presentation to exclude an incarcerated retroverted uterus
  • Findings
    • Extremely anterior cervix
    • Cervix posterior to pubic symphysis
    • Acutely angled vaginal canal
    • Unable to palpate uterus through abdomen

Transvaginal Ultrasound

  • Difficulty to identify cervix in 2nd and 3rd trimester
  • Cervix extends upward, superior to the bladder and pubic symphysis
  • Bladder will appear elongated and distended due to compression of uterus

Differential Diagnosis

Abdominal Pain in Pregnancy

The same abdominal pathologies as non-pregnant patients, plus:

<20 Weeks

>20 Weeks

Any time

  • Hemorrhagic ovarian cyst
  • Fibroid degeneration or torsion
  • Ovarian torsion
  • Constipation

Urinary retention

Evaluation

  • ABC’s and Resuscitation if necessary
  • 2 large bore IVs

Labs

  • Urine pregnancy, beta-HCG
  • CBC with differential
  • BMP, Mg/Phos, LFTs
  • UA/Urine Culture
  • PTT/PT/INR
  • Type and cross 2 units PRBC if bleeding concern

Imaging

  • Transvaginal Ultrasound
  • Non-emergent MRI if unable to obtain transvaginal ultrasound
  • Consider post-void residual

Management

  • Consultation with OB/GYN upon diagnosis

Reduction of Incarcerated Uterus (ACOG Recommendations, 2014)

  • Bladder decompression
    • Insertion of indwelling Foley Catheter
  • Pelvic exam to confirm diagnosis
    • Acute anterior angulation of vagina
    • Cervix positioned behind the pubic symphysis
    • Fundus not palpable abdominally

Next steps are performed to achieve reduction of uterus by external/internal manipulation and should be performed with OB/GYN consultation

  • Patient position
    • Knee-chest or all fours
  • Manual reduction
    • Ensure bladder fully void
    • Vaginal examination with or without anesthesia
  • Colonoscopic
    • Gas insufflation of colon under anesthesia
  • Other
    • Amnioreduction
    • Surgical exploration through laparotomy

Delivery

  • C-section
  • Risk of uterine rupture if allowed to labor

Complications

  • Maternal
  • Fetal
    • Premature labor
    • Fetal mortality rate 33% (Gibbons and Paley)

Disposition

  • Admit
    • From the limited number of case studies, it appears most patients were admitted for inability to void, pain control, reduction of incarcerated uterus.

See Also

External Links

References

  • Newell S, Crofts J, Grant S. The Incarcerated Gravid Uterus Complications and Lessons Learned. American College of Obstetricians and Gynecologist 2014, 123:423-427
  • Gardner C, Jaffe T, Hertzberg B, Javan R, Ho L. The Incarcerated Uterus: A review of MRI and Ultrasound Imaging Appearances. American Journal of Roentgenology. 2013;201: 223-229.
  • Gibbons JM Jr, Paley WB. The incarcerated gravid uterus. Obstet Gynecol 1969; 33:842–845