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
  • Occurs only during pregnancy
  • Symptomatology is the result of compression of pelvic structures from enlarging uterus
  • Urinary Symptoms
  • Rectal symptoms
  • Uncontrollable lower abdominal pain
  • Pelvic pain
  • Back pain
  • Vaginal Bleeding

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 pain differential as non-pregnant patients, plus:

<20 Weeks

>20 Weeks

Any time

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

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

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
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