View source for Incarcerated uterus

==Background==
[[File:Figure 28 02 01.png|thumb|Normal female anatomy with uterus highlighted.]]
[[File:Incarcerateduterus.JPG|thumb|Incarcerated Uterus: Compression and anterior displacement of bladder into abdominal cavity with compression of rectum. Most common presenting symptoms is urinary retention.]]
*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
**[[Urinary retention]] is the most common presenting symptom.
**Overflow [[urinary incontinence|incontinence]]
**Urgency, frequency
**[[Dysuria]]
*Rectal symptoms
**[[Constipation]]
**Rectal pressure, tenesmus
*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 Pregnancy DDX}}
{{Urinary retention DDX}}

==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
**[[Acute renal failure]]
**Severe [[hypertension]] resistant to medications
**Lower limb edema
**Uterine ischemia
**[[Sepsis]]
**[[DVT]], Post-partum [[PE]]
*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
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[[Category:OBGYN]]