Incarcerated uterus

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
  • Urinary retention is the most common presenting symptom.
  • Overflow incontinence
  • Urgency
  • Frequency
  • Dysuria
• Rectal symptoms
  • Constipation
  • Rectal pressure
  • Tenesmus
• Uncontrollable lower abdominal pain
• Pelvic pain
• Back pain
• Vaginal Bleeding

PMH

• Posterior fibroids
• 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

Urinary retention

• Obstructive causes
  • BPH
  • Prostate cancer
  • Blood clot
  • Urethral Stricture
  • Bladder Calculi
  • Bladder neoplasm
  • Foreign body, urethral or bladder
  • Ovarian/uterine tumor
  • Incarcerated uterus
• Neurogenic causes
  • Multiple sclerosis
  • Parkinson's
  • Brain tumor
  • Cerebral vascular disease
  • Cauda equina syndrome
  • Spinal cord compression (non-traumatic)
  • Intervertebral disk herniation
  • Neuropathy
  • Nerve injury from pelvic surgery
  • Postoperative retention
• Trauma
  • Urethral injury
  • Bladder injury
  • Spinal cord injury
• Extraurinary causes
  • Perirectal or pelvic abscesses
  • Rectal or retroperitoneal masses
  • Fecal impaction
  • Abdominal Aortic Aneurysm
• Psychogenic causes
  • Psychosexual stress
  • Acute anxiety
• Infection
  • Cystitis
  • Prostatitis
  • Herpes Simplex (genital)
  • Herpes Zoster involving pelvic region
  • Local Abscess
  • PID
• Meds
  • Anticholinergics
  • Antihistamines
  • Cold meds
  • Sympathomimetics
  • TCA
  • Muscle relaxants
  • Opioids

Abdominal Pain in Pregnancy

The same abdominal pain differential as non-pregnant patients, plus:

<20 Weeks

• Ectopic pregnancy
• First trimester abortion
  • Complete abortion
  • Threatened abortion
  • Inevitable abortion
  • Incomplete abortion
  • Missed abortion
  • Septic abortion
• Round ligament stretching
• Incarcerated uterus
• Malposition of the uterus

>20 Weeks

• Labor/Preterm labor
• Placental abruption
• Placenta previa
• Vasa previa
• Uterine rupture
• Vaginal trauma
• HELLP syndrome
• Cholestasis of pregnancy
• Chorioamnionitis
• Incarcerated uterus
• Acute fatty liver of pregnancy
• Malposition of the uterus
• Placenta accreta
• Placenta increta
• Placenta percreta

Any time

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

Gastroentestinal

• Appendicitis
• Small bowel obstruction
• Volvulus
• Hernia
• IBD & IBS
• Perforated viscous

Genitourinary

• Cystitis
• Urinary tract infection
• Pyelonephritis
• Hydronephrosis
• Bladder rupture

Spine

• Cauda Equina Syndrome
• Herniated Nucleus Pulposus
• Lumbar strain

Evaluation

• ABC’s and Resuscitation if necessary
• 2 large bore IVs
• Labs
  • Urine pregnancy
  • Beta-HCG
  • Stat Hematocrit
  • CBC with differential
  • BMP, Mg/Phos
  • LFT
  • UA/Urine Culture
  • PTT/PT/INR
  • HIV
  • 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 death
  • 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.

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