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Female Reproductive System ORGAN SYSTEMS

Gravid uterine incarceration (GUI)

Relatively rare condition that results in the uterus becoming trapped between the sacral promontory and the pubic symphysis during pregnancy.

Relatively rare condition that results in the uterus becoming trapped between the sacral promontory and the pubic symphysis during pregnancy.

Schematic diagram of the patient’s reproductive organs at delivery. The elongated cervix, vagina, and bladder were pulled up to the level of umbilicus. The fetal head was entrapped in the pouch of Douglas. The placenta was located in the posterior uterine wall that was easily misunderstood as placenta previa over the anterior uterine wall in the ultrasound image. The fetal position was breech, not vertex. | Hsu, P.-C., Yu, M.-H., Wang, C.-Y., Wang, Y.-K., Wang, C.-K., & Su, H.-Y. (2018). Asymptomatic uterine incarceration at term: Successful management of a rare complication in pregnancy. Taiwanese Journal of Obstetrics and Gynecology, 57(5), 745–749. https://doi.org/https://doi.org/10.1016/j.tjog.2018.08.025

Aetiology

Risk factors:

  • Uterine retroversion
  • Posterior pelvic adhesions
  • Adenomyosis
  • Benign & malignant neoplasms
  • Uterine malformations
  • Endometriosis
  • Prior abdominal surgery

Pathophysiology

Uterine retroversion:

Normal variant of uterus with a prevalence of up to 15% of pregnancies in the first trimester

In most cases, retroversion can spontaneously return to a normal axial position by 14th week of gestation when the gravid uterus grows into the abdominal cavity. In rare cases, the uterus remains retroverted and becomes retroflexed between the sub-promontory sacrum and pubis in the pelvic cavity, potentially caused by uterine anomalies, fibroids, pelvic adhesions or a deep sacral cavity with a prominent promontory. Failures to timely diagnose and properly treat uterine incarceration often result in obstetric complications.

Clinical features

The most typical presentation occurs during 14-16 weeks of gestation (2nd trimester) with a variety of symptoms mimicking common gastrointestinal, genitourinary, and musculoskeletal conditions.

Common features (35-55% cases):

  • Urinary manifestations (53.70%): Urinary retention, frequent micturition, dysuria, urgency and paradoxical incontinence
  • Abdominal pain (35.80%)

Other features (1-10% cases):

  • Constipation
  • Vaginal bleeding
  • Pelvic pain, back pain, perineal pain
  • Tenesmus
  • Pelvic organ prolapse (POP) (rare)

Diagnosis

Diagnosis remains difficult as symptoms are often non-specific and absent in early pregnancy.

USG:

Ultrasonography of the retroverted gravid incarcerated uterus: (a) A longitudinal section shows that the uterus is fixed in retroversion with the cervix anteriorly transfixed behind the pubic symphysis above the uterine fundus (red arrow indicating the uterine fundus). Placenta located at fundus of uterus. (b) A transverse image of placenta that is located below the cervix. The two positional images better defines the position of uterine retroversion. | BL: bladder; CX: cervix; PL: placenta | Han, C., Wang, C., Han, L., Liu, G., Li, H., She, F., Xue, F., & Wang, Y. (2019). Incarceration of the gravid uterus: a case report and literature review. BMC pregnancy and childbirth, 19(1), 408. https://doi.org/10.1186/s12884-019-2549-3

MRI:

MRI abdomen confirmed the presence of a retroverted gravid uterus. | Sadath, H., Carpenter, R., & Adam, K. (2016). Uterine incarceration in a primigravid retroverted bicornuate uterus. BMJ case reports, 2016, bcr2016215245. https://doi.org/10.1136/bcr-2016-215245

Management

Conservative management:

  • Knee-chest positioning & manual reduction

Surgical management:

  • Myomectomy ± abdominal hysterectomy
  • Abdominal hysterectomy without myomectomy

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