Incarceration of the gravid uterus: a case report and literature review

Role of ultrasound in diagnosing gravid uterine incarceration

OBJECTIVE

To summarize the ultrasound characteristics, diagnostic experiences, and pregnancy outcomes of gravid uterine incarceration.

METHODS

A retrospective analysis was conducted on the data of pregnant women diagnosed with gravid uterine incarceration by prenatal ultrasound at the Ultrasound Department of the Third Affiliated Hospital of Zhengzhou University from January 2020 to December 2023. Clinical data, ultrasound features, and pregnancy outcomes were analyzed.

RESULTS

In this study, a total of 23 pregnant women were included. Of these, eight were diagnosed in early pregnancy, and 15 were diagnosed in mid-pregnancy. Seven participants had concurrent uterine fibroids, 10 had a history of abdominal or pelvic surgery, and two had ovarian cysts. A total of 13 cases presented with symptoms of urethral obstruction, three with rectal pressure symptoms, five cases with tight and stiff lower abdomen and two cases without special discomfort. Seventeen cases exhibited cervical compression with thinning and elongation, measuring approximately 39 to 73 mm. All 23 cases underwent manual or knee-chest positioning repositioning, with one case requiring surgical intervention. Ultimately, 22 cases resulted in full-term live births, one case experienced fetal demise at 24 weeks and one case experienced gravid uterine incarceration again in the third week after successful manual reduction, and manual reduction was performed again.

CONCLUSION

Early diagnosis is critical for obstetric management and clinical prognosis, facilitating the successful release of the incarcerated uterus. The earlier the diagnosis, the higher the likelihood of successfully releasing the incarcerated uterus.

Incarcerated gravid uterus liberated by vaginal gauze packing under general anesthesia: a case report

Incarceration of the gravid uterus is a rare and serious obstetric complication that can lead to severe complications. We present the case of a 32-year-old woman (gravida 5, para 2022) at 12 weeks and 5 days of gestation who presented with urinary retention and lower abdominal pain. Despite attempts at positional changes and manipulative repositioning under epidural anesthesia, the incarceration of the gravid uterus persisted. Subsequent intervention under general anesthesia involved partially reducing the uterine fundus into the abdominal cavity and using gauze strips in the posterior vaginal fornix to maintain traction. In addition, the bilateral round ligaments of the uterus were sutured to release the incarcerated uterus via laparoscopy. Vaginal gauze packing under general anesthesia may be a beneficial intervention for addressing cases of an incarcerated uterus, particularly in patients in whom passive maneuvers and manual pressure fail to resolve the condition.

Incarcerated gravid uterus: a new treatment using the transvaginal ultrasound probe and narrative literature review

BACKGROUND

'Incarcerated gravid uterus' is a morbid complication that occurs in 1 in 3000 pregnancies. It is characterized by failure of a retropositioned uterus to become an abdominal organ between 12 to 14 weeks of gestation. If maternal symptoms develop or gestational age surpasses 14 to 16 weeks, replacement of a retropositioned uterus is recommended to reduce adverse outcomes. Previously described techniques for management include passive reduction, digital replacement, or more invasive methods such as laparoscopy, laparotomy, or sigmoidoscopy. These methods are either minimally effective, painful, or risky.

OBJECTIVE

The objective of this report is to describe our clinical experience with a new minimally invasive technique that uses the transvaginal ultrasound probe for uterine replacement in cases of incarceration, to conduct a narrative literature review on 'incarcerated gravid uterus,' and to propose an algorithm for management of this condition.

STUDY DESIGN

This is a case series of 8 patients with an incarcerated gravid uterus who were managed with the transvaginal ultrasound probe technique at one academic medical institution between March 2020 and July 2023, as well as a narrative review of the literature on 'incarcerated gravid uterus.' PubMed, Google Scholar, and Ovid MEDLINE databases were searched for the terms "incarcerated gravid uterus," "uterine incarceration," "uterine sacculation," and "retroverted uterus" up to April 2024.

RESULTS

The transvaginal ultrasound probe technique resulted in successful uterine replacement, with resolution of symptoms, in all 8 patients. All pregnancies resulted in live births with good neonatal outcomes-7 out of 8 patients delivered at term, and 1 delivered in the late preterm period.

CONCLUSION

Our proposed technique for treatment of an incarcerated gravid uterus with the transvaginal ultrasound probe is simple, minimally invasive and effective. Based on our experience and the narrative literature review, an algorithm for the management of an incarcerated gravid uterus is proposed.

Case study: Recurrent uterine incarceration during pregnancy

BACKGROUND

Uterine incarceration is a rare complication of pregnancy. The most frequent complications are pain and urinary retention.

CASE

We present the case of a patient who had presented a uterine incarceration during her first pregnancy, requiring a reduction under general anesthesia at 27+0 weeks of gestation complicated by premature delivery at 29+0 weeks of gestation. In the subsequent pregnancy, recurrent symptomatology encouraged earlier reduction at 19+5 weeks of gestation under locoregional anesthesia with term delivery.

CONCLUSION

Reccurent symptomatology of uterine incarceration during early mid trimester of pregnancy favored earlier diagnosis and successful reduction by digital manoeuver.

Incarcerated gravid uterus - A systematic review

Incarcerated gravid uterus (IGU) is a serious complication of pregnancy that leads to adverse obstetric outcomes. The aim of this review was to describe this entity in detail. We also aimed to understand if pregnancies with predisposing risk factors that increase the risk of developing IGU had a difference in their clinical manifestations, treatment, and obstetric outcomes. The PubMed, MEDLINE, Embase, Scopus databases and clinicaltrials.gov were searched from inception to July 2023. Case reports and series that provided all the details of the pregnancy and IGU outcome were included. Study quality and risk of bias were assessed using a tool that is an adaptation from criteria listed by Pierson, Bradford Hills and Newcastle Ottawa scale modification. Patients with the condition of interest included in this review were grouped into those with documented, identified risk factors and no risk factors. The two groups were compared to understand the difference in obstetric outcome and presentation of IGU. Data were analyzed and summarized descriptively, categorical variables were assessed by chi-squared test or Fisher's exact test, and continuous variables by the Wilcoxon Mann Whitney test. Of 236 articles found, 62 articles with 80 cases were included in the final analysis. The median age was 32 [27-35] years. The median gestational age of diagnosis was 17 [14-26] weeks. The most common risk factor was fibroids (N = 22, 27.5 %). Most common presentation was urinary complaints and lower abdomen pain (N = 47, 58.6 %). Twenty-seven patients (33.6 %) needed more than one visit for the diagnosis to be made. Conservative management was the first step to treat IGU in most patients. Most common complication was fetal malpresentation (N = 13, 40.6 %). Patients with or without risk factors developing IGU had no statistical difference in- parity, median gestational age of diagnosis, delay in diagnosis, increased chance of misdiagnosis, management of IGU or in obstetric outcome (all p > 0.05). It is important to recognize this entity early to prevent obstetric complications especially when patients report urinary retention and abdomen pain. The presence of risk factors does not change the management course or obstetric outcome in patients with IGU. Hence it is reasonable to start with conservative management of IGU regardless of presence of risk factors or the gestational age of diagnosis, in clinical practice.

A case of asymptomatic uterine incarceration in a patient undergoing dilation and evacuation

Uterine incarceration is a rare pregnancy complication that occurs when the uterine fundus becomes trapped beneath the sacral promontory. We present a case of incarceration in a patient seeking dilation and evacuation and a discussion of strategies for uterine reduction and cervical preparation.

Incarceration of the Gravid Uterus - a Rare Condition not to be Missed

BACKGROUND

Incarceration of a gravid uterus (IGU) is a rare manifestation in obstetrics that may be associated with serious complications.

CASE

We report on a 29-year-old patient at 34+2 weeks' gestation who presented with HELLP syndrome. IGU had been initially diagnosed in our department at 23+6 weeks' gestation. Urgent cesarean section was performed taking into account the specific characteristics of IGU. A healthy premature child was born. With the prior knowledge of IGU no complications during delivery occurred and mother and child had favorable outcomes.

CONCLUSION

IGU is a rare condition in pregnancy that should not be overlooked. Early diagnosis and treatment of IGU can prevent serious complications to the mother and child during pregnancy and delivery. In this report, we discuss the specific peculiarities of an incarcerated uterus that need to be considered in this regard.

HINTERGRUND

Ein Uterus incarceratus ist eine seltene Manifestation in der Geburtshilfe, welche mit schwerwiegenden Komplikationen einhergehen kann. FALL: Wir berichten über eine 29-jährige Patientin, die sich mit 34+2 Schwangerschaftswochen (SSW) mit einem HELLP-Syndrom in unserer Klinik vorgestellt hat. Die Erstdiagnose des inkarzerierten Uterus wurde in unserer Klinik mit 23+6 SSW gestellt. Aufgrund unserer Vorkenntnis über diese Diagnose konnte nun die dringend indizierte Sectio caesarea unter Berücksichtigung der spezifischen Merkmale in modifizierter Technik durchgeführt werden. Es wurde ein gesundes Frühgeborenes geboren. Es traten während der Geburt keine Komplikationen auf und Mutter und Kind hatten einen günstigen Verlauf.

SCHLUSSFOLGERUNG

Ein Uterus incarceratus ist eine seltene Manifestation in der Schwangerschaft, welche nicht übersehen werden sollte. Eine frühzeitige Diagnose und Behandlung kann schwerwiegende Komplikationen für Mutter und Kind während der Schwangerschaft und unter der Geburt verhindern. Wir diskutieren die spezifischen Besonderheiten eines Uterus incarceratus, die hierbei zu berücksichtigen sind.

Incarcerated Gravid Uterus in a Nulliparous Female Presenting With Urinary Hesitancy and Rectal Pressure: A Case Report

Incarcerated gravid uterus (IGU) is a rare condition that is associated with urinary obstruction, sepsis, peritonitis, and ultimately maternal death. IGU occurs when the retroverted uterus in a gravid patient becomes trapped in the pelvis during the second trimester. We present the case of a nulliparous female who came to our emergency department (ED) at 14 weeks and five days gestation with new onset intermittent urinary hesitancy and rectal pressure starting approximately 10 days prior to presentation. IGU was diagnosed based on pelvic examination and ultrasound in the ED. Emergency physicians should have a high index of suspicion for IGU in their differential diagnosis for pregnant females with urinary and rectal complaints. Point-of-care ultrasound (POCUS) should be used as an adjunct in identifying this condition.

Importance of the early diagnosis of incarcerated gravid uterus: Case report and systematic review

OBJECTIVE

To examine whether the early diagnosis of uterine incarceration before 20 weeks of gestation improves maternal-perinatal prognoses.

METHODS

A systematic review of all of the cases published in the past 30 years that met the inclusion and exclusion criteria was performed and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. A comparative analysis of diagnoses before and after 20 weeks of gestation was performed.

RESULTS

Eighty-nine studies with a total of 146 cases of uterine incarceration during pregnancy were included. For cases of incarceration diagnosed before 20 weeks of gestation, a higher proportion of clinical symptoms was observed; however, a lower proportion of complications, such as premature delivery, need for cesarean section, and poor perinatal outcomes, were observed (P < 0.05). The proportion of spontaneous resolution and minimally invasive techniques for the treatment of incarceration was significantly higher among patients diagnosed with this pathology before 20 weeks (P < 0.05).

CONCLUSION

The literature indicates that uterine incarceration is a rare complication during pregnancy with better maternal-perinatal results if diagnosed earlier than 20 weeks.

Abnormal uterine position during pregnancy secondary to abdominal surgery: Two case reports

RATIONALE

The umbilical cord is the way to exchange gas, supply nutrients, excrete metabolized. Thrombosis of the umbilical cord leads to fetal hypoxia, which jeopardizes fetal health and can cause fetal death. Umbilical vessel thrombosis, which is rarely reported, is difficult to detect prenatally.

PATIENT CONCERNS

Both individuals included in this study had a history of abdominal operation before pregnancy. The abnormal uterine position demonstrated in the first patient developed secondary to adhesions between the anterior bladder wall and lower segment of the uterus. As the uterus increased in size in proportion with the gestational age, the uterine body continued to enlarge even as the lower uterine segment remained fixed by the adhesions, which resulted in cervical displacement. In comparison, the abnormal uterine position in the second patient was due to a rare case of uterine incarceration developed.

DIAGNOSIS

Both cases were diagnosed as abnormal uterine position during pregnancy secondary to abdominal surgery.

INTERVENTIONS

The first patient underwent a cesarean section at 33 weeks and 5 days age of gestation for pregnancy complications. The second patient performed a cesarean section at 37 weeks age of gestation.

OUTCOMES

Due to reasonable treatment, the 2 cases achieved good maternal-infant outcomes.

CONCLUSION

Abnormal uterine position during pregnancy should be considered seriously, because it can affect the prognosis of the mother and child. When appropriate, a cesarean section is an effective method for terminating such pregnancies. During cesarean section, a longitudinal skin incision may be more beneficial in avoiding secondary injuries. However, the choice of uterine incision should be adjusted for each patient. Care should be given to prevent postpartum hemorrhage.

Urinary tract obstruction in the second trimester: a report of an incarcerated gravid uterus

Incarceration of the gravid uterus (IGU) is a rare obstetric disorder that may lead to pregnancy-related complications. Acute urinary retention (AUR) is one of the associated symptoms in IGU and it is mostly observed in the first semester and early second trimester. A case of a woman, in her 30s, is described, who presented AUR and lower abdominal pain in the early second trimester. The diagnosis was confirmed upon pelvic examination, and abdominal and transvaginal ultrasound. Management included long-term bladder catheterisation, manual reduction manoeuvres and passive positioning manoeuvres at home. At 24 weeks of gestation, the uterus returned in its correct polarity, the Foley catheter was removed and the patient was able to void spontaneously. A healthy infant was delivered vaginally at term.

No specific guidelines have been published for IGU treatment. However, prompt diagnosis and tight follow-up of these patients are essential to define strategies, reduce complications and prevent recurrences.

Incarcerated gravid uterus: A rare but potentially devastating obstetric complication

Incarceration of the gravid uterus is a rare obstetric complication characterized by entrapment of the gravid uterus between the sacral promontory and pubic symphysis. Clinical symptoms are highly variable and may include low back pain, urinary retention, and nausea. A presumptive diagnosis can often be established based on correlation of clinical history and physical examination. However, ultrasound and/or pelvic magnetic resonance imaging are essential for confirmation. Herein, we describe a 30-year-old female who presented with uterine incarceration and discuss the diagnosis, imaging features, and management of this uncommon but important clinical entity.

Incarceration of the Gravid Uterus: Proposal for a Shared Definition. Comment on Tachibana et al. Incarcerated Gravid Uterus: Spontaneous Resolution Is Not Rare. Diagnostics 2021, 11, 1544

We read with great interest the paper entitled “Incarcerated gravid uterus: spontaneous resolution is not rare” by Tachibana et al. [...]

Incarcerated Gravid Uterus: Spontaneous Resolution Is Not Rare

Aim: Incarcerated gravid uterus is a rare obstetrical complication that leads to adverse outcomes, especially if the uterus remains incarcerated and the condition goes undiagnosed until delivery. However, there is no consensus regarding the optimal management of this complication because of its rarity. In this study, we aimed to elucidate the incidence of incarcerated gravid uterus, as well as its natural courses and perinatal outcomes. Methods: We retrospectively reviewed medical records of patients who had incarcerated gravid uterus and managed at Osaka City University Hospital between April 2011 and March 2021. Incarcerated gravid uterus was defined as a retroverted or retroflexed uterus after 16 weeks of gestation. Results: There were 14 incarcerated cases among 6958 pregnant women, and 13 of them had some kind of gynecological complication and/or history. Spontaneous resolution of incarcerated gravid uterus after 16 gestational weeks was observed in six cases before the late second trimester and five cases at the late second trimester to early third trimester. Three cases remained incarcerated at term or near-term. One case with adenomyosis had severe abdominal pain, although it was difficult to ascertain whether the cause of pain was triggered by adenomyosis and/or incarceration. One case was misdiagnosed as placenta previa, and the uterine cervix was subsequently injured during cesarean delivery, resulting in massive hemorrhaging. Conclusions: Approximately 1 in 2300 pregnancies continued to be in an incarcerated condition at term or near-term, and 78.5% of cases showed a spontaneous resolution after 16 weeks of gestation. Expectant management with careful attention to the incarcerated gravid uterus may be one option in situations where there are no severe symptoms related to the incarceration itself.

[Incarceration of the Gravid Uterus in the Second Trimester - Diagnostics, Successful Therapy and Review of Literature]

A rare complication in obstetrics is the incarceration of the gravid uterus. If the uterus remains retroverted, the fundus persists in the pelvic cavity. Due to growth, the familiar anatomy of the uterus changes and undetected incarceration can lead to a serious maternal morbidity. Early treatment can enable a normal prolongation of pregnancy. In our case, we report a first gravida with initial diagnosis of a posterior sacculation of the uterus in the 21st week of pregnancy. After confirmed diagnosis by MRI, the reduction of the uterus by vaginal digital lifting of the uterus and simultaneous rectoscopic CO2 filling was successful. A spontaneous delivery without complications after rupture of membranes followed in the 35th week of pregnancy.

A case of uterine incarceration with unrecognized uterine torsion

Fetal imagers are tasked with diagnosing complex fetal anomalies, but maternal abnormalities that may impact the pregnancy are also of utmost importance to recognize and report. Two rare obstetrical complications are uterine incarceration and torsion which can lead to increased maternal/perinatal mortality. Uterine incarceration occurs secondary to a retroverted uterus that becomes retroflexed and entrapped within the pelvis during the first trimester of pregnancy. Uterine torsion is rotation of more than 45° around its long axis. We report a rare case of an incarcerated uterus with presumed spontaneous resolution on follow-up MRI that was ultimately recognized to be uterine torsion at the time of delivery. Knowledge of these entities may help aid in timely detection and diagnosis of complex imaging presentations and avoid downstream complications.