Incarcerated gravid uterus
- Alex C Vidaeff, MD, MPH
Alex C Vidaeff, MD, MPH
- Professor of Obstetrics and Gynecology
- Department of Obstetrics and Gynecology
- Baylor College of Medicine
- Karen M Schneider, MD
Karen M Schneider, MD
- Associate Professor
- Division of Gynecology and Obstetrics
- Department of Obstetrics and Gynecology
- Baylor College of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
The term incarcerated gravid uterus refers to a pregnant uterus that is entrapped in the pelvis between the sacral promontory and pubic symphysis (figure 1A-B). It has been reported to occur in 1 in 3000 to 10,000 pregnancies .
In very early pregnancy, the uterus is retroverted (retroflexed) in up to 20 percent of women . As the uterus enlarges during the first trimester, the fundus normally rises from the hollow of the sacrum to an anterior ventral position, spontaneously correcting any retroversion. In rare cases, however, the fundus becomes wedged below the sacral promontory, where it continues to enlarge . Concomitantly, the cervix becomes displaced cephalad against or above the symphysis pubis and pushes against the urethra and bladder, which interferes with normal voiding.
Eventually, the posterior pelvis becomes too small to accommodate the increasing size of the fundus; this typically occurs when the pregnancy progresses beyond 20 weeks of gestation. At this point, the anterior lower uterine wall begins to thin and balloon into the upper abdomen, developing a sacculation . This is termed "inverted polarity" because the anterior lower uterine wall becomes cephalad to the fundus, which is posterior-caudal. Concomitantly, both the bladder and the cervix are pulled up into the abdominal cavity, towards the umbilicus. The cervix can stretch to 10 cm or more in length, such that the internal os becomes located above the symphysis pubis, and occasionally above the bladder .
Conditions that may inhibit the fundus of the enlarging uterus from ascending out of the sacral hollow include: adhesions related to previous pelvic surgery, pelvic inflammatory disease, or endometriosis; large fibroids; uterine malformation; or a deep sacral concavity with an overhanging promontory and/or laxity of the supporting tissues [4,6]. Incarceration can also occur in the absence of predisposing factors, but this is uncommon [7,8].
Patient presentation — Typically, the patient presents at 14 to 16 weeks of gestation with symptoms, often vague, related to pressure on the anatomic structures adjacent to the entrapped enlarging uterus. The most common symptoms are pain and progressive difficulty voiding. The pain may be abdominal, suprapubic, or in the back; or may be limited to pelvic discomfort or a feeling of pelvic fullness. Urinary symptoms include frequency, dysuria, sensation of incomplete emptying, dribbling small volumes due to overflow incontinence, and, often, urinary retention. Gastrointestinal symptoms such as rectal pressure, tenesmus, and worsening constipation may occur due to compression of the rectum [4,6]. Vaginal bleeding has also been described. Symptoms can be intermittent, resolving for a period of time and then returning weeks later.
- van Beekhuizen HJ, Bodewes HW, Tepe EM, et al. Role of magnetic resonance imaging in the diagnosis of incarceration of the gravid uterus. Obstet Gynecol 2003; 102:1134.
- Feusner AH, Mueller PD. Incarceration of a gravid fibroid uterus. Ann Emerg Med 1997; 30:821.
- Gibbons JM Jr, Paley WB. The incarcerated gravid uterus. Obstet Gynecol 1969; 33:842.
- Jacobsson B, Wide-Swensson D. Incarceration of the retroverted gravid uterus--a review. Acta Obstet Gynecol Scand 1999; 78:665.
- Gottschalk EM, Siedentopf JP, Schoenborn I, et al. Prenatal sonographic and MRI findings in a pregnancy complicated by uterine sacculation: case report and review of the literature. Ultrasound Obstet Gynecol 2008; 32:582.
- Lettieri L, Rodis JF, McLean DA, et al. Incarceration of the gravid uterus. Obstet Gynecol Surv 1994; 49:642.
- Singh MN, Payappagoudar J, Lo J, Prashar S. Incarcerated retroverted uterus in the third trimester complicated by postpartum pulmonary embolism. Obstet Gynecol 2007; 109:498.
- O'Connell MP, Ivory CM, Hunter RW. Incarcerated retroverted uterus--a non recurring complication of pregnancy. J Obstet Gynaecol 1999; 19:84.
- Van Winter JT, Ogburn PL Jr, Ney JA, Hetzel DJ. Uterine incarceration during the third trimester: a rare complication of pregnancy. Mayo Clin Proc 1991; 66:608.
- Renaud MC, Bazin S, Blanchet P. Asymptomatic uterine incarceration at term. Obstet Gynecol 1996; 88:721.
- Matsushita H, Kurabayashi T, Higashino M, et al. Incarceration of the retroverted uterus at term gestation. Am J Perinatol 2004; 21:387.
- Al Wadi K, Helewa M, Sabeski L. Asymptomatic uterine incarceration at term: a rare complication of pregnancy. J Obstet Gynaecol Can 2011; 33:729.
- Haylen BT, Cerqui AJ. Postpartum uterine retroversion causing bladder outflow obstruction: cure by laparoscopic ventrosuspension. Int Urogynecol J Pelvic Floor Dysfunct 1999; 10:353.
- Gardner CS, Jaffe TA, Hertzberg BS, et al. The incarcerated uterus: a review of MRI and ultrasound imaging appearances. AJR Am J Roentgenol 2013; 201:223.
- Fernandes DD, Sadow CA, Economy KE, Benson CB. Sonographic and magnetic resonance imaging findings in uterine incarceration. J Ultrasound Med 2012; 31:645.
- Dierickx I, Van Holsbeke C, Mesens T, et al. Colonoscopy-assisted reposition of the incarcerated uterus in mid-pregnancy: a report of four cases and a literature review. Eur J Obstet Gynecol Reprod Biol 2011; 158:153.
- Gottschalk S. Zur Lehre von der Retroversio uteri gravidi. Arch Gynecol Obstet 1894; 46:358.
- Newell SD, Crofts JF, Grant SR. The incarcerated gravid uterus: complications and lessons learned. Obstet Gynecol 2014; 123:423.
- Hachisuga N, Hidaka N, Fujita Y, et al. Significance of pelvic magnetic resonance imaging in preoperative diagnosis of incarcerated retroverted gravid uterus with a large anterior leiomyoma: a case report. J Reprod Med 2012; 57:77.
- Gerscovich EO, Maslen L. The retroverted incarcerated uterus in pregnancy: imagers beware. J Ultrasound Med 2009; 28:1425.
- Hess LW, Nolan TE, Martin RW, et al. Incarceration of the retroverted gravid uterus: report of four patients managed with uterine reduction. South Med J 1989; 82:310.
- Algra LJ, Fogel ST, Norris MC. Anesthesia for reduction of uterine incarceration: report of two cases. Int J Obstet Anesth 1999; 8:142.
- Grossenburg NJ, Delaney AA, Berg TG. Treatment of a late second-trimester incarcerated uterus using ultrasound-guided manual reduction. Obstet Gynecol 2011; 118:436.
- Seubert DE, Puder KS, Goldmeier P, Gonik B. Colonoscopic release of the incarcerated gravid uterus. Obstet Gynecol 1999; 94:792.
- Takami M, Hasegawa Y, Seki K, et al. Spontaneous reduction of an incarcerated gravid uterus in the third trimester. Clin Case Rep 2016; 4:605.
- Lacoste CR, Seffert P, Chauleur C. [Acute urinary retention and retroverted uterus during pregnancy]. Gynecol Obstet Fertil 2013; 41:265.
- Hamoda H, Chamberlain PF, Moore NR, Mackenzie IZ. Conservative treatment of an incarcerated gravid uterus. BJOG 2002; 109:1074.
- van der Tuuk K, Krenning RA, Krenning G, Monincx WM. Recurrent incarceration of the retroverted gravid uterus at term - two times transvaginal caesarean section: a case report. J Med Case Rep 2009; 3:103.
- RISK FACTORS
- CLINICAL FEATURES
- Patient presentation
- Physical examination
- - Ultrasound examination
- - Magnetic resonance imaging
- Differential diagnosis
- Incarceration before 20 weeks of gestation
- - Passive reduction
- - Manual reduction
- - Colonoscopic reduction
- - Laparoscopic reduction
- - Laparotomy
- - Post-reduction care
- Incarceration after 20 weeks of gestation
- RECURRENCE RISK
- SUMMARY AND RECOMMENDATIONS