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Anterior uterine incarceration
International Journal of Gynecology & Obstetrics 57 (1997) 195-197
Brief communication
Anterior uterine incarceration E. Hirsch* Depamnent
of Obstetrics
and Gynecology,
Columbia New York,
University USA
College
of Physicians
and Surgeons,
Received 20 December 1996; revised 5 February 1997; accepted 21 February 1997
Keywords:
Uterus;
Complications
of pregnancy;
Incarceration
Uterine incarceration typically occurs at 12-20 weeks of gestation as a result of entrapment of the retrodisplaced uterus beneath the sacral promontory. The most common symptoms are pain and acute urinary obstruction caused by the anteriorly displaced cervix. We present here a case report of acute uterine incarceration in an anteverted, anteflexed gravid uterus - the first such case report of which we are aware. A 21-year-old gravida 3, para 0, was seen in the emergency room at 17 weeks’ gestation with severe, sharp, diffuse lower abdominal pain increasing in severity over the previous 7 h. While in the emergency room she vomited three times. Urinary and bowel function were normal. The prena-
*Corresponding author. Department necology, Columbia University College geons, 630 W. 168th St., Room 16-417, USA. Tel.: +l 212 3058693; fax: +l [email protected] 0020-7292/97/$17.00 PZZ SOO20-7292(97)
of Obstetrics and Gyof Physicians and SurNew York, NY 10032, 212 3053869; e-mail:
0 1997 International 02894-4
tal course had been unremarkable. The past history was significant only for one voluntary pregnancy termination, one spontaneous abortion and one hospitalization for pelvic inflammatory disease. The patient’s appearance prompted the emergency room physician to call for an urgent gynecological consultation to rule out an acute abdomen. She was pale and in severe discomfort. Her temperature was 98.6 “F, pulse 82 per minute and blood pressure 100/60 mmHg with no significant orthostatic changes. The abdomen was non-distended, the bowel sounds were hypoactive, and there was diffuse tenderness in the lower abdomen, most severe in the midline. There was no rebound tenderness. No mass was appreciated on abdominal examination. Pelvic examination revealed a sharply anteverted, anteflexed, non-mobile, tense and extremely tender uterus, which seemed to be impacted behind the symphysis pubis. The cervix was displaced high in the poste-
Federation of Gynecology and Obstetrics
196
E. Hirsch
/International
Journal
of Gynecology
rior vagina. The hematocrit was 36% and the white blood cell count was 18.2 x lo3 cells/pi. Urinalysis was normal. A genital culture was later reported positive for Chlamydia trachomatis. A urinary catheter was placed without difficulty, yielding 250 cm3 of clear urine. The patient’s discomfort was not affected by this maneuver. She was then administered 100 mg of meperidine hydrochloride intramuscularly with substantial improvement in her pain, although a repeat pelvic examination confirmed the physical findings and again demonstrated marked uterine tenderness. The uterus was reduced by rotating it posteriorly, using the cervix and uterine corpus as levers manipulated by the vaginal and abdominal hands, respectively. This resulted in immediate and nearly complete resolution of the patient’s pain and tenderness, leaving her with only vague, mild abdominal discomfort. The patient was admitted for continued observation. An ultrasound scan obtained a few hours after disimpaction demonstrated an anteverted uterus containing a normal 17-week gestation and no evidence of myomata. Approximately 15 h after admission she experienced an episode of vomiting and mild lower abdominal discomfort which resolved with analgesic agents and did not recur. She was discharged the following day. Treatment for Chlamydia was initiated. The patient subsequently had a vaginal delivery of a healthy term infant. She did not return for postpartum evaluation. Incarceration of the retroverted uterus is an uncommon but well-documented event. The complications of retroimpaction of the uterus include acute urinary retention, bowel malfunction, spontaneous abortion and posterior sacculation (outpouching of the anterior uterine wall to accommodate the growing fetus when the fundus is trapped in the posterior pelvis). The condition has been reported to occur in approximately 1 in 3000 pregnancies [l]. A hallmark of the condition, which has been suggested by some investigators as a criterion for diagnosis [1,2], is the resolution of symptoms coincident with treatment (manual reduction). Cehelsky and Mason [31 note that prior surgical ventral or vaginal fixation of the uterus may result
& Obstetrics
57 (1997) 195-197
in anterior sacculation (expansion of the posterior uterine wall to accommodate the pregnancy). They cite two cases of spontaneous anterior uterine sacculation at term reported in the German language literature from the 19th century. The cervix in each case was displaced high and posterior in the vagina, and in both of these labors the fetal head descended to the level of the introitus while covered with a layer of anterior uterine wall. In the case reported here, the differential diagnosis included adnexal torsion, degeneration or torsion of a myoma and acute appendicitis. However, the physical findings and immediate resolution following disimpaction suggest anterior uterine incarceration most strongly. The presence of restrictive adhesions, causing uterine fixation anteriorly as a result of the patient’s prior pregnancy termination or pelvic inflammatory disease, cannot be ruled out. Fig. 1 illustrates the speculated mechanism of anterior uterine incarceration of an anteflexed, anteverted uterine fundus en-
\
\b
-79
I I
--A-----
: \
Fig. 1. Proposed m&hanism of anterior uterine incarceration at 17 weeks’ gestation. Note the entrapped uterine fundus and the developing anterior sacculation (outpouching of the posterior uterine wall to accommodate the growing pregnancy).
E. Hirsch
/International
Journal
of Gynecology
trapped behind the symphysis pubis. A sacculation is developing to accommodate the growing fetus. It is possible that the pelvic discomfort common in the second trimester of pregnancy results in part from similar, self-limited episodes of the enlarging uterus negotiating the pelvis. References [I]
Gibbons Jr JM, Paley WB. The incarcerated gravid uterus.
& Obstetrics
57 (1997)
195-197
197
Obstet Gynecol 1969; 33: 842-845. [2] Silva PD, Berberich W. Retroverted impacted gravid uterus with acute urinary retention: report of two cases and a review of the literature. Obstet Gynecol 1986; 68: 121-123. 131 Cehelsky MR, Mason VC. Anterior sacculation of the pregnant uterus at tern. Am J Obstet Gynecol 1967; 99: 1000-1005.
Brief communication
Anterior uterine incarceration E. Hirsch* Depamnent
of Obstetrics
and Gynecology,
Columbia New York,
University USA
College
of Physicians
and Surgeons,
Received 20 December 1996; revised 5 February 1997; accepted 21 February 1997
Keywords:
Uterus;
Complications
of pregnancy;
Incarceration
Uterine incarceration typically occurs at 12-20 weeks of gestation as a result of entrapment of the retrodisplaced uterus beneath the sacral promontory. The most common symptoms are pain and acute urinary obstruction caused by the anteriorly displaced cervix. We present here a case report of acute uterine incarceration in an anteverted, anteflexed gravid uterus - the first such case report of which we are aware. A 21-year-old gravida 3, para 0, was seen in the emergency room at 17 weeks’ gestation with severe, sharp, diffuse lower abdominal pain increasing in severity over the previous 7 h. While in the emergency room she vomited three times. Urinary and bowel function were normal. The prena-
*Corresponding author. Department necology, Columbia University College geons, 630 W. 168th St., Room 16-417, USA. Tel.: +l 212 3058693; fax: +l [email protected] 0020-7292/97/$17.00 PZZ SOO20-7292(97)
of Obstetrics and Gyof Physicians and SurNew York, NY 10032, 212 3053869; e-mail:
0 1997 International 02894-4
tal course had been unremarkable. The past history was significant only for one voluntary pregnancy termination, one spontaneous abortion and one hospitalization for pelvic inflammatory disease. The patient’s appearance prompted the emergency room physician to call for an urgent gynecological consultation to rule out an acute abdomen. She was pale and in severe discomfort. Her temperature was 98.6 “F, pulse 82 per minute and blood pressure 100/60 mmHg with no significant orthostatic changes. The abdomen was non-distended, the bowel sounds were hypoactive, and there was diffuse tenderness in the lower abdomen, most severe in the midline. There was no rebound tenderness. No mass was appreciated on abdominal examination. Pelvic examination revealed a sharply anteverted, anteflexed, non-mobile, tense and extremely tender uterus, which seemed to be impacted behind the symphysis pubis. The cervix was displaced high in the poste-
Federation of Gynecology and Obstetrics
196
E. Hirsch
/International
Journal
of Gynecology
rior vagina. The hematocrit was 36% and the white blood cell count was 18.2 x lo3 cells/pi. Urinalysis was normal. A genital culture was later reported positive for Chlamydia trachomatis. A urinary catheter was placed without difficulty, yielding 250 cm3 of clear urine. The patient’s discomfort was not affected by this maneuver. She was then administered 100 mg of meperidine hydrochloride intramuscularly with substantial improvement in her pain, although a repeat pelvic examination confirmed the physical findings and again demonstrated marked uterine tenderness. The uterus was reduced by rotating it posteriorly, using the cervix and uterine corpus as levers manipulated by the vaginal and abdominal hands, respectively. This resulted in immediate and nearly complete resolution of the patient’s pain and tenderness, leaving her with only vague, mild abdominal discomfort. The patient was admitted for continued observation. An ultrasound scan obtained a few hours after disimpaction demonstrated an anteverted uterus containing a normal 17-week gestation and no evidence of myomata. Approximately 15 h after admission she experienced an episode of vomiting and mild lower abdominal discomfort which resolved with analgesic agents and did not recur. She was discharged the following day. Treatment for Chlamydia was initiated. The patient subsequently had a vaginal delivery of a healthy term infant. She did not return for postpartum evaluation. Incarceration of the retroverted uterus is an uncommon but well-documented event. The complications of retroimpaction of the uterus include acute urinary retention, bowel malfunction, spontaneous abortion and posterior sacculation (outpouching of the anterior uterine wall to accommodate the growing fetus when the fundus is trapped in the posterior pelvis). The condition has been reported to occur in approximately 1 in 3000 pregnancies [l]. A hallmark of the condition, which has been suggested by some investigators as a criterion for diagnosis [1,2], is the resolution of symptoms coincident with treatment (manual reduction). Cehelsky and Mason [31 note that prior surgical ventral or vaginal fixation of the uterus may result
& Obstetrics
57 (1997) 195-197
in anterior sacculation (expansion of the posterior uterine wall to accommodate the pregnancy). They cite two cases of spontaneous anterior uterine sacculation at term reported in the German language literature from the 19th century. The cervix in each case was displaced high and posterior in the vagina, and in both of these labors the fetal head descended to the level of the introitus while covered with a layer of anterior uterine wall. In the case reported here, the differential diagnosis included adnexal torsion, degeneration or torsion of a myoma and acute appendicitis. However, the physical findings and immediate resolution following disimpaction suggest anterior uterine incarceration most strongly. The presence of restrictive adhesions, causing uterine fixation anteriorly as a result of the patient’s prior pregnancy termination or pelvic inflammatory disease, cannot be ruled out. Fig. 1 illustrates the speculated mechanism of anterior uterine incarceration of an anteflexed, anteverted uterine fundus en-
\
\b
-79
I I
--A-----
: \
Fig. 1. Proposed m&hanism of anterior uterine incarceration at 17 weeks’ gestation. Note the entrapped uterine fundus and the developing anterior sacculation (outpouching of the posterior uterine wall to accommodate the growing pregnancy).
E. Hirsch
/International
Journal
of Gynecology
trapped behind the symphysis pubis. A sacculation is developing to accommodate the growing fetus. It is possible that the pelvic discomfort common in the second trimester of pregnancy results in part from similar, self-limited episodes of the enlarging uterus negotiating the pelvis. References [I]
Gibbons Jr JM, Paley WB. The incarcerated gravid uterus.
& Obstetrics
57 (1997)
195-197
197
Obstet Gynecol 1969; 33: 842-845. [2] Silva PD, Berberich W. Retroverted impacted gravid uterus with acute urinary retention: report of two cases and a review of the literature. Obstet Gynecol 1986; 68: 121-123. 131 Cehelsky MR, Mason VC. Anterior sacculation of the pregnant uterus at tern. Am J Obstet Gynecol 1967; 99: 1000-1005.