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Incarceration of a Gravid Fibroid Uterus
CASE REPORT
Incarceration of a Gravid Fibroid Uterus From the Department of Emergency Medicine, Orlando Regional Medical Center, Orlando,° and the Department of Surgery, University of Florida, Gainesville, FL.~
Amanda H Feusner, MD* Paula O Mueller, MD *~
Receivedfor publication October 21, 1996. Revision received May 14, 1997. Accepted for publication June 4, 1997.
The case of an incarcerated gravid fibroid uterus in a 32-year-old woman is presented. This rare complication of pregnancy is readily identified by specific symptoms, physical examination, and ultrasound findings. If the condition is undiagnosed and untreated, spontaneous abortion and preterm labor often occur.
[Feusner AH, Mueller PA: Incarceration of a gravid fibroid uterus. Ann ErnergMod December 1997;30:821-824.]
Copyright © by the American College of Emergency Physicians.
INTRODUCTION Uterine incarceration is a rare complication of pregnancy, occurring in 1 of 3,000 cases. ~ As a patient enters the 13th week of gestation, her uterus must pass between the subpromontory sacral prominence and the pubis. If the uterus is retroverted or retroflexed, as in 15% to 25% of pregnancies, it can become entrapped in the pelvis while continuing to enlarge. Incarceration can lead to compromise of uterine blood flow, as well as symptoms related to pressure on adjacent pelvic organs. Patients m o s t often present with pain, vaginal bleeding, and urinary tract symptoms. Without diagnosis and treatment, these patients face a higher rate of spontaneous abortion and other complications. It is therefore important for emergency physicians to recognize this condition and ensure timely treatment.
CASE REPORT A 32-year-old woman, gravida 2, para 0-0-1-0 (0 deliveries, 0 premature deliveries, 1 abortion, 0 living children), at 14 weeks' gestation, presented with a 3-day history of intermittent, crampy, lower abdominal pain. She denied fever, vaginal bleeding, dysuria, and urinary retention. She was taking no medications. Past medical history was significant for a fibroid uterus and an elective first-trimester abortion 6 years previously complicated by infection. She had not yet received any prenatal care. The vital signs were as follows: blood pressure, 101/42 mm Hg; pulse, 74; respirations, 18; and temperature, 37.3 ° C. Fetal heart rate was 160 beats/minute by Doppler ultrasound
DECEMBER 1997 30:6
ANNALS OF EMERGENCY MEDICINE
82 1
INCARCERATION OF UTERUS
Feusner& Mueller
measurement in the right lower quadrant. The abdominal examination was remarkable for tenderness at and below the umbilicus. The cervix could not be visualized on speculum examination but was palpated anteriorly, adjacent to the symphysis pubis, on bimanual examination. The uterus was retroverted and a full, firm mass was palpable in the cul de sac. Urinalysis was negative. Vaginal fluid prepared by wet mount revealed trichomonads. CBC results were unremarkable. Transabdominal ultrasound examination revealed a 15-week viable fetus and a 10-cm fundal fibroid. The majority of the uterus, except for the fibroid, appeared to be contained within the pelvis. The cervix and the bladder were not visualized (the patient refused Foley catheterization). Obstetric/gynecologic consultation was requested because of the patient's persistent abdominal pain, and the presumptive diagnosis of uterine incarceration was made. The patient was premedicated with 10 mg of intravenous morphine sulfate and placed in the knee-chest position. Her incarcerated uterus was reduced transvaginally with manual pressure on the fundus through the posterior fornix. The patient reported instant pain relief after the procedure. She was treated for trichomoniasis, and high-risk obstetric follow-up was arranged. DISCUSSION
As the uterus enlarges and becomes an intraabdominal organ in approximately the 12th week of gestation, it must pass Figure 1.
between the subpromontory sacrum and the pubis. Predisposing factors leading to entrapment include adhesions from prior surgery, endometriosis, pelvic inflammatory disease, leiomyomata, bicornuate uterus, and deep sacral concavity with prominent sacral overhang. >4 Uterine leiomyomata, occurring in 20% to 30% of women older than 30 years of age, are also reported to cause uterine incarceration in nongravid women. 2,5 In most pregnant patients uterine retroversion spontaneously corrects as the uterine fundus rises out of the penis and falls forward at the 12th week of gestation. However, in some patients this does not occur, and the result is uterine incarceration. Typically these patients present at 12 to 15 weeks' gestation with obstetric/gynecologic, urinary tract, or gastrointestinal complaints related to increased pressure on the anatomic structures adjacent to the enlarging uterus (Figures 1 and 2). Obstetric/gynecologic complaints include pelvic discomfort and lower abdominal or back pain. Compromised uterine circulation may lead to decidual bleeding and spontaneous abortion. 6 Urinary symptoms include dysuria, frequency, urinary retention, overflow incontinence, and urinary stasis leading to cystitis. 1,3,4.6,r These symptoms are caused by the marked anterior displacement of the cervix adjacent to the pubic symphysis. Obstruction, bilateral hydronephrosis, and bladder rupture can also result. 3,s Gastrointestinal symptoms include rectal pressure, tenesmus, and progresFigure 2.
Normal positions of uterus, bladder, cervix, rectum, spine, pubic s y m p h y s i s ~ . . . .
Abnormal positions of retroverted, retroflexed uterus, elongated cervix, displaced bladder, compressed rectum, spine, pubic symphysis.
Uterus
Bladder-~~
~)~J~
"m*'/"
0///i/¢,
Pubio
822
. 4"%
J -7-
/7"--._/
"°°'um
Bladder
Cervix
eab,o 4 - X \ ' I f
symphysis I \
Ii ail
lflV/Z/Z
// - 7 s,..e
'Jg/// 7"/"---/
ANNALS OF EMERGENCY MEDIC]NE
30:6
DECEMBER 1997
INCARCERATION OF UTERUS Feusner ~ MuelIer
sive constipation. Gangrene of the colon resulting in death has occurred. 3 If undiagnosed, incarceration may spontaneously resolve, but more often a portion of the uterus remains in the pelvis while the remainder enlarges and extends into the abdomen. Anterior uterine wall thinning or "sacculation" occurs and can lead to preterm labor, premature rupture of fetal membranes, or uterine rupture during labor. 9,1° Inadvertent incision into an elongated cervix or bladder because of distorted anatomy has occurred during cesarean section when incarceration was not recognized. 3,8 Physical examination of the patient with an incarcerated uterus produces characteristic findings. Abdominal examination may reveal a distended bladder. Pundal height is usually less Lhan expected for gestational age unless sacculation or a fibroid is present. The cervix is displaced anteriorly and typically is not visible on speculum examination. On bimanual examination, the retroverted uterus is palpable as a large, round mass in the cul de sac. Petal heart tones may be difficult to auscultate. 3 Characteristic ultrasound findings of uterine incarceration are recognized but can be misinterpreted if the clinical diagnosis is not entertained. The uterus is displaced posteriorly, with the fundus positioned in the cul de sac. A fundal placenta may appear to be a placenta previa. 3,tl The very anterior location of the cervix, whether diagnosed by ultrasound or by pelvic examination, is the most consistent clinical finding of incarcerated uterus. The bladder is displaced superior and anterior to the uterus rather than in its normal position anterior to the cervix. 5 Because of anLerior displacement and folding over of the nonexpanded lower uterine segment, a central cavity echo between the bladder and the products of conception may be seen. 5,1x This may lead to a misdiagnosis of ectopic pregnancy. As gestational age increases beyond 20 weeks, both the bladder and the cervix become thin and elongated and extend into the abdominal cavity, x2,13 At term, ultrasound has been helpful in diagnosing incarceration in breech pregnancies that had appeared to be vertex presentations with failure to progress, xx Reduction of uterine incarceration between 14 and 20 weeks' gestation can be accomplished by a variety of techniques. Reduction should be performed by or at least in close consultation with an obstetrician. Before manipulation begins, the bladder should be emptied. After adequate analgesia is provided, manual manipulation should be attempted with the patient in the dorsal lithotomy position in stirrups, using gentle pressure on the fundus with two fingers in the posterior fornix. 3 Pressure should be applied in a cephalad direction. Alternatively, a finger placed in the rectum may
DECEMBER 1997
30:6
ANNALS OF EMERGENCY MEDICINE
provide more pressure on the uterine fundus. If this is unsuccessful, the maneuver may be repeated with the patient in the knee-chest (Sims) position. 3,7,>~ Countertraction with a tenaculum or sponge forceps applied to the posterior cervical lip may be helpful. If these maneuvers fail and the patient has only mild symptoms, the patient may be discharged home with very dose obstetric follow-up. The more symptomatic patient should be admitted for ultrasoundguided manual reduction or laparoscopic-guided reduction under general anesthesia. If all else fails, a laparotomy should be performed. Vaginal packing or pessary placement after uterine reduction is recommended to help maintain anteversion of the uterus until it achieves sufficient size to maintain itself outside the pelvis. 3,~ Attempts at uterine reduction beyond 20 weeks' gestation are not recommended unless the patient has significant symptoms. Serial ultrasound examinations are recommended because of the potential for fetal growth retardation and oligohydramnios caused by restricted uterine volume. Close monitoring for preterm labor and premature rupture of membranes is necessary 3 A previous successful vaginal delivery does not preclude the possibility of uterine incarceration in subsequent pregnancies. Suggested preventive measures include knee-chest exercises, a repeat pelvic examination at l~r weeks' gestation to ensure that the uterus has ascended into the abdominal cavity, early vaginal pessary placement as indicated to maintain the uterus in anteversion, and uterine suspension to restore the uterus to an anteverted position. 3,9,M Prompt recognition and treatment of uterine incarceration in pregnancy is an important skill for an emergency physician. It is important to consider this rare diagnosis when treating the many pregnant patients who present to Lhe ED with symptoms of pelvic pain, dysuria, or vaginal bleeding. REFERENCES 1. Gibbons JM, Paloy WB: The incarcerated gravid uterus. ObstetGynecolt969;33:842-845. 2. Wittich AC, Polzin W J, Thomas CS: Incarceration of the gravid uterus due to an impacted leiomyoma: A case report. Mit Med 1994;159:583-584. 3. Lettied L, Rodis J, McLean DA, et ah incarceration of the gravid uterus. ObstetGynecolSurv 1994;49:642-848. 4. Smalbraak I, Bleker O, Schutte MF, et ah Incarceration of the retroverted gravid uterus: A report of four cases. EurJ ObstetGyneco/ReprodBie11991;39:151-155. 5. Hankins DV, Ceders Mh Uterine incarceration associated with uterine leiomyomata: Clinical and sonographic presentation. J CfinUhrasound1989;17:385-388. 6. Myers L, Scotti RJ: Acute urinary retention and the incarcerated, retroverted gravid uterus: A case report. J ReprodMed 1995;40:487-489. 7. Nelson M: Acute urinary retention secondary to an incarcerated gravid uterus. Am J Emerg Med 1986;4:231-232. 8. Keating PJ, Walton SM, Maouris P: Incarceration of a bicereuate retroverted gravid uterus presenting with bilateral ureteric obstruction. Br J ObstetGynaecel1992;99:345-347.
823
INCARCERATION OF UTERUS Feusner & Mueller
9. EvansAJ, Anthony J, Masson GM: Incarceration of the retroverted gravid uterus at term. BrJ ObstetGynaecel1986;93:883-885. 10. Weekes ARL, Atlay RD, Brown VA, at al: The retroverted gravid uterus and its effect on the outcome of pregnancy. Br Med J 1£76;1:622-624. 11. Van Winter JT, Ogburn P, Ney JA, et al: Uterine incarceration during the third trimester: A rare complication of pregnancy. Mayo CtinProc1991;68:608-613.
Reprint no. 47/1/86005 Address for reprints: Paula D Mueller, MD Department of Emergency Medicine 0rlando Regional Medical Center
12. Laing FC: Sonographyof a persistently retrevertedgravid uterus.Am J Raflio11981;136:413-414.
1414 South Orange Avenue
13. EmeryO, Nolan R: Ultrasonography of an incarcerated uterus during pregnancy. CanAssac RadialJ 1994;45:397-398.
Orlando, FL 32806
14. Hess LW, Nolan TE, Martin RW, et al: Incarceration of the retroverted gravid uterus: Report of 4 patients managedwith uterine reduction. SouthMedJ 1989;82:310-312.
824
407-237-6329
ANNALS OF EMERGENCY MEDICINE
30:6
DECEMBER1997
Incarceration of a Gravid Fibroid Uterus From the Department of Emergency Medicine, Orlando Regional Medical Center, Orlando,° and the Department of Surgery, University of Florida, Gainesville, FL.~
Amanda H Feusner, MD* Paula O Mueller, MD *~
Receivedfor publication October 21, 1996. Revision received May 14, 1997. Accepted for publication June 4, 1997.
The case of an incarcerated gravid fibroid uterus in a 32-year-old woman is presented. This rare complication of pregnancy is readily identified by specific symptoms, physical examination, and ultrasound findings. If the condition is undiagnosed and untreated, spontaneous abortion and preterm labor often occur.
[Feusner AH, Mueller PA: Incarceration of a gravid fibroid uterus. Ann ErnergMod December 1997;30:821-824.]
Copyright © by the American College of Emergency Physicians.
INTRODUCTION Uterine incarceration is a rare complication of pregnancy, occurring in 1 of 3,000 cases. ~ As a patient enters the 13th week of gestation, her uterus must pass between the subpromontory sacral prominence and the pubis. If the uterus is retroverted or retroflexed, as in 15% to 25% of pregnancies, it can become entrapped in the pelvis while continuing to enlarge. Incarceration can lead to compromise of uterine blood flow, as well as symptoms related to pressure on adjacent pelvic organs. Patients m o s t often present with pain, vaginal bleeding, and urinary tract symptoms. Without diagnosis and treatment, these patients face a higher rate of spontaneous abortion and other complications. It is therefore important for emergency physicians to recognize this condition and ensure timely treatment.
CASE REPORT A 32-year-old woman, gravida 2, para 0-0-1-0 (0 deliveries, 0 premature deliveries, 1 abortion, 0 living children), at 14 weeks' gestation, presented with a 3-day history of intermittent, crampy, lower abdominal pain. She denied fever, vaginal bleeding, dysuria, and urinary retention. She was taking no medications. Past medical history was significant for a fibroid uterus and an elective first-trimester abortion 6 years previously complicated by infection. She had not yet received any prenatal care. The vital signs were as follows: blood pressure, 101/42 mm Hg; pulse, 74; respirations, 18; and temperature, 37.3 ° C. Fetal heart rate was 160 beats/minute by Doppler ultrasound
DECEMBER 1997 30:6
ANNALS OF EMERGENCY MEDICINE
82 1
INCARCERATION OF UTERUS
Feusner& Mueller
measurement in the right lower quadrant. The abdominal examination was remarkable for tenderness at and below the umbilicus. The cervix could not be visualized on speculum examination but was palpated anteriorly, adjacent to the symphysis pubis, on bimanual examination. The uterus was retroverted and a full, firm mass was palpable in the cul de sac. Urinalysis was negative. Vaginal fluid prepared by wet mount revealed trichomonads. CBC results were unremarkable. Transabdominal ultrasound examination revealed a 15-week viable fetus and a 10-cm fundal fibroid. The majority of the uterus, except for the fibroid, appeared to be contained within the pelvis. The cervix and the bladder were not visualized (the patient refused Foley catheterization). Obstetric/gynecologic consultation was requested because of the patient's persistent abdominal pain, and the presumptive diagnosis of uterine incarceration was made. The patient was premedicated with 10 mg of intravenous morphine sulfate and placed in the knee-chest position. Her incarcerated uterus was reduced transvaginally with manual pressure on the fundus through the posterior fornix. The patient reported instant pain relief after the procedure. She was treated for trichomoniasis, and high-risk obstetric follow-up was arranged. DISCUSSION
As the uterus enlarges and becomes an intraabdominal organ in approximately the 12th week of gestation, it must pass Figure 1.
between the subpromontory sacrum and the pubis. Predisposing factors leading to entrapment include adhesions from prior surgery, endometriosis, pelvic inflammatory disease, leiomyomata, bicornuate uterus, and deep sacral concavity with prominent sacral overhang. >4 Uterine leiomyomata, occurring in 20% to 30% of women older than 30 years of age, are also reported to cause uterine incarceration in nongravid women. 2,5 In most pregnant patients uterine retroversion spontaneously corrects as the uterine fundus rises out of the penis and falls forward at the 12th week of gestation. However, in some patients this does not occur, and the result is uterine incarceration. Typically these patients present at 12 to 15 weeks' gestation with obstetric/gynecologic, urinary tract, or gastrointestinal complaints related to increased pressure on the anatomic structures adjacent to the enlarging uterus (Figures 1 and 2). Obstetric/gynecologic complaints include pelvic discomfort and lower abdominal or back pain. Compromised uterine circulation may lead to decidual bleeding and spontaneous abortion. 6 Urinary symptoms include dysuria, frequency, urinary retention, overflow incontinence, and urinary stasis leading to cystitis. 1,3,4.6,r These symptoms are caused by the marked anterior displacement of the cervix adjacent to the pubic symphysis. Obstruction, bilateral hydronephrosis, and bladder rupture can also result. 3,s Gastrointestinal symptoms include rectal pressure, tenesmus, and progresFigure 2.
Normal positions of uterus, bladder, cervix, rectum, spine, pubic s y m p h y s i s ~ . . . .
Abnormal positions of retroverted, retroflexed uterus, elongated cervix, displaced bladder, compressed rectum, spine, pubic symphysis.
Uterus
Bladder-~~
~)~J~
"m*'/"
0///i/¢,
Pubio
822
. 4"%
J -7-
/7"--._/
"°°'um
Bladder
Cervix
eab,o 4 - X \ ' I f
symphysis I \
Ii ail
lflV/Z/Z
// - 7 s,..e
'Jg/// 7"/"---/
ANNALS OF EMERGENCY MEDIC]NE
30:6
DECEMBER 1997
INCARCERATION OF UTERUS Feusner ~ MuelIer
sive constipation. Gangrene of the colon resulting in death has occurred. 3 If undiagnosed, incarceration may spontaneously resolve, but more often a portion of the uterus remains in the pelvis while the remainder enlarges and extends into the abdomen. Anterior uterine wall thinning or "sacculation" occurs and can lead to preterm labor, premature rupture of fetal membranes, or uterine rupture during labor. 9,1° Inadvertent incision into an elongated cervix or bladder because of distorted anatomy has occurred during cesarean section when incarceration was not recognized. 3,8 Physical examination of the patient with an incarcerated uterus produces characteristic findings. Abdominal examination may reveal a distended bladder. Pundal height is usually less Lhan expected for gestational age unless sacculation or a fibroid is present. The cervix is displaced anteriorly and typically is not visible on speculum examination. On bimanual examination, the retroverted uterus is palpable as a large, round mass in the cul de sac. Petal heart tones may be difficult to auscultate. 3 Characteristic ultrasound findings of uterine incarceration are recognized but can be misinterpreted if the clinical diagnosis is not entertained. The uterus is displaced posteriorly, with the fundus positioned in the cul de sac. A fundal placenta may appear to be a placenta previa. 3,tl The very anterior location of the cervix, whether diagnosed by ultrasound or by pelvic examination, is the most consistent clinical finding of incarcerated uterus. The bladder is displaced superior and anterior to the uterus rather than in its normal position anterior to the cervix. 5 Because of anLerior displacement and folding over of the nonexpanded lower uterine segment, a central cavity echo between the bladder and the products of conception may be seen. 5,1x This may lead to a misdiagnosis of ectopic pregnancy. As gestational age increases beyond 20 weeks, both the bladder and the cervix become thin and elongated and extend into the abdominal cavity, x2,13 At term, ultrasound has been helpful in diagnosing incarceration in breech pregnancies that had appeared to be vertex presentations with failure to progress, xx Reduction of uterine incarceration between 14 and 20 weeks' gestation can be accomplished by a variety of techniques. Reduction should be performed by or at least in close consultation with an obstetrician. Before manipulation begins, the bladder should be emptied. After adequate analgesia is provided, manual manipulation should be attempted with the patient in the dorsal lithotomy position in stirrups, using gentle pressure on the fundus with two fingers in the posterior fornix. 3 Pressure should be applied in a cephalad direction. Alternatively, a finger placed in the rectum may
DECEMBER 1997
30:6
ANNALS OF EMERGENCY MEDICINE
provide more pressure on the uterine fundus. If this is unsuccessful, the maneuver may be repeated with the patient in the knee-chest (Sims) position. 3,7,>~ Countertraction with a tenaculum or sponge forceps applied to the posterior cervical lip may be helpful. If these maneuvers fail and the patient has only mild symptoms, the patient may be discharged home with very dose obstetric follow-up. The more symptomatic patient should be admitted for ultrasoundguided manual reduction or laparoscopic-guided reduction under general anesthesia. If all else fails, a laparotomy should be performed. Vaginal packing or pessary placement after uterine reduction is recommended to help maintain anteversion of the uterus until it achieves sufficient size to maintain itself outside the pelvis. 3,~ Attempts at uterine reduction beyond 20 weeks' gestation are not recommended unless the patient has significant symptoms. Serial ultrasound examinations are recommended because of the potential for fetal growth retardation and oligohydramnios caused by restricted uterine volume. Close monitoring for preterm labor and premature rupture of membranes is necessary 3 A previous successful vaginal delivery does not preclude the possibility of uterine incarceration in subsequent pregnancies. Suggested preventive measures include knee-chest exercises, a repeat pelvic examination at l~r weeks' gestation to ensure that the uterus has ascended into the abdominal cavity, early vaginal pessary placement as indicated to maintain the uterus in anteversion, and uterine suspension to restore the uterus to an anteverted position. 3,9,M Prompt recognition and treatment of uterine incarceration in pregnancy is an important skill for an emergency physician. It is important to consider this rare diagnosis when treating the many pregnant patients who present to Lhe ED with symptoms of pelvic pain, dysuria, or vaginal bleeding. REFERENCES 1. Gibbons JM, Paloy WB: The incarcerated gravid uterus. ObstetGynecolt969;33:842-845. 2. Wittich AC, Polzin W J, Thomas CS: Incarceration of the gravid uterus due to an impacted leiomyoma: A case report. Mit Med 1994;159:583-584. 3. Lettied L, Rodis J, McLean DA, et ah incarceration of the gravid uterus. ObstetGynecolSurv 1994;49:642-848. 4. Smalbraak I, Bleker O, Schutte MF, et ah Incarceration of the retroverted gravid uterus: A report of four cases. EurJ ObstetGyneco/ReprodBie11991;39:151-155. 5. Hankins DV, Ceders Mh Uterine incarceration associated with uterine leiomyomata: Clinical and sonographic presentation. J CfinUhrasound1989;17:385-388. 6. Myers L, Scotti RJ: Acute urinary retention and the incarcerated, retroverted gravid uterus: A case report. J ReprodMed 1995;40:487-489. 7. Nelson M: Acute urinary retention secondary to an incarcerated gravid uterus. Am J Emerg Med 1986;4:231-232. 8. Keating PJ, Walton SM, Maouris P: Incarceration of a bicereuate retroverted gravid uterus presenting with bilateral ureteric obstruction. Br J ObstetGynaecel1992;99:345-347.
823
INCARCERATION OF UTERUS Feusner & Mueller
9. EvansAJ, Anthony J, Masson GM: Incarceration of the retroverted gravid uterus at term. BrJ ObstetGynaecel1986;93:883-885. 10. Weekes ARL, Atlay RD, Brown VA, at al: The retroverted gravid uterus and its effect on the outcome of pregnancy. Br Med J 1£76;1:622-624. 11. Van Winter JT, Ogburn P, Ney JA, et al: Uterine incarceration during the third trimester: A rare complication of pregnancy. Mayo CtinProc1991;68:608-613.
Reprint no. 47/1/86005 Address for reprints: Paula D Mueller, MD Department of Emergency Medicine 0rlando Regional Medical Center
12. Laing FC: Sonographyof a persistently retrevertedgravid uterus.Am J Raflio11981;136:413-414.
1414 South Orange Avenue
13. EmeryO, Nolan R: Ultrasonography of an incarcerated uterus during pregnancy. CanAssac RadialJ 1994;45:397-398.
Orlando, FL 32806
14. Hess LW, Nolan TE, Martin RW, et al: Incarceration of the retroverted gravid uterus: Report of 4 patients managedwith uterine reduction. SouthMedJ 1989;82:310-312.
824
407-237-6329
ANNALS OF EMERGENCY MEDICINE
30:6
DECEMBER1997