Incarcerated uterus: Difference between revisions

Line 51: Line 51:
*ABC’s and Resuscitation if necessary
*ABC’s and Resuscitation if necessary
*2 large bore IVs
*2 large bore IVs
*Labs
**Urine pregnancy
**Beta-HCG
**Stat Hematocrit
**CBC with differential
**BMP, Mg/Phos
**LFT
**UA/Urine Culture
**PTT/PT/INR
**HIV
**Type and cross 2 units PRBC if bleeding concern
*Imaging
**Transvaginal Ultrasound
**Non-emergent MRI if unable to obtain transvaginal ultrasound
**Consider Post-void residual


===Labs===
*Urine pregnancy
*Beta-HCG
*Stat Hematocrit
*CBC with differential
*BMP, Mg/Phos
*LFT
*UA/Urine Culture
*PTT/PT/INR
*HIV
*Type and cross 2 units PRBC if bleeding concern
===Imaging===
*Transvaginal Ultrasound
*Non-emergent MRI if unable to obtain transvaginal ultrasound
*Consider Post-void residual


==Management==
==Management==

Revision as of 17:05, 4 October 2016

Background

  • Retroverted uterus is a normal variant (up to 20% of the population).
  • During pregnancy, a retroverted uterus spontaneously flips to become anteverted at 14-16 weeks gestation age.
  • Incarcerated uterus = impregnated retroverted uterus that is unable to spontaneously revert because the fundus is wedged below the sacral promontory.
  • Growth of uterus during pregnancy in retroverted position leads to compression of pelvic organs leading to symptomatology.

Clinical Features

History

  • Occurs only during pregnancy
  • Symptomatology is the result of compression of pelvic structures from enlarging uterus
  • Urinary Symptoms
    • Urinary retention is the most common presenting symptom.
    • Overflow incontinence
    • Urgency
    • Frequency
    • Dysuria
  • Rectal symptoms
    • Constipation
    • Rectal pressure
    • Tenesmus
  • Uncontrollable lower abdominal pain
  • Pelvic pain
  • Back pain
  • Vaginal Bleeding

PMH

  • Posterior fibroids
  • Fundal fibroids
  • Endometriosis
  • Adhesive disease (prior surgery, peritonitis, PID)
  • Prior history of incarcerated uterus

Bimanual Exam

  • ACOG Recommendation: All women with second trimester urinary retention should have a pelvic exam performed at presentation to exclude an incarcerated retroverted uterus
  • Findings
    • Extremely anterior cervix
    • Cervix posterior to pubic symphysis
    • Acutely angled vaginal canal
    • Unable to palpate uterus through abdomen

Transvaginal Ultrasound

  • Difficulty to identify cervix in 2nd and 3rd trimester
  • Cervix extends upward, superior to the bladder and pubic symphysis
  • Bladder will appear elongated and distended due to compression of uterus

Differential Diagnosis

Abdominal Pain in Pregnancy

The same abdominal pain differential as non-pregnant patients, plus:

<20 Weeks

>20 Weeks

Any time

Urinary retention

Evaluation

  • ABC’s and Resuscitation if necessary
  • 2 large bore IVs

Labs

  • Urine pregnancy
  • Beta-HCG
  • Stat Hematocrit
  • CBC with differential
  • BMP, Mg/Phos
  • LFT
  • UA/Urine Culture
  • PTT/PT/INR
  • HIV
  • Type and cross 2 units PRBC if bleeding concern

Imaging

  • Transvaginal Ultrasound
  • Non-emergent MRI if unable to obtain transvaginal ultrasound
  • Consider Post-void residual

Management

  • Consultation with OB/GYN upon diagnosis

Reduction of Incarcerated Uterus (ACOG Recommendations, 2014)

  • Bladder decompression
    • Insertion of indwelling Foley Catheter
  • Pelvic exam to confirm diagnosis
    • Acute anterior angulation of vagina
    • Cervix positioned behind the pubic symphysis
    • Fundus not palpable abdominally

Next steps are performed to achieve reduction of uterus by external/internal manipulation and should be performed with OB/GYN consultation

  • Patient position
    • Knee-chest or all fours
  • Manual reduction
    • Ensure bladder fully void
    • Vaginal examination with or without anesthesia
  • Colonoscopic
    • Gas insufflation of colon under anesthesia
  • Other
    • Amnioreduction
    • Surgical exploration through laparotomy

Delivery

  • C-section
  • Risk of uterine rupture if allowed to labor

Complications

  • Maternal
    • Acute renal failure
    • Severe hypertension resistant to medications
    • Lower limb edema
    • Uterine ischemia
    • Sepsis
    • DVT
    • Post-partum PE
  • Fetal
    • Premature labor
    • Fetal death
    • Fetal mortality rate 33% (Gibbons and Paley)

Disposition

  • Admit
    • From the limited number of case studies, it appears most patients were admitted for inability to void, pain control, reduction of incarcerated uterus.

See Also

External Links

References

  • Newell S, Crofts J, Grant S. The Incarcerated Gravid Uterus Complications and Lessons Learned. American College of Obstetricians and Gynecologist 2014, 123:423-427
  • Gardner C, Jaffe T, Hertzberg B, Javan R, Ho L. The Incarcerated Uterus: A review of MRI and Ultrasound Imaging Appearances. American Journal of Roentgenology. 2013;201: 223-229.
  • Gibbons JM Jr, Paley WB. The incarcerated gravid uterus. Obstet Gynecol 1969; 33:842–845