Incarceration of the retroverted uterus in the early second trimester performed by hysterotomy delivery

2012 
About 15% of women have a retroverted uterus prior to pregnancy, and retroversion occurs in 11% of women in the Wrst trimester of pregnancy [1]. Usually it spontaneously reverts to an upward position before the 14th week [2, 3]. If the uterus remains retroverted as the pregnancy advances, it may become wedged in the pelvic cavity, so called incarcerated uterus. It has been reported that this condition occurs in one case per 3,000–10,000 pregnancies [4–6]. Incarceration of the retroverted gravid uterus may have an adverse eVect on the pregnancy, because it will often give symptoms such as lower abdominal pain, frequent painful micturition and gastrointestinal symptoms like rectal tenesmus, and it is associated with higher incidences of abortion, fetal death, intrauterine growth restriction, and preterm labor [7]. If incarceration of a retroverted uterus has been missed until shortly before delivery, it can lead to serious obstetric emergencies, such as uterine rupture, labor dystocia, and uncontrollable postpartum hemorrhage. Since symptoms are non-speciWc, every obstetrician should keep it Wrmly in mind to avoid complications and negative outcomes. Here we present a case of an incarcerated retroverted gravid uterus in 18 gestational weeks, and termination of pregnancy was performed by hysterotomy delivery. A 25-year-old gravida 2, para 0 presented at 18 weeks of gestation. As she was worried about the adverse eVect of medicine on the fetus in the Wrst trimester, she decided to end this gestation. In addition, the termination of pregnancy was approved by the Local Government and the Hospital Ethical Committee. Because of a failed induced abortion in another hospital, the patient consulted our hospital and was then hospitalized for termination of pregnancy. She did not present with abdominal and back pain, urinary retention, constipation, and so on. She had no history of sexually transmitted diseases, pelvic inXammatory diseases, endometriosis, Wbromas, or previous abdominal surgery. Pelvic examination revealed a closed, very anterior cervix and a markedly retroverted, incarcerated uterus of 18 weeks’ size. At the same time, transabdominal ultrasound imaging was performed. It was found that the cervix was displaced anteriorly and elongated approximately 7.1 cm. The gravid uterine body was wedged in the pelvic cavity (Figs. 1a, b). Attempts to reduce the incarceration by intravaginal pressure in the lithotomy position combining with the patient’s intermittent knee-chest position were not successful. With the patient placed in the dorsal lithotomy position or in the knee-chest position, reduction was made by a Wrm, unhurried pressure on the uterus and a Wnger placed in the rectum to provide increased pressure on the fundus. However, because of patient’s discomfort, this strategy was unsuccessful. Afterwards, the above maneuver was tried again with the patient relaxed by the epidural anesthesia; after a close consultation between the urologists and the obstetricians, the uterus was not reduced successfully. Therefore, termination of pregnancy was performed by hysterotomy delivery at the same time. Adhesions between the fundus of uterus and the pouch of Douglas were found in the process of surgery. Incarceration of a gravid retroverted uterus is a rare condition. However, a woman with a retroverted uterus is predisposed to this condition [8]. Factors and preexisting conditions that may predispose a patient to an incarcerated L. Wang · J. Wang · L. Huang (&) Department of Family Planning, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang, People’s Republic of China e-mail: fbhuanglili@163.com
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