Uterus incarceratus

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Drawing of a uterus incarceratus (without child) with the upwardly displaced urinary bladder (yellow) and the cervix (pink) marked.

The incarceration of the uterus (dt., Entrapment of the uterus') is an obstetric complication, wherein the in pregnancy increasing uterus (lat. Uterus ) due to an atypical location in the small basin ( pelvis minor is clamped).

frequency

The frequency of this complication is given in numerous publications as about 1 in 3000 pregnancies, the authors apparently referring to an old source from 1895. Another, also older source (1909) gives a frequency of about 1 in 2590 pregnancies for symptomatic cases.

Causes / origin

An incarceration that occurs during pregnancy is very often associated with a previous bending of its longitudinal axis backwards ( retroflexion ) in the non-pregnant uterus . In women who are not pregnant, the proportion with a retroflexed uterus is reported to be relatively high at around 19% and classified as a harmless system variant, although a clear distinction is not always made between retroversion and retroflexion. An examination of over 5000 pregnant women found a proportion of almost 9% with a retroflected uterus.

Normally, during the first trimester, the uterus is straightened upwards and forwards, so that it lies more and more stretched in the abdomen and the backward flexion is eliminated. Failure to straighten up until the end of pregnancy is rare. Why this happens in some cases and then the backward-facing uterus becomes trapped in the pelvis as it gets bigger (incarceration), cannot be answered in every case. A number of medical conditions are described as possible causes. These include

Symptoms / complications

If the uterus remains bent back in the pelvis in the course of pregnancy, it fills most of the pelvis after about 14 weeks and, due to the rotated position, tensions the vagina and cervix forward and upwards. Then, above a certain size, the uterus is pinched between the promontory and the symphysis . As it grows, stomach, pelvic and back pain can occur. Difficulties in urinating occur due to the pinching of the bladder and the urethra and, accordingly, constipation due to the narrowing of the sigmoid colon and rectum . However, cases are also reported in which no symptoms occurred until the beginning of the birth .

The atypical position of the uterus with the corresponding atypical pressure load can lead to so-called sacculation of the uterus . This means that part of the uterus is locally thinning and bulging, similar to an aneurysm . In extreme cases, the uterus can rupture . Other possible complications are dystocia , premature birth , placental retention , and postpartum bleeding . If a caesarean section is performed without the correct diagnosis being known, there can be significant difficulty in identifying the bladder and cervix and thus opening the uterus in the right place. This can result in bladder injuries, severance of the vagina, and ultimately a hysterectomy .

diagnosis

Diagnosis is made in a good half of cases in the second trimester, but it can be difficult and the incarceration can go undetected until due date, which increases the risk of complications. A primary suspicion can be made when symptoms appear that increase as the uterus grows. During the physical examination, the cervix is ​​found to be shifted upwards and forwards or it cannot be felt at all. The pelvis is completely filled by the soft mass of the pregnant uterus. The ultrasound can show the retroverted position of the uterus, the cervix shifted forward and upward, and the constricted urinary bladder, possibly also an overcrowded urinary bladder if voiding disorders have already occurred. The magnetic resonance imaging has proven to be helpful in diagnosis. Here the situation in the pelvis can best be assessed in its entirety in sagittal and axial slices. The crucial question for both sonography and magnetic resonance imaging is whether it is possible to correctly determine the position of the cervix. It can be important to detect a deviation of the cervical position from the midline, as this can influence the access for a possibly necessary caesarean section.

treatment

There is no uniform concept for the treatment of uterine incarceratus. If the diagnosis is made early, the aim is usually to reposition the uterus to its natural upright position. An experiment with knee-elbow position is recommended up to the 20th week of pregnancy . Manual interventions are not always successful and there is an increased risk of complications such as B. connected a premature birth. They should be done with an empty urinary bladder (urinary catheter ). The spontaneous erection without manipulation after spinal anesthesia has been described. Surgical removal of the uterus from the pelvis is discussed in various ways, but is apparently associated with a risk of complications.

If an erection fails or occurs spontaneously during pregnancy, planning a caesarean section is recommended.

Web links

Commons : Uterus incarceratus  - Collection of images, videos and audio files

Sources and literature

  1. ↑ a b c d e f g h i C. Han, C. Wang, L. Han, G. Liu, H. Li, F. She, F. Xue, Y. Wang: Incarceration of the gravid uterus: a case report and literature review. In: BMC pregnancy and childbirth. Volume 19, number 1, November 2019, p. 408, doi : 10.1186 / s12884-019-2549-3 , PMID 31703641 , PMC 6839127 (free full text) (review).
  2. ↑ a b K. van der Tuuk, RA Krenning, G. Krenning, WM Monincx: Recurrent incarceration of the retroverted gravid uterus at term - two times transvaginal caesarean section: a case report. In: Journal of medical case reports. Volume 3, November 2009, p. 103, doi : 10.1186 / 1752-1947-3-103 , PMID 19946581 , PMC 2783044 (free full text).
  3. ^ A b I. Dierickx, T. Mesens, C. Van Holsbeke, L. Meylaerts, W. Voets, W. Gyselaers: Recurrent incarceration and / or sacculation of the gravid uterus: a review. In: The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. Volume 23, Number 8, August 2010, pp. 776-780, doi : 10.3109 / 14767050903410680 , PMID 19903108 (review).
  4. ^ H. Oldham: Case of retroflexion of the gravid uterus during labor at term. In: Trans Obstet Soc Lond. 1895; 1: 317-322.
  5. ↑ a b R. W. Lobenstein: Incarceration of the Pregnant Uterus . In: Am J Obs Dis Women & Child. 1909 V-60.
  6. ↑ TO Sweigart, MJ Matteucci: Fever, sacral pain, and pregnancy: an incarcerated uterus. In: The western journal of emergency medicine. Volume 9, Number 4, November 2008, pp. 232-234, PMID 19561753 , PMC 2672273 (free full text).
  7. ^ GK Döring, Erika Kauka: [Arguments for a hesitamt [sic! Meant: hesitant] attitude in the management of retroflexion of the pregnant uterus] (translation from German), In: progress of medicine. Volume 96, Number 33, September 1978, pp. 1660-1662, PMID 700548 .
  8. ↑ T. Bultez, M. Vincienne, C. Noël: [Incarceration of the retroverted uterus in the third trimester: report of 2 cases]. In: Gynecologie, obstetrique & fertilite. Volume 41, Number 6, June 2013, pp. 409-411, doi : 10.1016 / j.gyobfe.2013.04.013 , PMID 23756025 (review).
  9. ↑ S. Pongthai, V. Sumawong: Placenta increta as a cause of uterine sacculation. In: Journal of the Medical Association of Thailand = Chotmaihet thangphaet. Volume 61, Number 12, December 1978, pp. 703-706, PMID 739200 .
  10. ↑ a b c d J. T. Van Winter, PL Ogburn, JA Ney, DJ Hetzel: Uterine incarceration during the third trimester: a rare complication of pregnancy. In: Mayo Clinic Proceedings. Volume 66, Number 6, June 1991, pp. 608-613, doi : 10.1016 / s0025-6196 (12) 60520-5 , PMID 2046399 (review).
  11. ^ EM Gottschalk, JP Siedentopf, I. Schoenborn, S. Gartenschlaeger, JW Dudenhausen, W. Henrich: Prenatal sonographic and MRI findings in a pregnancy complicated by uterine sacculation: case report and review of the literature. In: Ultrasound in obstetrics & gynecology: the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. Volume 32, Number 4, September 2008, pp. 582-586, doi : 10.1002 / uog.6121 , PMID 18677703 (Review) full text .
  12. ↑ a b D. D. Fernandes, CA Sadow, KE Economy, CB Benson: Sonographic and magnetic resonance imaging findings in uterine incarceration. In: Journal of Ultrasound in Medicine . Volume 31, number 4, April 2012, pp. 645-650, doi : 10.7863 / jum.2012.31.4.645 , PMID 22441922 full text .
  13. ↑ N. Hachisuga, N. Hidaka, Y. Fujita, K. Fukushima, N. Wake: Significance of pelvic magnetic resonance imaging in preoperative diagnosis of incarcerated retroverted gravid uterus with a large anterior leiomyoma: a case report. In: The Journal of reproductive medicine. Volume 57, Numbers 1-2, 2012 Jan-Feb, pp. 77-80, PMID 22324275 .
  14. ^ CH Rose, BC Brost, WJ Watson, NP Davies, JM Knudsen: Expectant management of uterine incarceration from an anterior uterine myoma: a case report. In: The Journal of reproductive medicine. Volume 53, Number 1, January 2008, pp. 65-66, PMID 18251368 .
  15. ↑ MG Hire, KE Reynolds, JR Farrer: Spontaneous Resolution of Gravid Uterine Incarceration With Spinal Anesthesia: A Case Report. In: A&A practice. Volume 13, Number 11, December 2019, pp. 433-435, doi : 10.1213 / XAA.0000000000001103 , PMID 31577539 .