Case 17 - A 25-Year-Old at 14 Weeks’ Gestation with Pelvic Pain and Inability to Void

Summary

Timely diagnosis of uterine incarceration of the gravid uterus is critical for optimal outcomes and to avoid serious maternal morbidity. The most common presenting symptom is urinary retention. Any case of urinary retention in the late first or early second trimester should increase the suspicion for uterine incarceration. The proper diagnosis of uterine incarceration is aided by physical exam that shows the cervix displaced behind the pubic symphysis at a 90° angle, and an ultrasound that shows a sharp curve to the cervix. When diagnosed, the uterus should be reduced. It is reasonable to try conservative methods first. However, if not successful, manual reduction is warranted – sometimes requiring either spinal or general anesthesia. If not diagnosed until the third trimester, there is risk for significant complications, including uterine rupture. Delivery of an incarcerated uterus that has not been reduced by the third trimester should be by a carefully planned cesarean section via a vertical uterine incision. There is high risk of injury to the vagina and bladder as they are typically abnormally stretched superiorly. A preoperative MRI can be helpful to map the distorted anatomy.