Management of Incarcerated Gravid Uterus
Manual reduction of the incarcerated gravid uterus should be attempted as the first-line intervention, ideally between 12-20 weeks gestation when this complication typically presents, as persistent incarceration carries significant maternal and fetal risks including urinary retention, uterine rupture, and pregnancy loss. 1, 2
Initial Recognition and Diagnosis
Suspect incarcerated uterus when a pregnant patient presents with urinary retention, lower abdominal pain, or inability to void between 12-20 weeks gestation, as the gravid uterus normally ascends through the pelvic brim during this period 2, 3
Perform pelvic examination and ultrasound imaging to confirm the diagnosis, identifying the uterine fundus trapped behind the sacral promontory in the pelvis 1, 4
Consider MRI for detailed anatomic delineation, particularly when planning delivery or if ultrasound findings are unclear, as this can help identify predisposing factors like fibroids or adhesions 1
Predisposing factors include uterine fibroids, pelvic adhesions from prior surgery or infection, endometriosis, and posterior wall leiomyomas that cause fixed retroflexion of the uterus 1, 2, 5
Primary Management: Manual Reduction
Attempt manual reduction as soon as the diagnosis is confirmed, as this is the optimal management approach to prevent serious maternal and fetal complications 1
Position the patient in knee-chest position or Trendelenburg position to facilitate gravitational assistance in uterine repositioning 2
Perform manual reduction under epidural or spinal anesthesia initially, which provides adequate analgesia and muscle relaxation for the procedure 3
If epidural/spinal anesthesia fails, escalate to general anesthesia for deeper muscle relaxation and better conditions for manipulation 3
Use vaginal gauze packing in the posterior fornix to maintain traction after partially reducing the uterine fundus, as this technique has been successful when passive maneuvers fail 3
Surgical Intervention for Failed Manual Reduction
Consider diagnostic laparoscopy when multiple attempts at manual reduction are unsuccessful, as adhesive disease may be the underlying cause even without prior surgical history 5
Perform adhesiolysis laparoscopically to release dense posterior adhesions between the uterus and sigmoid mesentery or other pelvic structures 5
Laparoscopic suturing of bilateral round ligaments can provide additional support to maintain the reduced uterine position 3
Use intraoperative transabdominal ultrasound to confirm fetal viability, assess placental location, and verify successful uterine repositioning 5
Conservative Management When Reduction Fails
Conservative management throughout pregnancy is a reasonable option if all attempts at manual reduction are unsuccessful, though this carries higher risks 1
Use MRI to plan for delivery when conservative management is chosen, as anatomic delineation is critical for surgical planning 1
Plan for cesarean delivery with a vertical and more cephalad uterine incision to reduce the risk of bladder perforation and injury to the cervix and vagina 4
Assemble a multidisciplinary team including obstetricians, urologists, and anesthesiologists before delivery, as serious complications during cesarean section are common 4
Critical Positioning Considerations
Position pregnant women after 20 weeks with left uterine displacement to prevent aortocaval compression during any procedure or intervention 6
Avoid prolonged supine positioning in the second and third trimesters, as this can compromise maternal hemodynamics and uteroplacental perfusion 6
Postoperative Surveillance and Complications
Maintain close antenatal surveillance even after successful reduction, as technically successful intervention does not preclude adverse pregnancy outcomes 5
Monitor for signs of chorioamnionitis, preterm premature rupture of membranes, and placental complications, which can occur even after successful uterine repositioning 5
Watch for urinary retention recurrence, uterine rupture, and preterm labor as potential complications of persistent or recurrent incarceration 2
Counsel patients about the risk of pregnancy loss, particularly when surgical intervention is required, as intrauterine fetal demise has been reported even after successful adhesiolysis 5
Key Clinical Pitfalls
Do not delay intervention once diagnosed, as persistent incarceration beyond 20 weeks significantly increases maternal and fetal morbidity 1, 2
Do not assume absence of prior surgery excludes adhesive disease, as dense adhesions can occur without surgical history 5
Do not proceed with cesarean delivery without detailed anatomic planning in cases managed conservatively to term, as bladder and lower uterine segment anatomy is severely distorted 4