What is the appropriate management of an incarcerated gravid uterus in a pregnant patient in the late second or third trimester?

Management of Incarcerated Gravid Uterus

Immediate Initial Management

For pregnant patients in the late second or third trimester with an incarcerated gravid uterus, attempt manual reduction under sedation or anesthesia as the first-line intervention, and if this fails, proceed to colonoscopic release or vaginal gauze packing under general anesthesia before considering surgical intervention. 1, 2

Clinical Recognition and Diagnosis

• Suspect incarceration when pregnant patients present with urinary retention, lower abdominal pain, or rectal pressure after 16 weeks gestation 3, 4
• The incarcerated uterus becomes trapped between the sacral promontory and pubis, with the cervix pointing anteriorly toward the abdominal wall 4
• Use transvaginal ultrasound to confirm the diagnosis by visualizing the retroflexed or retroverted uterus position 3, 4
• Point-of-care ultrasound in the emergency setting can rapidly identify this condition 3

Treatment Algorithm by Gestational Age

Late Second Trimester (16-28 weeks)

Step 1: Conservative Manual Reduction

• Position the patient in knee-chest position or Trendelenburg position 1, 4
• Attempt manual reduction with the patient under epidural or general anesthesia 2, 4
• Apply gentle upward pressure on the uterine fundus through the posterior vaginal fornix while simultaneously applying downward pressure on the anterior abdominal wall 4

Step 2: Colonoscopic Release (if manual reduction fails)

• Administer sedation and one to two enemas 1
• Reattempt manual reduction after sedation 1
• If unsuccessful, pass a colonoscope above the level of the uterine fundus to generate external anterior forces that dislodge the uterus from beneath the sacral promontory 1
• This technique has demonstrated 100% success rate in published case series with no pregnancy losses or colonoscopy complications 1

Step 3: Vaginal Gauze Packing Under General Anesthesia (alternative to colonoscopy)

• Partially reduce the uterine fundus into the abdominal cavity 2
• Place gauze strips in the posterior vaginal fornix to maintain traction on the uterus 2
• Consider laparoscopic suturing of bilateral round ligaments to the anterior abdominal wall to prevent recurrence 2

Third Trimester (28+ weeks)

Expectant Management May Be Appropriate

• Approximately 78.5% of incarcerated cases show spontaneous resolution after 16 weeks gestation, with some resolving as late as the early third trimester 5
• Continue expectant management if the patient has no severe symptoms related to incarceration itself 5
• Monitor closely for urinary obstruction, which can lead to sepsis and maternal death 3

Critical Warning for Delivery Planning:

• Do not misdiagnose incarcerated uterus as placenta previa - this error has resulted in cervical injury during cesarean delivery with massive hemorrhage 5
• Carefully identify the true location of the cervix and lower uterine segment before any surgical intervention 5
• The cervix in an incarcerated uterus points anteriorly, which can be mistaken for abnormal placental position 5, 4

Surgical Intervention (Last Resort)

• Reserve laparotomy for cases where all minimally invasive techniques have failed 1
• Laparoscopic intervention with round ligament suspension may be performed if manual and colonoscopic methods are unsuccessful 2

Key Clinical Pitfalls to Avoid

• Do not delay intervention - prolonged incarceration increases risk of urinary obstruction, sepsis, peritonitis, and maternal death 3
• Do not assume spontaneous resolution will occur - while common before 28 weeks, approximately 1 in 2300 pregnancies remain incarcerated at term 5
• Do not proceed directly to laparotomy - minimally invasive techniques (colonoscopy or vaginal gauze packing) should be attempted first 1, 2
• Screen high-risk patients - approximately 93% of incarcerated cases have gynecological complications such as adenomyosis, fibroids, or prior uterine surgery 5

Follow-up Monitoring

• Monitor for recurrence, which can occur even after successful reduction 1
• Assess for severe abdominal pain that may indicate associated adenomyosis or other uterine pathology 5
• Perform serial ultrasounds to confirm maintained anterior uterine position 5