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Expectant management of uterine incarceration from an anterior uterine myoma: A case report

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Abstract

Uterine incarceration is an infrequent complication of pregnancy in the early second trimester. Although imaging can be confirmatory, the diagnosis is made primarily on clinical grounds, and definitive treatment involves manual reduction to restore the proper anatomic position. Except for preexisting uterine retroversion, often this event is idiopathic. A 30-year-old primigravida presented at 15 weeks' gestation with uterine incarceration. Manual replacement was unsuccessful. Spontaneous resolution occurred at 20 weeks, followed by uneventful pregnancy. The patient underwent a classical cesarean section at term due to fetal malpresentation. Uterine incarceration may be managed conservatively, with a favorable outcome.

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... Treatment of reposition was successfully attempted in 83 cases. After reposition, 68 patients successfully delivered infants [2, 15, 16, 19, 21, 23, 25, 27, 28, 36, 37, 41, 43, 44, 48, 50, 55, 62, 63, 66, 76, 77, 82, 83, 85, 88-92, 95, 98-101], including 36 term deliveries [16,19,21,27,28,35,37,41,43,44,48,50,62,66,76,77,87,91,98,100,101], and information for other cases was not available. Treatment methods vary in invasiveness, and because incarceration was quite rare, no study has yet been performed to determine the supremacy of any single treatment modality. ...
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Background: Incarceration of the gravid uterus is a rare obstetric disorder that contributes to pregnancy-related complications. To understand its clinical characteristics and managements, we have reviewed the etiology, risk factors, clinical characteristics and current treatments of an incarcerated gravid uterus based on 162 cases reported in the English language literature, including our patient. Case presentation: A 25-year-old primigravida, with a history of lymphatic tuberculosis, infertility due to blocked fallopian tubes and received in vitro fertilization. The patient presented with urine retention and lower abdominal pain in the early second trimester. Uterine incarceration was diagnosed based on pelvic examination and abdominal ultrasound. A Foley catheter was placed and manual reposition was successful. No episode of retention was experienced after the further enlargement of the uterus and its ascent. A healthy infant was delivered vaginally on 38th week of pregnancy. Conclusions: Uterine incarceration due to pelvic adhesions is rare and, because of it non-specific clinical presentations, is often misdiagnosed. Abdominal ultrasound is instrumental for the diagnosis because it can directly image the disturbed uterine and pelvic anatomy. There are limited treatment options for uterine incarceration, but definitive diagnosis allows procedures to treat and to reduce severe complications of uterine incarceration.
... Reduction of the incarcerated uterus is not recommended beyond 20 weeks owing to the risk of PPROM or PTL [11]. Spontaneous reduction can be expected for anterior wall myoma [12]. However, it may be difficult in posterior myoma owing to its easy recurrence [9]. ...
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Although gravid uterine incarceration is typically diagnosed during the early second trimester, we encountered two unusual cases in early pregnancy. A 34-year-old multiparous woman with adenomyosis presented at 7 + 2 weeks of gestation with increased urinary frequency and a sensation of incomplete bladder emptying. The uterine incarceration was successfully reduced by manual reduction and pessary insertion, and she delivered a normal infant at term. In the second case, a 31-year-old nulliparous woman with a large myoma complained of dysuria, acute urinary retention, and intense back pain at 6 weeks of gestation. Manual reduction was successful in the knee-chest position. Subsequent pessary insertion failed; however, a slight reduction in pain was achieved. After a week, the fetus spontaneously aborted. In summary, gravid uterine incarceration is a rare but potentially fatal condition for the fetus, and a suspicion of this condition in patients with urinary symptoms, especially urinary retention and pelvic pain, is important in the early gestation period.
... This rapid growth is not supported by an appropriate increase in blood supply resulting in necrosis and degeneration with hemorrhagic infarction (''Red Degeneration'') [5]. Other less common complications can be subserosal torsion, premature labor and, rarely, with reported rates of 1/ 3000-10,000 pregnancies, uterine incarceration with the uterus fixed between the sacral promontory and the pubic bone [16,42]. ...
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Pregnant women with an acute abdomen present a critical issue due to the necessity for an immediate diagnosis and treatment; in fact, a diagnostic delay could worsen the outcome for both the mother and the fetus. There is evidence that emergencies during pregnancy are subject to mismanagement; however, the percentage of errors in the diagnosis of emergencies in pregnancy has not been studied in depth. The purpose of this article is to review the most common imaging error emergencies. The topics covered are divided into gynecological and non-gynecological entities and, for each pathology, possible errors have been dealt with in the diagnostic pathway, the possible technical errors in the exam execution, and finally the possible errors in the interpretation of the images. These last two entities are often connected owing to a substandard examination, which can cause errors in the interpretation. Consequently, the systemization of errors reduces the possibility of reoccurrences in the future by providing a valid approach in helping to learn from these errors.
... Ultrasonogram of the posterior wall myoma in pregnancy Укље ште ње гра вид не ма те ри це је рет ка ком пли ка ци ја труд но ће ко ја се ја вља по чет ком дру гог три ме стра. Осим код ре тро вер зи је ма те ри це, обич но је иди о пат ска, али у ли те ра ту ри по сто је при ка зи бо ле сни ца у ко ји ма се као узрок на во де и ми о ми ма те ри це [26]. ...
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Fibroids are the most common benign tumors of the genital organs of women in reproductive age. Achieving reproductive function later in life, with more frequent use of assisted reproductive technologies, leads to an increased number of pregnancies complicated with fibroids. Their size may change during pregnancy, but the changes are mostly individual. Most fibroids stop growing or decline during the puerperium. The effect of fibroids on pregnancy depends on their number, size and location. The mechanisms bringing about perinatal complications are not fully understood. Fibroids during pregnancy can cause many perinatal complications, such as bleeding in pregnancy, miscarriage, pain due to red degeneration, malpresentation, preterm labor, premature rupture of membranes, placental abruption and obstruction of delivery and are associated with higher incidence of cesarean section, operative vaginal delivery, uterine atony and postpartum hemorrhage. Postpartum hysterectomy in these women is also more likely than in general population. Postpartum infections are more common in patients with fibroids, and myomas may also cause retained placenta. The most common cause of neonatal morbidity is prematurity, due to pregnancy ending in an earlier gestational age. Monitoring of pregnancies complicated with fibroids is essentially indistinguishable from monitoring normal pregnancies. Therapy includes only bed rest and observation, symptomatic therapy in case of pain and intensive fetal surveillance, and surgery in the acute situations.
... Je to především riziko intrauterinního úmrtí plodu a předčasného porodu [2,8]. Ve druhé polovině těhotenství se doporučuje pečlivé sledování pacientky a v případě asymptomatického průběhu ukončení gravidity plánovaným císařským řezem před termínem porodu [5,9]. V případě subjektivních obtíží, které se nedaří konzervativně zvládnout, je nutno myslet i na reálné riziko děložní ruptury v oblasti vytaženého a ztenčeného dolního děložního segmentu. ...
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Objective: Analysis of two cases of incarcerated uterus during pregnancy. Design: Two case reports. Setting: Department of Gynecology and Obstetrics, Masaryk University, University Hospital Brno. Methods and results: In two cases of incarcerated uterus, which were resolved on Department of Gynaecology and Obstetrics, University Hospital Brno is shown a different clinical course, leading to the detection and solutions at different gestational weeks. The first case was detected in 31st week of pregnancy and was characterized by nearly asymptomatic course in a pregnant woman with a scar in the lower uterine segment after a previous caesarean section. The delivery was scheduled for the end of the 36th week of pregnancy by iterative caesarean section. The second case was detected on the 27th week of pregnancy due to significant subjective difficulties of pregnant woman that impressed as acute event of abdomen. Despite all attempts at conservative therapy was necessary to terminate the pregnancy by caesarean section at 28 week of pregnancy due to the high risk of uterine rupture. Conclusion: Incarcerated uterus is a rare complication of pregnancy. Diagnostics complains varied clinical picture of the nonspecific subjective difficulties. Missed diagnosis can lead to a number of serious obstetric complications. In case of failure of conservative therapy and progression of difficulties is necessary to think about the real risk of uterine rupture. Before performing a caesarean section is essential knowledge of the mutual position of the lower uterine segment, urinary bladder and cervix.
... Sporadic case reports of uterine incarceration appear in the literature; however, to the best of our knowledge, only one of these reports involves a case with an anterior wall leiomyoma. 20 In our case a failure of the fundal height to increase was not appreciated as the anterior leiomyoma was palpated to represent the fundus. At laparotomy it was initially impossible to restore the normal pelvic anatomy due to the large anterior uterine leiomyoma; however, the highly detailed images from the preoperative MRI confirmed the diagnosis, and cesarean delivery could be approached with sufficient caution. ...
Article
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Incarceration of the gravid uterus is a rare but serious complication of pregnancy. The often required cesarean section is technically complicated, and preoperative planning is critical. An important initial surgical step is to lift the fundus out of the pelvis prior to creating the hysterotomy in order to facilitate adequate visualization of the pelvic anatomy. A 38-year-old primigravida with uterine incarceration from a large anterior leiomyoma underwent cesarean delivery at 29 weeks' gestation. In this case, a failure of the fundal height to increase was not appreciated as the anterior leiomyoma was palpated to represent the fundus. Intraoperatively the uterus was unable to be repositioned because of the leiomyoma. However, the surgery did proceed smoothly primarily due to the highly detailed images obtained on pelvic magnetic resonance imaging. Although uterine incarceration is rare, knowledge of this condition is important. Magnetic resonance imaging is a useful tool in that it enables the detailed evaluation of the pelvic anatomy in cases with suspected uterine incarceration.
Chapter
Uterine fibroids, also known as leiomyomas or myomas, are the most common benign uterine neoplasms, especially over the age of 30. They are now observed more frequently in pregnancy because many women are delaying childbearing beyond that age. Uterine myoma can be asymptomatic or symptomatic with presentations that include red degeneration, spontaneous bleeding, obstructed labor, and torsion of the gravid uterus. It is important to accurately define the type of uterine myoma presentation. All these presentations can be defined by transabdominal or transvaginal sonography or in unequivocal cases by abdominal MRI. If bleeding is the cause, then radiologic or surgical interventions to stop the bleeding are mandatory. If red degeneration is the cause of acute abdominal pain, the therapy is conservative and symptomatic. Torsion of the gravid uterus is discussed in the separate chapter. Potential of obstructed labor is a complex issue that should be diagnosed before the labor starts to prevent emergency obstetric interventions.
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Incarceration of the gravid uterus occurs in the early second trimester in approximately one in 3000 pregnancies. If conventional manual attempts at restoring the uterine fundus to the anterior position are unsuccessful, correction by an invasive laparotomy procedure is necessary. We describe a minimally invasive technique to dislodge the incarcerated gravid uterus. Gravid patients with an incarcerated uterus refractory to manual reduction are administered sedation, and one to two enemas. After sedation, manual reduction is attempted again. If unsuccessful, a colonoscope is passed above the level of the uterine fundus generating external anterior forces, which dislodge the uterus from beneath the sacral promontory. The procedure was performed six times in five patients. One patient required a second procedure because of recurrence of the condition. All procedures were successful. No pregnancy losses occurred after the procedure, and no complications of colonoscopy were encountered. Colonoscopic release of the incarcerated gravid uterus is an option when attempts at manual reduction fail. This procedure may avoid laparotomy to correct this condition.
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Incarcerated uterus is a rare condition with potentially serious complications that is often difficult to diagnose. This series shows the value of magnetic resonance imaging (MRI). Five pregnant women with incarcerated uterus are presented and the MRI findings compared with MRI in normal pregnancy. The use of MRI can be helpful in diagnosing this rare condition.