Incarcerated gravid uterus liberated by vaginal gauze packing under general anesthesia: a case report

Abstract

Incarceration of the gravid uterus is a rare and serious obstetric complication that can lead to severe complications. We present the case of a 32-year-old woman (gravida 5, para 2022) at 12 weeks and 5 days of gestation who presented with urinary retention and lower abdominal pain. Despite attempts at positional changes and manipulative repositioning under epidural anesthesia, the incarceration of the gravid uterus persisted. Subsequent intervention under general anesthesia involved partially reducing the uterine fundus into the abdominal cavity and using gauze strips in the posterior vaginal fornix to maintain traction. In addition, the bilateral round ligaments of the uterus were sutured to release the incarcerated uterus via laparoscopy. Vaginal gauze packing under general anesthesia may be a beneficial intervention for addressing cases of an incarcerated uterus, particularly in patients in whom passive maneuvers and manual pressure fail to resolve the condition.

Introduction

Incarceration of the gravid uterus (IGU) refers to the rare and critical obstetric complication in which the pregnant uterus becomes trapped between the sacral promontory and the pubic symphysis within the pelvis. The reported incidence of IGU ranges from 1 in 2000 to 1 in 10,000 cases.^1,2 IGU can manifest at any stage of pregnancy and is typically characterized by symptoms, such as urinary retention and lower abdominal pain. ³ Failure to address an incarcerated uterus can lead to severe consequences, such as bladder rupture, uterine rupture, restricted fetal growth, and even intrauterine fetal demise.^4,5 While manual reduction is commonly the initial approach for managing IGU, its success is not always guaranteed. ⁶

In this report, we present a unique resolution of an incarcerated uterus using vaginal gauze packing under general anesthesia. This technique could be an alternative method for cases of IGU in which conventional techniques prove ineffective. The reporting of this study conforms to the CARE guidelines. ⁷

Case report

A 32-year-old woman (gravida 5, para 2022) presented to our department at 12 weeks and 5 days of gestation after being transferred from a local hospital because of urinary retention and lower abdominal pain. She had a history of two prior cesarean sections, the most recent of which was 7 years previously.

This pregnancy was spontaneous, with a weight gain of 10 kg and a current body mass index of 37.46 kg/m². Initial ultrasound findings did not show any major abnormalities, but subsequent ultrasound examinations during hospitalization indicated an incarcerated gravid uterus. Specifically, the cervix was elongated to 6.5 cm, displaced anteriorly behind the pubic symphysis, and the fetal head encroached into the pouch of Douglas. Furthermore, the uterine fundus was retroverted towards the posterior fornix, resulting in it being the lowest point of the uterus (Figure 1(a)).

Figure 1.

Transabdominal ultrasonographic reduction (transverse section). (a) Ultrasound image of a uterine incarceration. The elongated CX (red line) is pulled and lies just behind the BL. A retroverted uterus can be seen, with the UF positioned in close proximity to the pouch of Douglas. (b) and Normal gravid uterus after reduction. BL, bladder; CX, cervix; PL, placenta; H, head; UF, uterine fundus; AC, abdominal circumference.

Upon admission, a Foley catheter (Hangzhou Xiaoshan Aodeshu Medical Treatment Appliance Co., Ltd., Hangzhou, China) was inserted, and 750 mL of urine was drained, which relieved the patient’s lower abdominal pain. However, because of discomfort, a vaginal examination was not tolerated by the patient. Initial attempts to manually relieve the incarcerated uterus under epidural anesthesia were unsuccessful. Subsequent efforts, including changing the patient’s position to knee–chest recumbency, also failed to reposition the uterus.

These approaches were switched to laparoscopic reduction under general anesthesia. A laparoscopic examination showed a purplish-blue gravid uterus with retroflexion and retroversion, although the fundus was only partially visible. Notably, in a bimanual examination, the uterine fundus gradually assumed a convex shape towards the abdominal cavity and was successfully repositioned to its normal anatomical location by manipulating the posterior fornix. However, upon withdrawal of the examiner’s hand from the vagina, the uterus partially returned to the pouch of Douglas. To prevent a recurrence of retroflexion, the two following additional measures were implemented. The posterior vaginal fornix was filled with gauze strips, and the round ligaments of the uterus were bilaterally collapsed and sutured (Supplementary movie 1). Polysorb™ braided absorbable suture (CL-914; Covidien Inc., Mansfield, MA, USA) was used for shortening of the round ligaments.

An ultrasonogram conducted after 48 hours confirmed the sustained proper positioning of the uterus within the abdominal cavity (Figure 1(b)). Subsequently, the gauze strips and Foley catheter were removed, and the patient was discharged home. Finally, a cesarean section was performed at 38 weeks of gestation without any complications.

Discussion

Conservative treatment is the preferred approach for treating IGU, which has progressed from simple urinary catheterization to incorporating positional changes such as the knee–chest position and transvaginal or transrectal balloon inflation. ⁸ Manual reduction techniques may also involve rectal manipulation with colonic insufflation. ⁹ A retrospective analysis examining IGU treatments up to 2023 showed that approximately 11.5% of patients who were initially managed conservatively eventually required conversion to laparoscopic surgery.^3,10

In this particular case, initial attempts at reduction through bladder decompression and manipulation were unsuccessful, possibly because of the patient’s high body mass index and incomplete muscle relaxation under epidural anesthesia. Subsequently, a laparoscopic procedure under general anesthesia was performed, resulting in partial resolution of the incarcerated uterus, likely facilitated by improved muscle relaxation. By strategically placing gauze in the posterior vaginal fornix to provide upward support to the fundus, successful repositioning was achieved. While proactive bilateral round ligament folding sutures were placed, the main factors contributing to the realignment of the uterus were the muscle relaxants administered during general anesthesia and the support provided by the vaginal gauze packing.

The uterus increases during pregnancy, and abdominal manipulation needs to be carefully carried out. Improper use of any instrument can lead to uterine rupture, secondary miscarriage, intrauterine fetal death, and other adverse events. In addition, vaginal gauze packing and shortening of the round ligament laparoscopically may induce contractions, which can lead to preterm miscarriage. Although these adverse effects did not occur in this case, fully communicating the risks to the patient is important when such methods are performed by subsequent individuals.

In a recent report by Abelman et al., the use of a vaginally inserted Bakri balloon was proposed as a method for resolving IGU. ¹¹ However, there are concerns regarding this balloon’s mobility and potential for rupture. In our case, we introduced an alternative approach by applying vaginal gauze packing in conjunction with uterine relaxation, which may offer an accessible and inexpensive method of repositioning the uterus. This approach could potentially be more universally adopted in obstetric settings for managing cases of IGU.

Summary

IGU is a rarely known disease but is important to be aware of. Our findings provide new ideas for the treatment of failed manipulative repositioning in the first trimester of IGU. Vaginal gauze packing under general anesthesia is a unique resolution for an incarcerated uterus in patients in whom conventional techniques prove ineffective.

Supplemental Material

sj-mp4-1-imr-10.1177_03000605241275006 - Supplemental material for Incarcerated gravid uterus liberated by vaginal gauze packing under general anesthesia: a case report

Supplemental material, sj-mp4-1-imr-10.1177_03000605241275006 for Incarcerated gravid uterus liberated by vaginal gauze packing under general anesthesia: a case report by Mingbao Li, Zhou Yang, Wanjun Yin, Yafei Ma, Rui Li, Yonghui Jiang and Yuan Liu in Journal of International Medical Research