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Case report

  1. Top of page
  2. Case report
  3. Discussion
  4. References

A 35 year old primigravid woman who was known to have multiple fibroids was transferred from another area for antenatal care at 25 weeks of gestation. An ultrasound scan had shown three fibroids on the anterior and posterior walls of the uterus, 8 to 10 cm in diameter. She developed urinary retention at 14 weeks of gestation and was treated by catheterisation; the problem subsequently resolved. An ultrasound at 20 weeks of gestation showed no fetal deformity. When she was transferred to our hospital, a scan showed a large fibroid on the anterior wall measuring 15 × 13 × 9 cm. Fetal growth was satisfactory. The placenta was anterior. A grade III placenta praevia was present.

The woman was admitted at 26 weeks of gestation with severe abdominal pain and pain in her left calf; there was no swelling of the leg. A provisional diagnosis of degeneration of the fibroid was made and she was treated with analgesia. Doppler examination of the leg was negative and D-dimer estimation was normal. She was catheterised on one occasion, although she subsequently managed to pass urine normally. Ultrasound assessment of fetal growth remained normal. Her plasma creatinine concentration was 154 mmol/L, blood urea was 5.3 mmol/L, and creatinine clearance was 45 mL/min. An ultrasound scan of her kidneys and ureters was normal. She was allowed home.

She was readmitted at 30 weeks of gestation from the antenatal clinic and other blood tests showed a plasma creatinine concentration of 258 mmol/L, blood urea of 10 mmol/L and serum urate of 410 mmol/L. An ultrasound scan of her kidneys was again normal. Her blood pressure remained normal and she had no proteinuria. Her left leg became more swollen and the concentration of D-dimers was increased. Doppler examination revealed a non-occlusive thrombus in the external iliac vein extending as far as the popliteal vein, and a therapeutic dose of low molecular weight heparin was administered. The case was discussed with a renal physician and it was decided to perform a caesarean section due to deteriorating renal function. A definitive diagnosis of the cause of her renal failure was not made at this stage because a renal biopsy was thought to be unwise. Corticosteroids were given. Her caesarean section was planned for 32 weeks of gestation. Major anterior placenta praevia was present. In view of her uterine fibroids and her placenta praevia, the woman was advised of the possibility of hysterectomy.

Before her caesarean section, the midwife catheterising the bladder had great difficulty finding the urethra, which was located within the vagina. During the caesarean section, the anatomy was found to be grossly distorted. The bladder was attached very high on the anterior wall of the uterus. After dissecting the bladder, a transverse incision was made in which was thought to be the lower segment. The anterior uterine wall appeared thickened, and initially this was thought to be due to a lower segment fibroid that had softened and thinned out making identification on ultrasound examination difficult. Once the incision was made deep enough, liquor was seen and the baby delivered by Wrigleys' forceps. Once the baby was delivered, the anatomy was identified. The uterus was retroverted with the fundus incarcerated in the pouch of Douglas (Fig. 1). The placenta, although ‘praevia’ on ultrasound was in fact over the uterine fundus. The incision had been made through the elongated vagina and then through the posterior wall of the uterus (Fig. 2). As the uterus was completely detached at the level of the vagina, it was decided to perform a hysterectomy.

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Figure 1. Illustration of the position of the fibroid in relation to the uterine fundus and fetus. The placenta is not shown, but was over the uterine fundus in front of the fetal head.

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Figure 2. Hysterectomy specimen orientated to show the position it occupied in situ.

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The woman made an excellent post-operative recovery and was discharged on the seventh post-operative day. Although her renal function improved and post delivery there was an immediate diuresis, renal function six weeks post-operatively remained slightly impaired with a serum creatinine of 90 mmol/L.

Discussion

  1. Top of page
  2. Case report
  3. Discussion
  4. References

This case illustrates the difficulties that may arise as a result of the distorted anatomy that may occur in the presence of uterine fibroids in pregnancy. Although rare, many of the symptoms and signs that suggest this problem were present in this case and have been described1–5. These include urinary retention, abdominal pain, disordered renal function and the distorted anatomy of the urethra.

Retroversion of the first trimester uterus occurs in 6% of all pregnancies1,2. As pregnancy advances, the uterus enlarges in size and by 14 weeks becomes an abdominal organ. If the uterus remains retroverted, it becomes impacted in the pelvis, a condition termed ‘incarceration’. The incidence of incarceration is 1 in 3000 pregnancies1,2. Uterine incarceration almost always occurs secondary to a retroverted retroflexed uterus that fails to ascend into the abdominal cavity. Contributing factors may be pelvic adhesions, endometriosis, large ovarian tumours, a uterine leiomyoma, a bicornuate uterus and a deep sacral concavity1–4. During the first trimester, the condition is usually asymptomatic, although if it persists the women typically appears between 12 and 15 weeks of gestation with symptoms that can be divided into four catogories: (a) obstetric and gynaecologic (vaginal bleeding, miscarriage), (b) pressure (pelvic discomfort, low abdominal pain), (c) urinary (dysuria, frequency of micturition) and (d) gastrointestinal (rectal pressure, tenesmus and progressive constipation)2.

An incarcerated gravid uterus in the late second and third trimester can cause severe abdominal pain, worsening urinary symptoms, preterm labour and premature rupture of the membranes. Once in labour, the problem can present with dystocia.

Physical examination of a woman with an incarcerated uterus produces characteristic findings. Abdominal examination may reveal a distended bladder, the fundal height is less than expected for her gestational age, and on speculum examination, the cervix cannot be visualised. On vaginal examination, the cervix is displaced anteriorly and can be felt behind the pubic symphysis and a firm mass (the fetal head) can be palpated in the recto-vaginal pouch2.

Ultrasound examination shows the bladder to be displaced anteriorly and superiorly in relationship to the uterus. It may also show hydronephrosis due to ureteric obstruction. The fetus is positioned posteriorly and is impacted against the curve of sacrum. The cervix and vagina are obscured because of the displacement of the bladder, and a placenta located at the fundus of the uterus can be mistaken for a placenta praevia5.

Treatment is usually not necessary, as in most instances the uterus ascends into the abdominal cavity. Between 14 and 20 weeks of gestation, manual manipulation can be performed while the woman is in the dorsal or lithotomy position. It can be repeated after one week or under general anaesthesia. Once incarceration has been reduced, a pessary will help the uterus to remain anteverted, the pessary being removed after a week. Manual manipulation can also be performed after creating a pneumoperitoneum through the laparoscope.

Beyond 20 weeks, however, attempts to reduce the incarceration will most likely fail and may cause serious complications such as preterm labour. Close monitoring of the woman for signs of preterm labour or premature rupture of membranes should be undertaken. Serial ultrasound assessment of fetal growth and assessment of liquor volume are recommended. If a diagnosis is made in labour, a decision must be made whether a vaginal delivery is possible. During caesarean section, the uterine incision must be made as high as possible to ensure that the uterine wall rather than the vagina is incised. In our case, this was not possible due to the position of the fibroid above the site of the incision.

References

  1. Top of page
  2. Case report
  3. Discussion
  4. References