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Spinal Anesthesia for Reduction of Incarcerated Gravid Uterus
Abstract Number: T-64
Abstract Type: Case Report/Case Series
Incarceration of the gravid uterus is a rare complication of pregnancy with an incidence of 1 in 3000. As a result of persistent retroversion by the end of the first trimester, the growing uterus remains positioned within the sacral promontory and pubic symphysis. Incarcerated uterus poses significant potential risk to both maternal and fetal morbidity and mortality. Early manual reduction is recommended as the first-line treatment in the management of incarcerated uterus. We present a case of incarcerated uterus in a patient at 20 weeks and 1 day managed with manual reduction under spinal anesthesia.
A 37 year old G2P0 at 20+1 presented following three days of vaginal pain. The patient also noted several weeks of urinary frequency and occasional incontinence. Her past medical and obstetric history were otherwise noncontributory. Bimanual exam was significant for an absent cervix and a palpable fundus within the vagina. Ultrasound exam indicated an anterior cervix with a retroverted uterus, consistent with incarceration. Attempted manual reduction was unsuccessful. The decision was made to reattempt manual reduction under anesthesia. Hyperbaric bupivacaine 11.25 mg and fentanyl 25 mcg were delivered intrathecally through a 24G Sprotte spinal needle at the L3-L4 interspace. The patient was subsequently positioned in lithotomy before undergoing manual reduction with ultrasound guidance; the fundus was successfully repositioned anteriorly to a normal anatomic position. The patient tolerated the procedure well, and was discharged upon recovery from her spinal anesthetic.
Management of incarcerated uterus is recommended before 20 weeks gestation.(1) After 20 weeks, attempts at manual reduction are less successful, and the risk of preterm labor increases. More invasive measures have been described ranging from insufflation via colonoscopy to surgical laparotomy. Previous case reports indicate successful manual reduction in later second trimester and third trimester individuals under general endotracheal anesthesia. We present a case in which spinal anesthesia was sufficient to allow for successful reduction of incarcerated uterus in a patient who presented beyond the recommended gestational age for manual intervention. Currently, no guidelines exist regarding anesthetic considerations in the management of this rare presentation. Spinal anesthesia has been previously shown to improve success rates for external cephalic version without any increased risk in maternal or fetal morbidity. We propose that the pelvic floor relaxation provided by a spinal anesthetic can potentially increase the rate of safe and successful manual reduction of incarcerated uterus. In turn, this could also extend the window of opportunity in which manual reduction can be considered while simultaneously avoiding a general anesthetic.
1. Obstet Gynecol Surv. 2016, vol. 71, 613.