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A Case of Gravid Uterine Incarceration Resolved with Spinal Anesthesia
Abstract Number: RF3BC-303
Abstract Type: Case Report Case Series
Uterine incarceration is a rare obstetric complication that impacts approximately 1 in 3,000 pregnancies1. Women typically present with pelvic pressure and pain, however severe cases can cause urinary retention, constipation, bowel ischemia, bladder atony, and possible impaired placental blood flow with unclear effects on fetal outcomes2. Diagnosis is made with ultrasound in many cases, though MRI may be necessary. There is currently no consensus on first line treatment, however reduction of the incarceration is important to avoid potential significant morbidity.
The patient presented with pelvic pain and urinary retention in the setting of a 12-week gestation incarcerated uterus. Attempts at manual reduction were performed in the outpatient setting by several providers without success. The patient was admitted to labor and delivery for attempted reduction with anesthesia support. An ultrasound performed immediately prior to initiation of anesthesia confirmed a sharply retroverted, incarcerated uterus (see figure 1). Our institution’s standard labor analgesic dose of 2.5 milligrams of 0.5% bupivacaine with 15 micrograms of fentanyl was administered intrathecally and an epidural catheter was placed to facilitate surgical anesthesia in the event that further measures, such as laparotomy, were necessary. Spinal anesthesia was successful, and provided the patient with complete pain relief. An ultrasound performed immediately prior to the manual reduction attempt showed full resolution of uterine incarceration.
Despite the variable anesthetic techniques described in the literature for reduction of uterine incarceration, combined spinal-epidural analgesia may be a reasonable first line option as it provides quick onset of analgesia to facilitate intravaginal manual reduction, the potential for conversion to surgical anesthesia if necessary, as well as avoidance of systemically administered sedatives and analgesics. Furthermore, as evidenced in our case, spinal anesthesia may also promote spontaneous resolution, potentially through abdominal muscular relaxation.
1. Slama R, Barry M, McManus K, Latham D, Berniard M. Uterine Incarceration: Rare Cause of Urinary Retention in Healthy Pregnant Patients. West J Emerg Med. 2015;16(5):790-792.
2. Jacobsson B, Wide-Swensson D. Incarceration of the retroverted gravid uterus--a review. Acta Obstet Gynecol Scand. 1999;78(8):665-668.