Obstetrics Simplified - Diaa M. EI-Mowafi

Retroverted Gravid Uterus

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During pregnancy the following may occur:

• Spontaneous correction:
  • occurs in the majority of cases about the 12th week.
• Incarceration:
  • occurs usually around 14-16 weeks where the uterus continue to grow posteriorly in the pelvis and its fundus is below the promontory of the sacrum. This may be due to:
    • jutting promontory,
    • pelvic adhesions,
    • posterior wall fibroid.
• Abortion:
  • may occur around 14-16 weeks due to:
    • congestion of the uterus, and
    • stretching of the internal os as the body of the uterus is unable to expand to accommodate the pregnancy.
• Anterior sacculation:
  • If the incarceration is not relieved the anterior part of the lower uterine segment distends to accommodate the growing pregnancy. This may lead to rupture of the uterus.

Clinical Picture of Incarceration

Symptoms

• Urinary symptoms: Frequency then difficulty which may progress to acute retention of urine due to elongation and compression of the urethra.
• Pain: may be due to:
  • bladder distension,
  • pressure on pelvic organs, or
  • abortion.

Signs

• Abdominally: The distended bladder may be felt.
• Vaginally:
  • The cervix is high and directed anteriorly,
  • The body of the uterus is felt in Douglas pouch as a soft mass.

Differential Diagnosis

• Ovarian cyst with pregnancy.
• Posterior wall fibroid with pregnancy.
• Pelvic haematocele.

Management

Prophylactic

Avoid overdistention of the bladder. Frequent prone position. Examine the patient during 14-18 weeks if spontaneous correction was not occur, manual correction is advised.

Curative

• Slow evacuation of the bladder and leave Foley’s catheter to keep it empty. Place the patient in prone or Sims' position.
• These usually succeed to correct the retroversion, if fail do:
• Manual correction with or without anaesthesia. In extremely rare cases, laparotomy may be needed to free the adhesions.
• Management of anterior sacculations:
• In early pregnancy: manual correction is attempted and if fails, do laparotomy to free the uterus. In late pregnancy: deliver the foetus by caesarean section.

Pendulous Abdomen

It is marked weakness of the anterior abdominal wall leading to forward falling of the pregnant uterus to overhang the symphysis pubis.

Predisposing Factors

• Grand multiparity which causes laxity of the abdominal wall.
• Contracted pelvis.
• Increased lumbar lordosis.

Complications

Discomfort to the patient. Malpresentations and nonegagement. Premature rupture of membranes and prolapse of the cord. Prolonged labour. Obstructed labour and rupture uterus.

Management

Abdominal binder. Exclude disproportion and maintain the dorsal position during labour. Ventouse, forceps or breech extraction may be used in prolonged labour to direct the presenting part in the pelvis.