Minimally Invasive Adhesiolysis for the Incarcerated Gravid Uterus: A Case Report of Early Second Trimester Intervention.

Abstract

Introduction: Incarceration of the gravid uterus is a rare obstetric complication in which the retroverted uterus becomes trapped in the pelvis, often resulting in maternal and fetal morbidity if not recognized and managed early.

Case report: We present the case of a 36-year-old multigravida at 15 weeks' gestation with no prior abdominal surgeries who initially presented with urinary retention and was diagnosed with an incarcerated gravid uterus. Multiple attempts at manual reduction under spinal and general anesthesia were unsuccessful. Intraoperative transabdominal ultrasound demonstrated a live intrauterine pregnancy with normal fetal heart rate, a uterine fundus wedged behind the sacral promontory consistent with persistent incarceration and raised concern for a Grade 1 (minor) placenta previa. Diagnostic laparoscopy revealed dense posterior adhesions between the uterus and sigmoid mesentery. Adhesiolysis was performed, resulting in successful uterine repositioning and symptom resolution. Although the patient initially recovered well, she re-presented with vaginal bleeding with resolution of her previa but with evidence of chorion-amnion separation. Ultimately, she experienced previable preterm premature rupture of membranes and was subsequently diagnosed with intrauterine fetal demise at 22 weeks and 4 days. Placental pathology demonstrated severe acute chorioamnionitis, funisitis, umbilical vasculitis, and features of uteroplacental underperfusion.

Conclusion: This case demonstrates the role of laparoscopy in management of gravid uterine incarceration refractory to manual reduction. It also underscores that technically successful surgical intervention may not preclude adverse pregnancy outcomes, emphasizing the importance of close antenatal surveillance.