19/40. Pelvic discomfort increasing during gestation. Some difficulty passing urine. Cervix unable to be palpated, not visualised on speculum examination or seen on ultrasound scan.
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The vagina is seen to extend anteriorly behind the bladder with the cervix quite high (90mm) from the vestibule to the internal os. The cervix is elongated behind the upper bladder and measures 30mm in sagittal length x 15mm in depth. The fundus of the uterus is pushing against the rectum. The uterus is incarcerated within the pelvis with the lower segment ballooning into the maternal abdomen. Incidental finding of synechiae over the right lower uterus.
The treating clinicians were unable to feel or visualize the patient's cervix which led to ultrasound examination which could not identify the cervix. A smooth "bulge" in the expected region of the cervix was palpated which raised suspicion for a dilated cervix and presenting membranes (although these could not be visualized), and MRI was performed. In retrospect these clinical findings were typical for uterine incarceration and the MRI confirmed this diagnosis. This patient had undergone pelvic surgery for fibroids in the past which may have led to the development of this condition.
An incarcerated uterus often resolves without intervention, as it did in this case. There have been reports of the uterus freeing itself from the sacral hollow with an audible "pop" similar to a champagne cork being removed. If the uterus does not return to the abdomen in the third trimester, it is extremely important to be aware of the position of the cervix and vagina before mode of delivery is determined - if a standard lower segment cesarean section was performed, the cervix and anterior vagina wall are at risk of injury and the surgical approach should be altered.