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Malposition of the Uterus

Overview

Neither uterine size, shape or position is permanently fixed. Intermittent myometrial contractions and changes in uterine shape and position are normal during pregnancy. Some of the alterations in the shape of the uterus during pregnancy, such as transient asymmetry related to early gestation (Piskacek uterus) or in the immediate postpartum state, are simply normal variants.

Uncommonly, obstetric complications result from acute or chronic changes in uterine shape or position prior to labor (retroversion or incarceration, prolapse, torsion, herniation or sacculation), during labor (pathologic retractions rings), or postpartum (acute or chronic inversion).
The most common uterine malpositioning seen during pregnancy, retroversion with incarceration, is depicted below.

Uterine retroversion and incarceration progressing

Uterine retroversion and incarceration progressing to sacculation as pregnancy advances.

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In nonpregnant women, the uterus also assumes numerous positions. Uterine retroversion in nonpregnant women is now recognized as a normal variant that, in most cases, does not result in symptoms. The resort to surgery for the correction of chronic uterine retroversion in the absence of distinct pathologic process (eg, endometriosis, other inflammatory condition) has fallen into appropriate disrepute. This is because of the lack of scientific or experimental evidence supporting the effectiveness of repositioning operations in removing symptoms such as chronic pain or menstrual disturbances or as an isolated treatment for infertility.

Among healthy women, 1 in 5 have a retroverted uterus either as a normal variant of uterine position or as an acquired condition. However, fixed retroversion is not necessarily benign. It can result from important gynecologic pathology. When the uterine contour is distorted by a müllerian anomaly or a strategically placed leiomyoma, or an inflammatory process has occurred in the past (eg, endometriosis or salpingitis with pelvic adhesions), the uterus may become fixed in retroversion/retroflexion and lose its normal mobility.

Fixation of the uterus by adhesions is a risk factor for the rare pregnancy complications of uterine torsion, incarceration, or sacculation. Uncommonly during pregnancy, a uterus in retroflexion but without restricting adhesions can also become incarcerated behind the sacral promontory due to a peculiar combination of malpositioning and laxity of the supporting tissues. When uterine retroversion with incarceration develops for any reason during pregnancy, acute symptoms and serious complications are possible, and initial misdiagnosis is frequent.

Most uncommonly, cases of chronic uterine retroversion/incarceration develop uterine sacculation. This is an aneurysmal-like dilatation of the most superior portion of the uterine wall that permits the uterus to enlarge with the consequence of major anatomic distortion. These rare cases can then present at or about term with acute signs and symptoms of maternal or fetal distress, necessitating prompt surgical intervention.

Based on compiled clinical reports and the author’s experience, the diagnosis and management of the principal types of both benign and pathologic uterine malpositionings that occur during pregnancy are described in this review.

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