Incarcerated Uterus in pregnancy: Symptoms & Solutions

On September 21, 2021 at 20 weeks, we delivered our sweet baby boy who was already with Jesus. It’s been a long time coming, telling his story. Levi and I know with as close to 100% certainty the cause of our loss: incarcerated uterus. His death could have likely been prevented if we had known. Now, I want others to know.

Is Incarcerated Uterus Rare?

Incarcerated uterus, a potentially devastating pregnancy complication, is said to be “very rare.” The estimated occurrence is 1 in 3000 pregnancies¹.

We know though, somewhere between 1/4 and 1/3 of women have a retroverted uterus, a precursor to this pregnancy complication.

Additionally, a knowledge deficit exists within obstetrics and midwifery. Per my experience and those shared on-line by other women, most in the field don’t have the basic knowledge needed to recognize and link presenting symptoms with the underlying problem: uterine incarceration. Providers who are able to recognize the problem may lack understanding of the seriousness and how to properly care for the mother and particularly, the baby.

The belief that incarcerated uterus is rare combined with prevalence of retroversion and lack of basic knowledge leads me to believe uterine incarceration may not be quite as rare as previously thought. In other words, without basic knowledge of a condition it’s hard to determine the condition’s prevalence.

Regardless of prevalence, knowledge on the topic could have prevented my heartache; therefore, I will educate in hopes of preventing someone else’s.

Retroverted Uterus: A Precursor

Retroverted vs. Normal non-pregnant uterine position Source: Cleveland Clinic

The term ‘retroverted’ is simply one common position of the uterus within the pelvis.

A retroverted uterus is also commonly referred to as a ’tilted’ uterus. This means your “uterus is tilted backward toward your spine,” according to Cleavland Clinic. “It doesn’t cause any serious health problems” but can be a source of “discomfort during sex and painful menstruation.”

The retroverted uterus, as stated above, is common. Likely 25% of women hold this uterine position² sometimes from birth and sometimes the position develops later for various reasons.

Almost all articles on this uterine position state it isn’t an issue or reason for concern, even in pregnancy… which is true, with exception. A retroverted uterus is the common precursor to an incarcerated uterus³ which can devastate the hopes and plans of bringing a beautiful growing life into the world.

Incarcerated Uterus: a Pregnancy Emergency

Anatomy of the Incarcerated Uterus:

the incarcerated uterus is prevented from coming forward by the sacral promontory

Pelvic anatomy: Sacral Promontory visualized Source: Oregon State

Above I explained the anatomy of a retroverted (retroflexed or tipped) uterus. Uterine Incarceration is essentially the same positioning but with a growing baby which leaves the expanding uterus mal-positioned and anatomically trapped in the pelvis.

In pregnancy, as a uterus that is retroverted or tipped back grows, it should naturally ascend out and forward moving out of the pelvic cavity and into an anteverted position.

But, in some cases and for varying reasons it becomes what is referred to as incarcerated. The incarcerated uterus remains tipped backward and continues to grow in that position behind the sacral promonatory which inhibits spontaneous proper positioning.

Eventually, without spontaneous or manual reduction the uterus runs out of room to expand within the pelvic cavity.

Potential Complications:

If the uterus remains trapped in the pelvis and runs out of room to grow, this can eventually cause intrauterine growth restriction (IGUR). Essentially, the baby runs out of room to grow, stops growing and eventually dies if not corrected. This is what we believe happened to our baby boy (discussed in detail on the podcast).

In addition, fetal death, possibly not associated with growth restriction and premature labor and delivery are major risks for baby.

For the mother, there are potential complications as well, beyond the loss of her once developing baby. Among those risks are renal (kidney) failure, sepsis, bladder and uterine rupture (rupture is usually associated with manual repositioning in second and third trimesters)¹.

Defining Terms:

incarcerated: confined, imprisoned or trapped

reduction/reduced: correction or realignment to proper position

spontaneous reduction: on its own without help, moving into proper position

manual reduction: physical intervention by provider to help the uterus out of the pelvic cavity into proper position

Incarcerated Uterus: Signs and Symptoms

There is hope for preventing complications and carrying a healthy full term pregnancy just as I did after our loss, if the provider and/or mother are educated on common signs and symptoms.

The most notable sign documented: inability to void (pee) properly. This rang true for me with 3 of my 4 pregnancies.

With the uterus tipped back the cervix naturally pushes forward. As the uterus grows, the cervix begins to press on the urethra making it hard to urinate. I compare the presentation to that of an elderly man with a prostate issue. While some women may find themselves completely unable to urinate, others might be able to go but with straining, lots of starting and stopping, retention and frequent urge.

Other signs are constipation, back pain but in my experience and reading other women’s, the interference with urination is the most common and noticeable red flag.

Can Incarcerated Uterus be Prevented?

Short answer: Yes¹.

Yes, it may be prevented completely if you are educated on the topic. If not initially prevented, the uterus may be reduced (put into proper position) when incarceration is noted early in the pregnancy, usually by late first trimester.

Most women who have a retroverted uterus will never experience an incarcerated uterus, but it’s good to be aware if you have this uterine position that puts you in a favorable position for the complication.

On the other hand, if you have experienced uterine incarceration once, you are more likely to experience it again, be educated.

How do you prevent Incarcerated Uterus?

The pregnancy following our loss, an ultrasound at 9 weeks revealed my baby growing in my uterus that was tipped back “like a rainbow”… it had to come forward.

Early on in pregnancy you might get it to come forward in proper position but it’s unlikely to stay put until the uterus has grown a bit making it unable to easily fall back into the position it’s accustom. So, early on, surveillance and symptom recognition coupled with encouragement of proper positioning through purposeful daily movement as well as avoidance of positions that encourage maintenance of the retroverted uterine position, are the best management.

By 9 weeks I was already having symptoms. Slight trouble urinating at night and in the mornings, I knew what was coming if we didn’t do something.

Every day my focus was moving in ways to encourage my uterus out of the pelvic space.

Here’s what I did:

Absolutely no back sleeping. Side/stomach sleeping only, propped with pillows.
Cat/Cow position
Inversion with knees on bed, hands on floor, head down gentle rocking back and forth at least every morning and night but usually 3 times a day.
Walk and move especially with prolonged sitting (as with long car rides) was necessary
Avoid sitting reclined back with feet up

We planned for another ultrasound at 12 weeks to see if my uterus was in proper position… it (praise God) was. We likely could have used symptoms to guide us without additional ultrasound imaging. I had absolutely no signs of incarceration at that point and was able to urinate normally – a stark contrast from my previous pregnancy. But, after a late loss the certainty was valuable.

If my uterus had not been in proper position, a manual reduction would be the next step.

Manual reduction would have likely involved placing a catheter to ensure my bladder would be fully emptied as to ensure it wouldn’t be taking up space we wanted the uterus to move into. We discussed the scenario of me on my hands and knees (so as to let gravity help) with the possibilities from there involving gentle traction on the cervix and/or going through the rectum to push the uterus forward.

If a manual reduction didn’t work, there would likely have been surgical intervention which we did not discuss in detail.

Contrast in care and management…

At my first appointment with the midwife service, I met with a midwife who told me all five of the midwives within the practice had met and discussed my case. From there, the one overseeing my care that day had researched. We could tell in speaking with her, she had read everything I had, listened to the entire story of our loss and the symptoms I presented with, in that pregnancy and with my living second child.

She asked questions.

Then, she told me, “if you lose this baby it will absolutely not be due to an incarcerated uterus.”

Bold? Maybe. But, we believed her. Not because of any blind wishful thinking. But because we had knowledge of the problem and so did our provider. There was no pride or arrogance on behalf of the midwives. Just a will to learn anything they needed to, in order to give my baby the best care possible.

There is something so rare and valuable about the combination of humility and ability within any area of healthcare.

Lessons from our loss…

“We’ll place a foley catheter if you can’t urinate” and have a 16 week “in person appointment” instead of a video chat. (insert jaw drop) That was “THE PLAN” the hospital provider, who cared for me during the pregnancy we lost, had for my next pregnancy after our loss.

Check, please! I’m outta here…

The baby boy we lost had stopped growing at 16 weeks… 16 weeks was too late. A catheter, sure that would fix the symptom, but that symptom was there to alert us of a major problem, a problem it was clear this set of providers had written off, not yet researched and had no intentions of researching.

I had researched. I knew anatomically what had happened and I needed providers prepared to intervene appropriately if it happened again and best case scenario, work with me to prevent my uterus from becoming incarcerated in the first place.

So, that’s what I found.

I ended up cancelling all my appointments with the hospital obstetrics department and going with a midwife service that, at the time had no extensive knowledge themselves, but as described above was willing to humble themselves, research and learn.

You have to be willing to advocate for yourself.

Part of advocating is trusting that God-given gut instinct when something isn’t right with your body. Another part is heeding that same God-given instinct when you know something isn’t sitting well with you regarding your providers, not hanging on, hoping they start taking you seriously.

Why didn’t you advocate for the boy you lost?

You might be reading this thinking, “you should have done something the first time.”

The thing is, I did. I researched. I asked. Even still I’ve thought the same, “I should have known.”

I’m my own worst critic and it’s only by God’s grace that I haven’t beat myself up daily.

At our 10 week appointment, I didn’t personally hear the word incarcerated. If I had alarm bells would have went off in my ICU nurse brain. (I give details on that appointment in this podcast episode).

I already had a daughter, alive and well without any issues after having the same symptoms. With her, one morning at about 12 weeks, I woke up and despite the urge to ‘pee’ and my bladder feeling full, I was completely unable to urinate. I instinctively got on my hands and knees and within a few minutes found myself able to ‘go.’ This was the only time I had symptoms during my pregnancy with her. But this made my symptoms with our son, familiar and easier to write off as annoying but not harmful.

Lastly, I did research extensively the term “retroverted uterus” combined with “pregnancy” and “problems” etc. Nothing. I found no articles alerting me to be aware of uterine incarceration. Which is my main driver for this article.

My hope in writing this and linking retroversion and incarceration:

I deeply hope that providers who see mothers through their pregnancies will take time to educate themselves and women who have these symptoms will have necessary information populate when they go on-line seeking information.

Lacking Evidence to Guide Management

*Uptodate.com states “The literature about incarcerated pregnant uterus consists primarily of single case reports; thus, there is a lack of high-quality evidence to guide management.”

Sometimes, unfortunately, there is opportunity to gather information so that there is high quality evidence but those opportunities are squandered. The reasons may be as innocent as lacking basic knowledge needed to know there is cause for investigation. However, dismissal of patient complaints and unwillingness to grow a knowledge base due to arrogance is another. Some providers feel superior or above admitting there may be a knowledge gap. This is always a dangerous scenario for patients regardless of the situation. Humility is such an important piece to practicing medicine and just living life well in general.