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Uterine displacement

presented by

Dr.Methal

A.

Alrubaie

Assistant professor

Department of Obstetric & Gynecology

Objectives

*To define what is uterine displacement & how it is classified

*To discuss in details backward displacement.

* Explain the etiology behind backward displacement & what is the differential diagnosis.

*Discuss the methods of diagnosis & treatment.

* Identify the prognosis of

retroverted

uterus during pregnancy.

Position of uterus

*Normal position of uterus is

anteverted anteflexed

(i.e. the body of uterus is directed forward & the cervix backward).

*

The supra-vaginal portion of cervix is relatively fixed point.

* So uterine displacement mean rotation of body of uterus around this fixed point.

* uterus has limited range of movements.

* Factors affect the position of uterus are:- 1. Full bladder. 2. Raised intra-abdominal pressure as by cough, bear down. 3. Altered posture; the uterus lie lower in standing & lowest in squatting position.

Backward displacement

Retroversion:-

The long axis of cervix is directed upward backward in relation to long axis of the trunk.

Retro flexion:-

The long axis of the body of uterus is bend backward on the long axis of the cervix. Usually retroversion retro flexion occur together.

Frequency:-

It affect 15% of women.

Etiology:-

1. congenital:-

This type occur in

nulliparous,

there is mobile

retroverted

uterus with shallow anterior vaginal fornix ,the cervix is continuous with anterior vaginal wall & the vagina appear shorter than average.

2. Prolapse:-

As the uterus is prolapsed it pull the vagina with it so it is slightly

retroverted

.

3. Endometriosis:-

It caused fixed type of retroversion if it affect utero-sacral ligament & P.O.D.

4. Tumors & adhesions:-

Tumor in front of uterus push uterus backward or adhesions behind the uterus pull it backward.

5. Puerperal:-

After delivery the uterus involute while the controlling ligaments remain slacking & sub involute so the uterus directed backward , it last for (3-6 weeks) & then corrected to ante version ant flexion. If remain

retroverted

retroflexed it mean the original position of uterus is

retroverted

. It is usually mobile type.

Clinical features:

-

A. Symptoms:-

In mobile type it is symptomless & the only risk is the perforation of uterus if not diagnosed during D& C.

In fixed type there is:- * Spasmodic dysmenorrhea. * Lower backache & pelvic pain. * Deep dyspareunia:- due to direct pressure on uterus during coitus so it is position dependent & pain can be reduced by change the position during intercourse. *Pelvic congestion syndrome:- this in arise due to broad ligament torsion by retroversion so it cause inference with venous & lymphatic drainage & leave pelvic organs edematous & congested. It is presented with congestive dysmenorrhea, deep dyspareunia, menorrhagia, premenstrual pelvic pain & leucorrhea. * Infertility:- the cervix is directed a away from seminal pool & ejaculation directly into external

os

of cervix is less likely in addition that cervix is closed by anterior vagina. * Recurrent abortion.

B. Signs:-

*

By pelvic examination ;the cervix is directed upward & the external

os

is unusually visible easily. * The body of uterus is felt in P.O.D. * Tenderness is a striking feature during pelvic examination.

Differential diagnosis:-

* Tubal & ovarian tumor prolapsed into P.O.D. * Mass in large bowel. * Endometriosis in P.O.D. * Hematoma or abscess in P.O.D. * Uterine

myoma

in posterior wall of uterus.

Prevention:-

*Regular emptying of bladder to avoid over distension. * Early mobilization. * Pelvic floor exercise.

*

Encourage the patient to lie with face downward for half –one hour once or twice daily to induce ante version. The important time is (10-28 days) after labor since before that the uterus is large so promontory of sacrum prevent correction this is applied for puerperal retroversion.

Treatment:-

1. Mobile type:-

No treatment is required since it is symptomless & just reassure the patient that it is normal.

2. Fixed type:-

The treatment is directed primarily to the disease that cause retroversion. Methods of treatment are:-

A. Manual replacement:-

By move the cervix backward so the fundus will rotate forward & can caught by abdominal hand to keep it in its original position.

B. Pessary use:-

this type of treatment will correct retroversion temporarily & not cure the retroversion.

Hodge pessary

is the most efficient; it add pressure on posterior vaginal fornix & uterosacral ligament so pull the cervix backward. It is indicated in:-

* As therapeutic test:-

If there is doubt that symptoms are caused by

Retroversion or not so insert the pessary for one month & ask the patient to report whether the symptoms disappear or not, if disappear so advise to keep it for (2-3)months.

* pregnancy:-

If spontaneous correction not occur.

C. Surgery:-

it is indicated in the following:- 1. If the symptoms are caused by retroversion proved by pessary test. 2. In cases of deep dyspareunia. 3. As part of operation for endometriosis &

myoma

. 4.In cases of infertility & habitual abortion.

Types:- 1. Baldy Webster operation:-

By hold the loops of round ligaments through anterior & posterior leaves of broad ligament & sutured to the back of uterus.

2.

Gilliams

operation:-

By hold the loops of round ligaments through internal abdominal ring & sutured to the back of rectus sheath using permanent suture.

3. Laparoscopic

ventro

-suspension. 4. Shortening of utero-sacral ligaments.

Retroverted gravid uterus:-

It affect 15% of pregnancies. The prognosis can be:-

* Spontaneous correction:-

It occur by tenth week of gestation in nearly almost pregnancies.

* Sacculation of uterus

:-

If the fundus remain beneath the sacral promontory so the pregnancy continue by growing of anterior uterine wall producing a saccule or diverticulum, if this not recognized the body of uterus remain in pelvis act as tumor obstruct the delivery & safe treatment is C/S.

* Impaction of uterus (incarcerated uterus):-

The fundus of uterus fail to clear above the sacral promontory & the whole uterus remain in pelvis by (12-14weeks).

The uterus push the fundus of bladder forward & the base backward so acute retention of urine arise due to interference with internal urethral opening posteriorly. On examination there is soft abdominal mass which is full bladder & mistaken with uterus. By pelvic examination it is difficult to feel cervix because it is drawn high up in anterior vaginal wall. Differential diagnosis include:- 1. Other causes of acute retention of urine. 2. Other causes of tumor in P.O.D. as hematocele. Treatment:- * Slow drainage of bladder while the patient is kept prone in exaggerated Sims position. *If no spontaneous correction occur after drainage so insert large pessary. * if no response so surgical treatment is indicated.

Thank you