he fallopian tubes develop from the unpaired distal ends of the mlillerian ducts. Congenital anomalies include accessory ostia, complete or segmental tubal agenesis, and several embryonic cystic remnants. The most common is a small, benign cyst attached by a pedicle to the distal end of the fallopian tube-the hydatid of Morgagni. In other cases, benign paratubal cysts may be of mesonephric or mesothelial origin. Last, in utero exposure to DES is associated with various tubal abnormalities. Of these, short, tortuous tubes or ones with shriveled fimbria and small ostia are linked to infertility (DeCherney, 1981).
The pregnant uterus may infrequently show exaggerated flexion. Mild or moderate lexion is typically inconsequential, but congenital or acquired extremes may lead to pregnancy complications.
Antlexion describes forward angling of the uterine fundus in the sagittal plane relative to the cervix. Exaggerated degrees usually pose no problem in early pregnancy. Later, however, particularly when the abdominal wall is lax such as with diastasis recti or ventral hernia, the uterus may fall forward. In extreme cases, the fundus lies below the lower margin of the symphysis. Sometimes, this abnormal uterine position prevents proper transmission of labor contractions, but this is usually overcome by repositioning and application of an abdominal binder.
Retrolexion describes posterior uterine fundal angling in the sagittal plane. A growing retrolexed uterus will occasionally become incarcerated in the hollow of the sacrum. Symptoms include abdominal discomfort, pelvic pressure, and voiding dysfunction or retention. During bimanual pelvic examination, the cervix will be anterior and behind the symphysis pubis, whereas the uterus is appreciated as a mass wedged in the pelvis. Sonography or MR imaging can aid the clinical diagnosis (Gardner, 2013; Grossenburg, 2011; van Beekhuizen, 2003).
With continued uterine growth, the incarcerated uterus can spontaneously resolve over 1 to 2 weeks. An indwelling urinary catheter or intermittent self-catheterization may be needed in the interim to empty the bladder. Persistent cases require manual repositioning. For this, after bladder catheterization, the uterus can usually be pushed out of the pelvis when the woman is placed in a knee-chest position. Often, this is best accomplished by digital pressure applied through the rectum.
FIGURE 3-7 Anterior sacculation of a pregnant uterus. Note the markedly attenuated anterior uterine wall and atypical location of the true uterine fundus. Rood, 2014).
Conscious sedation, spinal analgesia, or general anesthesia may be necessary. Following repositioning, the catheter is left in place until bladder tone returns. Insertion of a soft pessary for a few weeks usually prevents recurrent incarceration.
Lettieri and colleagues (1994) described seven cases of uterine incarceration not amenable to these simple procedures. In two women, laparoscopy was used at 14 weeks' gestation to reposition the uterus using the round ligaments for traction. Alternatively, in case series, advancing a colonoscope or colonoscopic insulation was used to dislodge an incarcerated uterus (Dierickx, 2011; Newell, 2014; Seubert, 1999).