{"paper_id":"df933c19-9e9b-4e3a-ae16-d888c941c120","body_text":"Diagnostic Pitfalls of Incarcerated Gravid Uterus: Report of Two Cases and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Diagnostic Pitfalls of Incarcerated Gravid Uterus: Report of Two Cases and Literature Review Xin Du, Zhimin Sun, Juan Juan Sheng, Wei Gao, Yunshan Zhang, Jinfang Gao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7601608/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Incarcerated gravid uterus (IGU), which is characterized by entrapment of the retroverted uterus within the pelvis during the gestational period, is an uncommon condition but might potentially lead to serious maternal-fetal outcomes. Delayed recognition may result in maternal and fetal morbidity. Case Presentations : In this article, we describe two IGU cases diagnosed in the second trimester of gestation but initially considered as placenta previa. Case 1 was a 33-year-old woman who conceived through IVF measures but experienced repeated episodes of vaginal bleeding during pregnancy. At 23+6 weeks, ultrasonography revealed IGU, which initially was misdiagnosed as central placenta previa. Her worsening hemorrhage at 24+3 weeks of gestation necessitated urgent cesarean delivery. In the process of the procedure, it was found that the uterus was severely retroverted and densely adherent to the rectovaginal space. Case 2 was also about a patient conceived through IVF-ET who was complicated with adenomyosis and uterine fibroid. She presented with recurrent abdominal pain from 20 weeks onwards. The ultrasound and MRI imaging examination also detected placenta previa initially. Afterwards, the ultrasound revealed IGU with an elongated cervix. Persistent exacerbating pain led to cesarean section at 32+6 weeks, which confirmed IGU during the procedure. Conclusion : One of the significant diagnostic pitfalls for IGU is the early misreading of imaging investigations, particularly the incorrect diagnosis of placenta previa. For prompt diagnosis and better maternal-fetal outcomes, patients who arrive with unusual pain or aberrant cervical findings should have a high index of suspicion for IGU. Figures Figure 1 Figure 2 Introduction Incarceration of the gravid uterus (IGU) is defined as persistent retroversion or retroflexion of the pregnant uterus so that the uterine fundus remains trapped beneath the sacral promontory within the pelvis. Although its rarity with an estimated incidence of approximately 1 in 3,000 pregnancies [ 1 ] , the IGU’s true frequency is likely underreported. Clinical presentation varies from asymptomatic to severe urinary retention, pelvic pain. The pathogenesis of IGU includes elongation and upward displacement of the cervix due to mechanical entrapment of the expanding uterus brought on by pelvic adhesions, posterior pelvic masses, or congenital abnormalities. Negative maternal-fetal outcomes, including pregnancy loss, premature labor, obstructed labor, and intraoperative damage during cesarean section, might arise from a missed or postponed diagnosis. We detail two IGU cases that we came across at our medical center. Both conceived through IVF-ET and were initially misdiagnosed as placenta previa—one in the context of adenomyosis and a uterine fibroid, and the other complicated by preterm premature rupture of membranes. These cases illustrate the diagnostic pitfalls and management challenges of this rare condition. Case Presentation Case 1 Following previous bilateral salpingectomy for treatment of tubal ectopic pregnancies, a 33-year-old patient was conceived by IVF-ET. She presented with significant vaginal hemorrhage in her 12 weeks and 18 weeks of gestation. Fetal structural abnormality screening at 20 weeks was unremarkable. At 23 weeks of gestation, she complained of continual vaginal watery discharge, which was later confirmed as preterm premature rupture of membrane (PPROM). The concurrent ultrasound examination performed at her local medical center suggested complete placenta previa without recognition of IGU signs. However, re-examination of transabdominal and transvaginal ultrasonography at our center demonstrated a retroverted and incarcerated gravid uterus (Fig. 1 ). Pelvic examination revealed that the cervical os was located at the anterior fornix in a high position. The cervix appeared soft and small, and exposure was difficult. The cervical margin was indistinct, and the cervical canal length could not be adequately assessed. The posterior fornix was full and bulging into the vagina. She was hospitalized and treated expectantly with antibiotics and tocolytic medication. On hospital day 4 (24 + 3 weeks), she experienced heavy vaginal bleeding (~ 300 mL) and abdominal pain. An emergency cesarean section was performed. During surgery, the uterus was found to be severely retroverted and adherent to the rectovaginal space, making adnexal exposure very difficult. A female infant weighing 680 g was delivered but died shortly after birth due to extreme prematurity. The patient recovered well and was discharged 5 days postoperatively, with no subsequent complications noted during follow-up. Case 2 A woman with a history of adenomyosis and uterine fibroids conceived through IVF-ET. Early ultrasound confirmed a viable intrauterine pregnancy. At 16 weeks, she experienced abdominal pain, and an ultrasound showed a low-lying placenta and myometrial nodularity. From 20 weeks of gestation onward, the patient was repeatedly hospitalized for recurrent abdominal pain, with limited response to progestogen therapy and tocolytic agents. At 32 weeks’ gestation, ultrasound demonstrated a singleton fetus in transverse lie with central placenta previa and an elongated cervix (> 9 cm) displaced anterior to the bladder. A marked thickening of the posterior uterine wall was noted, with apparent adhesion to the rectouterine pouch (Fig. 2 ). Following antenatal corticosteroid administration for promoting fetal lung maturation, cesarean section was performed at 32 + 6 weeks of gestation. Intraoperatively, the uterus was markedly retroverted and incarcerated, with dense adhesions in the rectouterine pouch, and a 5-cm myometrial mass on the posterior wall was found. The lower uterine segment and cervix were elongated. A live infant was delivered, and bleeding was controlled with uterotonic agents and intrauterine gauze packing. The patient had an uneventful postoperative course and was discharged on the fifth day, remaining well on follow-up without further sequelae. Discussion About 15% of pregnant women suffer uterine retroversion or retroflexion in the first trimester [ 2 ] , while in most cases it resolves spontaneously before 14 weeks of gestation [ 3 ] . Incarcerated gravid uterus (IGU) is referred to the condition that the uterine fundus remains in the pelvic cavity trapped beneath the sacral promontory without “self-correction” after 16 gestational weeks, which is a rare disease reported to occur in 1 in 3000 to 10,000 pregnancies [ 4 ] . In IGU cases, the posterior pelvis can no longer accommodate further expansion of the uterine fundus. As a result, the anterior lower uterine wall progressively thins and balloons upward into the abdomen, forming a sacculation that houses the products of conception. This configuration is referred to as “inverted polarity,” in which the anterior lower uterine wall lies cephalad to the fundus, which remains posterior and caudal [ 5 – 7 ] . Simultaneously, both the bladder and cervix are displaced upward into the abdominal cavity toward the umbilicus. The cervix may elongate to 10 cm or more, with the internal os positioned above the symphysis pubis and, in some cases, even superior to the bladder, exerting pressure on the urethra and bladder, which may obstruct normal urination [ 8 ] . The adhesive conditions including endometriosis, fibroids, PID, and multiple prior pelvic surgeries are risk factors for IGU [ 9 ] . Other risk factors than conditions above include uterine anomaly (eg, uterus didelphys, bicornuate uterus), deep sacral concavity with an overhanging sacral promontory, multifetal gestation, ovarian cysts, and prior uterine incarceration [ 10 ] . The majority of the IGU patients presented with urinary complaints and lower abdominal pain [ 11 ] . Gastrointestinal symptoms are caused by rectal compression. Some patients are asymptomatic until labor in delivery, while others might present with atypical abdominal pain or vaginal bleeding. The hallmark physical examination finding is the anterior displacement of the cervix behind the pubic symphysis, often making it difficult of visualization with a speculum and making the external os difficult to palpate during vaginal examination [ 12 ] . Incarcerated uterus should be suspected when physical examination reveals the characteristic findings of marked anterior displacement of the cervix behind the pubic symphysis in conjunction with a mass occupying the cul-de-sac. The presence of typical symptoms, such as pelvic pain and voiding difficulty, further supports the presumptive diagnosis. Definitive diagnosis is established when the classic constellation of anatomic abnormalities, as illustrated in Fig. 1 and described below, is confirmed by transabdominal ultrasound in the second or third trimester [ 2 ] . Although the definitive ultrasound diagnostic criteria of IGU is not well established, the diagnosis commonly requires the presence of all of the following findings [ 13 ] : Cervical displacement: The cervix is obscured or appears elongated and thinned, drawn anterior to the uterus, positioned between the bladder and the pregnant uterus. Bladder displacement: The bladder is compressed by the cervix and uterus, resulting in elongation and upward displacement. Fundal position: The uterine fundus is lodged within the sacral hollow, occupying the posterior pelvis below the level of the sacral promontory. Magnetic resonance imaging (MRI), using either T1- or T2-weighted sequences, can be employed in cases of diagnostic uncertainty, particularly after 20 weeks of gestation. MRI not only confirms uterine incarceration but may also help identify the underlying causes and delineate distorted pelvic anatomy, thereby providing valuable guidance for preoperative planning before cesarean delivery [ 14 ] . Regarding our reported cases, both highlight the diagnostic and management challenges of an incarcerated gravid uterus. In both patients, the condition was initially mistaken for placenta previa based on early imaging, which is a common diagnostic mistake. Paying close attention to uterine orientation and cervical displacement on ultrasound is essential, and additional imaging such as MRI may be necessary when results are unclear. These cases underscore the surgical challenges posed by distorted pelvic anatomy during cesarean delivery. Careful recognition of the displaced cervix and elongated lower uterine segment is critical to avoid adjacent organ injury, and in such situations, a higher uterine incision may offer a safer route of delivery. These cases highlight the necessity to consider uterine incarceration in patients with atypical pelvic pain, abnormal cervical position, or apparent placenta previa, especially in those with prior pelvic surgery or uterine pathology. Early recognition and multidisciplinary management are key to reducing maternal and fetal morbidity. Although the existing literature has helped us deepen our understanding of IGU, there still remain several significant gaps. The true incidence and recurrence risk are uncertain, largely due to underreporting and reliance on isolated case reports. We still lack comparative data on the effectiveness of different reduction techniques—ranging from manual maneuvers to newer approaches such as transvaginal ultrasound–assisted reduction, leaving clinicians with insufficient clear evidence to guide the choice of intervention. Furthermore, standardized imaging protocols have yet to be established. Structured sonographic assessment of uterine orientation and cervical canal trajectory, particularly in cases initially suspected as placenta previa, could help reduce misdiagnosis and prevent intraoperative complications. Future multicenter studies is necessary to address these uncertainties and to establish evidence-based strategies for timely diagnosis and optimal management. Declarations FUNDING INFORMATION This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CONFLICT OF INTEREST The authors declare no potential conflict of interest. Contributors Xin Du and Zhimin Sun contributed equally to the study and are joint first authors. Jinfang Gao conceived the study. Yunshan Zhang contributed the ultrasound images. Wei Gao and Juanjuan Sheng supported with manuscript editing and language refinement. DATA AVAILABILITY STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request. ETHICS STATEMENT No Ethics Committee approval was necessary for this study. CONSENT FOR PUBLICATION Both patients mentioned in the paper provided their written informed consent for the publication of their clinical details and any identifying images. References Hamod H, Chamberlain PF, Moore NR, Mackenzie IZ. Conservative treatment of an incarcerated gravid uterus. BJOG. 2002;109:1074–5. Gardner CS, Jaffe TA, Hertzberg BS, Javan R, Ho LM. The incarcerated uterus: a review of MRI and ultrasound imaging appearances. AJR Am J Roentgenol. 2013;201:223–9. O’Connell MP, Ivory CM, Hunter RW. Incarcerated retroverted uterus—A non recurring complication of pregnancy. J Obstet Gynaecol. 1999;19:84–5. van Beekhuizen HJ, Bodewes HW, Tepe EM, Oosterbaan HP, Kruitwagen R, Nijland R. Role of magnetic resonance imaging in the diagnosis of incarceration of the gravid uterus. Obstet Gynecol. 2003;102(5 Pt 2):1134–7. Gibbons JM Jr, Paley WB. The incarcerated gravid uterus. Obstet Gynecol. 1969;33(6):842–5. Jacobsson B, Wide-Swensson D. Incarceration of the retroverted gravid uterus–a review. Acta Obstet Gynecol Scand. 1999;78(8):665–8. Hsu PC, Yu MH, Wang CY, Wang YK, Wang CK, Su HY. Asymptomatic uterine incarceration at term: successful management of a rare complication in pregnancy.Taiwan. J Obstet Gynecol. 2018;57:745–9. Gottschalk EM, Siedentopf JP, Schoenborn I, Gartenschlaeger S, Dudenhausen JW, Henrich W. Prenatal sonographic and MRI findings in a pregnancy complicated by uterine sacculation: case report and review of the literature. Ultrasound Obstet Gynecol. 2008;32(4):582–6. Han C, Wang C, Han L, Liu G, Li H, She F, Xue F, Wang Y. Incarceration of the gravid uterus: a case report and literature review. BMC Pregnancy Childbirth. 2019;19(1):408. Narayanamoorthy S, Hillebrand A, Pendam R, McLaren R Jr. Incarcerated gravid uterus - A systematic review. Eur J Obstet Gynecol Reprod Biol X. 2023;19:100227. Fernandes DD, Sadow CA, Economy KE, Benson CB. Sonographic and magnetic resonance imaging findings in uterine incarceration. J Ultrasound Med. 2012;31(4):645–50. Feusner AH, Mueller PD. Incarceration of a gravid fibroid uterus. Ann Emerg Med. 1997;30(6):821–4. Gupta A, Gleason K, Joshi A. Incarcerated gravid uterus: an imaging challenge. Quant Imaging Med Surg. 2024;14(5):3768–72. Dierickx I, Meylaerts LJ, Van Holsbeke CD, de Jonge ET, Martens IF, Mesens T, Gyselaers WJ. Incarceration of the gravid uterus: diagnosis and preoperative evaluation by magnetic resonance imaging. Eur J Obstet Gynecol Reprod Biol. 2014;179:191–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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15:45:36\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":482444,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eUltrasound revealed a retroverted and incarcerated gravid uterus\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7601608/v1/19f98039a3cffc718584ba25.png\"},{\"id\":94474082,\"identity\":\"bc8edced-c246-41c5-9f35-6429d2ff833f\",\"added_by\":\"auto\",\"created_at\":\"2025-10-27 15:47:15\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":737132,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eElongated cervix displaced anterior to the bladder\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7601608/v1/ff5e4480091e806e67b1faea.png\"},{\"id\":110768322,\"identity\":\"c0a657ac-cf52-4c34-995a-d2675c24d94f\",\"added_by\":\"auto\",\"created_at\":\"2026-06-03 07:11:09\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1514002,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7601608/v1/2717b872-f735-4eee-8dd1-17a07d7ba0eb.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Diagnostic Pitfalls of Incarcerated Gravid Uterus: Report of Two Cases and Literature Review\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eIncarceration of the gravid uterus (IGU) is defined as persistent retroversion or retroflexion of the pregnant uterus so that the uterine fundus remains trapped beneath the sacral promontory within the pelvis. Although its rarity with an estimated incidence of approximately 1 in 3,000 pregnancies\\u003csup\\u003e[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]\\u003c/sup\\u003e, the IGU\\u0026rsquo;s true frequency is likely underreported. Clinical presentation varies from asymptomatic to severe urinary retention, pelvic pain.\\u003c/p\\u003e\\u003cp\\u003eThe pathogenesis of IGU includes elongation and upward displacement of the cervix due to mechanical entrapment of the expanding uterus brought on by pelvic adhesions, posterior pelvic masses, or congenital abnormalities. Negative maternal-fetal outcomes, including pregnancy loss, premature labor, obstructed labor, and intraoperative damage during cesarean section, might arise from a missed or postponed diagnosis.\\u003c/p\\u003e\\u003cp\\u003eWe detail two IGU cases that we came across at our medical center. Both conceived through IVF-ET and were initially misdiagnosed as placenta previa\\u0026mdash;one in the context of adenomyosis and a uterine fibroid, and the other complicated by preterm premature rupture of membranes. These cases illustrate the diagnostic pitfalls and management challenges of this rare condition.\\u003c/p\\u003e\"},{\"header\":\"Case Presentation\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eCase 1\\u003c/h2\\u003e\\u003cp\\u003eFollowing previous bilateral salpingectomy for treatment of tubal ectopic pregnancies, a 33-year-old patient was conceived by IVF-ET. She presented with significant vaginal hemorrhage in her 12 weeks and 18 weeks of gestation. Fetal structural abnormality screening at 20 weeks was unremarkable. At 23 weeks of gestation, she complained of continual vaginal watery discharge, which was later confirmed as preterm premature rupture of membrane (PPROM). The concurrent ultrasound examination performed at her local medical center suggested complete placenta previa without recognition of IGU signs. However, re-examination of transabdominal and transvaginal ultrasonography at our center demonstrated a retroverted and incarcerated gravid uterus (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Pelvic examination revealed that the cervical os was located at the anterior fornix in a high position. The cervix appeared soft and small, and exposure was difficult. The cervical margin was indistinct, and the cervical canal length could not be adequately assessed. The posterior fornix was full and bulging into the vagina.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eShe was hospitalized and treated expectantly with antibiotics and tocolytic medication. On hospital day 4 (24\\u0026thinsp;+\\u0026thinsp;3 weeks), she experienced heavy vaginal bleeding (~\\u0026thinsp;300 mL) and abdominal pain. An emergency cesarean section was performed. During surgery, the uterus was found to be severely retroverted and adherent to the rectovaginal space, making adnexal exposure very difficult. A female infant weighing 680 g was delivered but died shortly after birth due to extreme prematurity. The patient recovered well and was discharged 5 days postoperatively, with no subsequent complications noted during follow-up.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eCase 2\\u003c/h3\\u003e\\n\\u003cp\\u003eA woman with a history of adenomyosis and uterine fibroids conceived through IVF-ET. Early ultrasound confirmed a viable intrauterine pregnancy. At 16 weeks, she experienced abdominal pain, and an ultrasound showed a low-lying placenta and myometrial nodularity. From 20 weeks of gestation onward, the patient was repeatedly hospitalized for recurrent abdominal pain, with limited response to progestogen therapy and tocolytic agents.\\u003c/p\\u003e\\u003cp\\u003eAt 32 weeks\\u0026rsquo; gestation, ultrasound demonstrated a singleton fetus in transverse lie with central placenta previa and an elongated cervix (\\u0026gt;\\u0026thinsp;9 cm) displaced anterior to the bladder. A marked thickening of the posterior uterine wall was noted, with apparent adhesion to the rectouterine pouch (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eFollowing antenatal corticosteroid administration for promoting fetal lung maturation, cesarean section was performed at 32\\u0026thinsp;+\\u0026thinsp;6 weeks of gestation. Intraoperatively, the uterus was markedly retroverted and incarcerated, with dense adhesions in the rectouterine pouch, and a 5-cm myometrial mass on the posterior wall was found. The lower uterine segment and cervix were elongated. A live infant was delivered, and bleeding was controlled with uterotonic agents and intrauterine gauze packing. The patient had an uneventful postoperative course and was discharged on the fifth day, remaining well on follow-up without further sequelae.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eAbout 15% of pregnant women suffer uterine retroversion or retroflexion in the first trimester\\u003csup\\u003e[\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]\\u003c/sup\\u003e, while in most cases it resolves spontaneously before 14 weeks of gestation\\u003csup\\u003e[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]\\u003c/sup\\u003e. Incarcerated gravid uterus (IGU) is referred to the condition that the uterine fundus remains in the pelvic cavity trapped beneath the sacral promontory without \\u0026ldquo;self-correction\\u0026rdquo; after 16 gestational weeks, which is a rare disease reported to occur in 1 in 3000 to 10,000 pregnancies\\u003csup\\u003e[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]\\u003c/sup\\u003e. In IGU cases, the posterior pelvis can no longer accommodate further expansion of the uterine fundus. As a result, the anterior lower uterine wall progressively thins and balloons upward into the abdomen, forming a sacculation that houses the products of conception. This configuration is referred to as \\u0026ldquo;inverted polarity,\\u0026rdquo; in which the anterior lower uterine wall lies cephalad to the fundus, which remains posterior and caudal\\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR6\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]\\u003c/sup\\u003e. Simultaneously, both the bladder and cervix are displaced upward into the abdominal cavity toward the umbilicus. The cervix may elongate to 10 cm or more, with the internal os positioned above the symphysis pubis and, in some cases, even superior to the bladder, exerting pressure on the urethra and bladder, which may obstruct normal urination\\u003csup\\u003e[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]\\u003c/sup\\u003e. The adhesive conditions including endometriosis, fibroids, PID, and multiple prior pelvic surgeries are risk factors for IGU\\u003csup\\u003e[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]\\u003c/sup\\u003e. Other risk factors than conditions above include uterine anomaly (eg, uterus didelphys, bicornuate uterus), deep sacral concavity with an overhanging sacral promontory, multifetal gestation, ovarian cysts, and prior uterine incarceration\\u003csup\\u003e[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]\\u003c/sup\\u003e. The majority of the IGU patients presented with urinary complaints and lower abdominal pain\\u003csup\\u003e[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]\\u003c/sup\\u003e. Gastrointestinal symptoms are caused by rectal compression. Some patients are asymptomatic until labor in delivery, while others might present with atypical abdominal pain or vaginal bleeding. The hallmark physical examination finding is the anterior displacement of the cervix behind the pubic symphysis, often making it difficult of visualization with a speculum and making the external os difficult to palpate during vaginal examination\\u003csup\\u003e[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]\\u003c/sup\\u003e. Incarcerated uterus should be suspected when physical examination reveals the characteristic findings of marked anterior displacement of the cervix behind the pubic symphysis in conjunction with a mass occupying the cul-de-sac. The presence of typical symptoms, such as pelvic pain and voiding difficulty, further supports the presumptive diagnosis. Definitive diagnosis is established when the classic constellation of anatomic abnormalities, as illustrated in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e and described below, is confirmed by transabdominal ultrasound in the second or third trimester\\u003csup\\u003e[\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]\\u003c/sup\\u003e. Although the definitive ultrasound diagnostic criteria of IGU is not well established, the diagnosis commonly requires the presence of all of the following findings\\u003csup\\u003e[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]\\u003c/sup\\u003e:\\u003c/p\\u003e\\u003cp\\u003eCervical displacement: The cervix is obscured or appears elongated and thinned, drawn anterior to the uterus, positioned between the bladder and the pregnant uterus.\\u003c/p\\u003e\\u003cp\\u003eBladder displacement: The bladder is compressed by the cervix and uterus, resulting in elongation and upward displacement.\\u003c/p\\u003e\\u003cp\\u003eFundal position: The uterine fundus is lodged within the sacral hollow, occupying the posterior pelvis below the level of the sacral promontory.\\u003c/p\\u003e\\u003cp\\u003eMagnetic resonance imaging (MRI), using either T1- or T2-weighted sequences, can be employed in cases of diagnostic uncertainty, particularly after 20 weeks of gestation. MRI not only confirms uterine incarceration but may also help identify the underlying causes and delineate distorted pelvic anatomy, thereby providing valuable guidance for preoperative planning before cesarean delivery\\u003csup\\u003e[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]\\u003c/sup\\u003e.\\u003c/p\\u003e\\u003cp\\u003eRegarding our reported cases, both highlight the diagnostic and management challenges of an incarcerated gravid uterus. In both patients, the condition was initially mistaken for placenta previa based on early imaging, which is a common diagnostic mistake. Paying close attention to uterine orientation and cervical displacement on ultrasound is essential, and additional imaging such as MRI may be necessary when results are unclear.\\u003c/p\\u003e\\u003cp\\u003eThese cases underscore the surgical challenges posed by distorted pelvic anatomy during cesarean delivery. Careful recognition of the displaced cervix and elongated lower uterine segment is critical to avoid adjacent organ injury, and in such situations, a higher uterine incision may offer a safer route of delivery.\\u003c/p\\u003e\\u003cp\\u003eThese cases highlight the necessity to consider uterine incarceration in patients with atypical pelvic pain, abnormal cervical position, or apparent placenta previa, especially in those with prior pelvic surgery or uterine pathology. Early recognition and multidisciplinary management are key to reducing maternal and fetal morbidity.\\u003c/p\\u003e\\u003cp\\u003eAlthough the existing literature has helped us deepen our understanding of IGU, there still remain several significant gaps. The true incidence and recurrence risk are uncertain, largely due to underreporting and reliance on isolated case reports. We still lack comparative data on the effectiveness of different reduction techniques\\u0026mdash;ranging from manual maneuvers to newer approaches such as transvaginal ultrasound\\u0026ndash;assisted reduction, leaving clinicians with insufficient clear evidence to guide the choice of intervention. Furthermore, standardized imaging protocols have yet to be established. Structured sonographic assessment of uterine orientation and cervical canal trajectory, particularly in cases initially suspected as placenta previa, could help reduce misdiagnosis and prevent intraoperative complications. Future multicenter studies is necessary to address these uncertainties and to establish evidence-based strategies for timely diagnosis and optimal management.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eFUNDING INFORMATION\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCONFLICT OF INTEREST\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no potential conflict of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eContributors\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eXin Du and Zhimin Sun contributed equally to the study and are joint first authors. Jinfang Gao conceived the study. Yunshan Zhang contributed the ultrasound images. Wei Gao and Juanjuan Sheng supported with manuscript editing and language refinement.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDATA AVAILABILITY STATEMENT\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eETHICS STATEMENT\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNo Ethics Committee approval was necessary for this study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCONSENT FOR PUBLICATION\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eBoth patients mentioned in the paper provided their written informed consent for the publication of their clinical details and any identifying images.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eHamod H, Chamberlain PF, Moore NR, Mackenzie IZ. Conservative treatment of an incarcerated gravid uterus. BJOG. 2002;109:1074\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGardner CS, Jaffe TA, Hertzberg BS, Javan R, Ho LM. The incarcerated uterus: a review of MRI and ultrasound imaging appearances. AJR Am J Roentgenol. 2013;201:223\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eO\\u0026rsquo;Connell MP, Ivory CM, Hunter RW. Incarcerated retroverted uterus\\u0026mdash;A non recurring complication of pregnancy. J Obstet Gynaecol. 1999;19:84\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003evan Beekhuizen HJ, Bodewes HW, Tepe EM, Oosterbaan HP, Kruitwagen R, Nijland R. Role of magnetic resonance imaging in the diagnosis of incarceration of the gravid uterus. Obstet Gynecol. 2003;102(5 Pt 2):1134\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGibbons JM Jr, Paley WB. The incarcerated gravid uterus. Obstet Gynecol. 1969;33(6):842\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eJacobsson B, Wide-Swensson D. Incarceration of the retroverted gravid uterus\\u0026ndash;a review. Acta Obstet Gynecol Scand. 1999;78(8):665\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHsu PC, Yu MH, Wang CY, Wang YK, Wang CK, Su HY. Asymptomatic uterine incarceration at term: successful management of a rare complication in pregnancy.Taiwan. J Obstet Gynecol. 2018;57:745\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGottschalk EM, Siedentopf JP, Schoenborn I, Gartenschlaeger S, Dudenhausen JW, Henrich W. Prenatal sonographic and MRI findings in a pregnancy complicated by uterine sacculation: case report and review of the literature. Ultrasound Obstet Gynecol. 2008;32(4):582\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHan C, Wang C, Han L, Liu G, Li H, She F, Xue F, Wang Y. Incarceration of the gravid uterus: a case report and literature review. BMC Pregnancy Childbirth. 2019;19(1):408.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eNarayanamoorthy S, Hillebrand A, Pendam R, McLaren R Jr. Incarcerated gravid uterus - A systematic review. Eur J Obstet Gynecol Reprod Biol X. 2023;19:100227.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eFernandes DD, Sadow CA, Economy KE, Benson CB. Sonographic and magnetic resonance imaging findings in uterine incarceration. J Ultrasound Med. 2012;31(4):645\\u0026ndash;50.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eFeusner AH, Mueller PD. Incarceration of a gravid fibroid uterus. Ann Emerg Med. 1997;30(6):821\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGupta A, Gleason K, Joshi A. Incarcerated gravid uterus: an imaging challenge. Quant Imaging Med Surg. 2024;14(5):3768\\u0026ndash;72.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eDierickx I, Meylaerts LJ, Van Holsbeke CD, de Jonge ET, Martens IF, Mesens T, Gyselaers WJ. Incarceration of the gravid uterus: diagnosis and preoperative evaluation by magnetic resonance imaging. Eur J Obstet Gynecol Reprod Biol. 2014;179:191\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7601608/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7601608/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e: Incarcerated gravid uterus (IGU), which is characterized by entrapment of the retroverted uterus within the pelvis during the gestational period, is an uncommon condition but might potentially lead to serious maternal-fetal outcomes. Delayed recognition may result in maternal and fetal morbidity.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCase Presentations\\u003c/strong\\u003e: In this article, we describe two IGU cases diagnosed in the second trimester of gestation but initially considered as placenta previa. Case 1 was a 33-year-old woman who conceived through IVF measures but experienced repeated episodes of vaginal bleeding during pregnancy. At 23+6 weeks, ultrasonography revealed IGU, which initially was misdiagnosed as central placenta previa. Her worsening hemorrhage at 24+3 weeks of gestation necessitated urgent cesarean delivery. In the process of the procedure, it was found that the uterus was severely retroverted and densely adherent to the rectovaginal space. Case 2 was also about a patient conceived through IVF-ET who was complicated with adenomyosis and uterine fibroid. She presented with recurrent abdominal pain from 20 weeks onwards. The ultrasound and MRI imaging examination also detected placenta previa initially. Afterwards, the ultrasound revealed IGU with an elongated cervix. Persistent exacerbating pain led to cesarean section at 32+6 weeks, which confirmed IGU during the procedure.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e: One of the significant diagnostic pitfalls for IGU is the early misreading of imaging investigations, particularly the incorrect diagnosis of placenta previa. For prompt diagnosis and better maternal-fetal outcomes, patients who arrive with unusual pain or aberrant cervical findings should have a high index of suspicion for IGU.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Diagnostic Pitfalls of Incarcerated Gravid Uterus: Report of Two Cases and Literature Review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-10-27 14:31:25\",\"doi\":\"10.21203/rs.3.rs-7601608/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"0331d2b2-c602-45ef-aa50-23d586fd92c3\",\"owner\":[],\"postedDate\":\"October 27th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-06-03T07:10:49+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-10-27 14:31:25\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7601608\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7601608\",\"identity\":\"rs-7601608\",\"version\":[\"v1\"]},\"buildId\":\"_2-kVJe1T_tPrBINL-cwx\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC0","license_restricted":false}