Uterine Sacculation in Pregnancy

Editor
We report a case of uterine sacculation noted during Caesarean section for a 28-year-old fourth gravid woman, who was booked for elective Caesarean section at 39 weeks gestation for breech presentation. The woman had had two previous uncomplicated vaginal deliveries at term and two complete miscarriages at 8 weeks gestation. Her medical history was normal and there was no history of any uterine surgery. She was booked at 16 weeks, and her booking bloods were normal and serology was negative. She commenced antenatal visits at 28 weeks gestation. Her antenatal follow up was unremarkable with regular visits at 28, 32, 36, 37 and 38 weeks. A decision was made for elective lower segment Caesarean section (LSCS) in view of persistent breech presentation.

The woman was admitted at 39 weeks gestation for elective LSCS. A transabdominal scan was performed prior to the surgery, which confirmed breech presentation. LSCS was performed and a live female baby was born. Birth weight was 2,595 g. The neonate’s APGAR at one and 5 minutes were 9 and 10, respectively. After the delivery of the baby, the placenta was retained. The uterus was exteriorised, which revealed a saccular pouch herniating from the right uterine fundus containing the placenta. The placenta was very adherent and was removed piecemeal. The estimated blood loss was 800cc. After placental removal, the uterus was well contracted and haemostasis achieved. The reminder of the surgery was completed in the usual fashion. The woman’s recovery course was uncomplicated. She had a normal amount of vaginal bleeding postpartum. Postoperative haemoglobin was 10 g/dl. Both the woman and newborn were discharged home in satisfactory condition on postoperative day three.

Uterine sacculation is a rare complication of pregnancy occurring in one in 3,000 pregnancies1, 2. There are two types of uterine sacculation: simple sacculation, which is a structural outpouching of the wall of a normally positioned uterus, and incarcerated uterine sacculation, which occurs in a retroverted uterus to accommodate a growing foetus3. Both types of the condition are difficult to diagnose antenatally owing to its rarity and unspecific symptoms such as abdominal pain, constipation, urgency and urinary retention. Complications associated with sacculation include intrauterine death, uterine rupture, adherent retained placenta, and post-partum haemorrhage4. Uterine sacculation can be asymptomatic, as in our patient where it was discovered after the delivery of the baby. As the uterus contracts postpartum and the opening of the sacculation obliterates, the placenta becomes adherent and difficult to remove4. Diagnosis of uterine sacculation is difficult and it has often been missed until shortly before birth or Caesarean section. Therefore, awareness and early diagnosis of the condition, particularly in individuals with a history of the same condition would allow clinicians to anticipate emergency situations and appropriately manage the complications, hence minimising maternal and foetal morbidity and mortality4.

Langhe, W. M. Blake, M. Gannon
Department of Obstetrics & Gynaecology, Regional Hospital Mullingar, Longford Road, Co Westmeath

Correspondence:
Ream Langhe, Registrar Obstetrics & Gynaecology, Department of Obstetrics & Gynaecology, Regional Hospital Mullingar, Longford Road, Co Westmeath
Email: reamlanghe@yahoo.co.uk

References
1. Lee, SW, Kim, MY, Yang, JH, Moon, MH, Cho, JY. Sonographic findings of uterine sacculation during pregnancy. Ultrasound in Obstetrics & Gynecology. 2008; 32(4): 595-7.
2. Gibbons JM, Jr., Paley WB. The incarcerated gravid uterus. Obstetrics and Gynecology. 1969; 33(6): 842-5.
3. Gerscovich EO, Maslen L. The retroverted incarcerated uterus in pregnancy: imagers beware. Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine. 2009; 28(10): 1425-7.
4. Kokila, MS, Indira, H, Dwivedi, AD, Dwarakinath, L. Trapped placenta and conceptus in uterine sacculation: Two rare case reports. Journal of South Asian Federation of Obstetrics and Gynaecology. 2013; 5(2): 89-90.

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