a Case reportA 24 year old woman in her first pregnancy was admitted at 18 weeks of gestation with acute urinary retention. This was preceded by a one-week history of urinary frequency, passing small volumes of urine. On examination, the posterior vaginal wall was pushed forward and the cervix was high behind the symphysis pubis; urethral catheterisation drained 1000 mL of urine. A pelvic ultrasound examination was interpreted as showing a fundal fibroid measuring 7.6 Â 8.0 Â 9.4 cm within the body of the uterus, situated posterior to the bladder, low in the pelvis. The urethral catheter was removed after 24 hours and the woman was discharged home.She was admitted five days later with further urinary retention requiring recatheterisation. Repeat ultrasound examination again showed a retroverted uterus with the fibroid low on the anterior wall. Magnetic resonance imaging confirmed the retroverted uterus occupying the pelvis in front of the sacral promontory, the fibroid on the anterior wall and placenta on the posterior uterine wall (Fig. 1). The risks and uncertainties about the outcome for her and her pregnancy were discussed; she preferred conservative treatment rather than the termination of her pregnancy. The catheter was removed, with apparently satisfactory spontaneous voiding. She was discharged home.Two weeks later at 22 weeks of gestation, she was admitted with abdominal pain and tenderness, and a diagnosis of probable fibroid degeneration was made; this was treated conservatively. The following day, she again developed urinary retention and was catheterised for 24 hours. The urinary infection was treated with antibiotics. She was taught intermittent self-catheterisation before discharge, but she managed to avoid further urinary retention by applying suprapubic pressure at regular intervals.Further ultrasound examinations were performed at 28 and 32 weeks of gestation. These showed persistence of the retroversion; the fetal lie remaining longitudinal with the breech low in the maternal pelvis; and normal fetal growth measurements were recorded. Delivery by elective caesarean section was planned at 36 weeks of gestation.In theatre, an ultrasound examination showed the lie was transverse and that the retroversion had probably corrected. At caesarean section, the corrected uterine position was confirmed, as was the low anterior wall fibroid; the uterus was otherwise normal. A transverse incision was made in the lower segment below the fibroid and a baby boy weighing 2493 g was delivered by breech extraction; his Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. The fibroid was removed at the time of the caesarean Fig. 1. Sagittal T2 weighted fast spin magnetic resonance image at 20 weeks of gestation showing the uterine fundus containing the breech (curved arrow) in the Pouch of Douglas. The placenta (*) is attached to the posterior uterine wall with a large intramural fibroid (arrowheads) superiorly on the lower portion of the anterior wall, with the cervix (arrows) just below, above the level ...
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