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Torsion of pregnant uterus: A case report

  Dr.Padmakshi.,Allied Hospital, Kunnamkulam.

 

Mrs.X, a 18 year old primigravida presented at 24 weeks pregnancy.  She had recurrent abdominal pain, which was diagnosed as gastritis, and for which she was undergoing treatment for 2-3 months. 

She presented in the middle of the night at 2 AM with acute epigastric pain and was administered injectable Ranitidine and Inj.Buscopan. By 6 AM in the morning the uterus was of 34 weeks size.

 Ultrasonography showed fluid in the uterus The foetus was dead and a diagnosis of abruptio placenta was made. 

A laparotomy was done.  The uterus was fully on the right side of the abdomen. On attempting to reflect the bladder peritoneum, bladder could not be identified and then it was diagnosed that the uterus had rotated through 270 degrees.  The uterus was pink in colour instead of being blue or gangrenous as in ovarian torsion.  The tube and ovary on the left side could not be seen.  It was probably a unicornuate uterus and this was probably the aetiological factor leading to torsion. 

The uterus was untwisted and the dead baby delivered by a routine LSCS in the anterior wall.  After the baby and placenta was delivered, a lot of fluid came out.  Probably some of it was inflammatory fluid in addition to the amniotic fluid.  The patient was given 4 pints of blood transfusion.  In spite of Inj. Prostodine and Methergine, the uterus was flabby.  The patient was stabilized and the abdomen closed.  She was shifted to the intesnsive care unit (ICU) at 9.30.AM.

At 6PM, the abdomen distended again and there was fluid in the abdomen, as evidenced on ultrasonography.  She was diagnosed to be having PPH, provisionally and a re-laparotomy was planned, and consent for hysterectomy was taken.  At laparotomy, the uterus was found to have re-rotated.  This time the tube and ovary was found to be gangrenous.  A subtotal hysterectomy was done, severing the uterus at the level of the LSCS incision made earlier. 

Post-operatively, the patient did not develop coagulation disorders and in spite of two laparotomies, she did not go into sepsis or systemic inflammatory reaction. 

 

Literature review:

Aetiopathology:   Pathologic uterine torsion, defined as rotation greater than 45 degrees around the long axis, was first described in 1863 by Virchow.  The extent of the torsion is most often 180°. However, cases involving twists from 60-720° have also been described. Dextrorotation is the most common finding, probably because of the physiologic rightward shift of uterus during pregnancy.   Rarely, torsion is of sufficient degree to arrest uterine circulation. This results in acute maternal symptoms or threatens fetal survival through restriction in blood flow or associated abruptio placentae.Uterine torsion occurs in all trimesters of pregnancy and in the nongravid state. No known association exists between torsion and maternal age or parity. Many predisposing factors are described. It is often associated to pathologies of the uterus such as uterine myomas or congenital deformities, abnormal fetal presentations, pelvic tumours or abnormal pelvis.

 

Clinical diagnosis: Patients may be asymptomatic, or may present with abdominal pain, bleeding, gastrointestinal symptoms or urinary symptoms.  Obstructed labor, uterine hypertonus, maternal shock have also been reported. Variable symptomatology and lack of a specific diagnostic sign make uterine torsion extremely difficult to recognize before laparotomy. Typical preoperative diagnoses include abruption, uterine rupture, fetal malpresentation, abdominal pregnancy, appendicitis, or pelvic mass torsion. Such diagnoses lead to immediate surgical intervention, revealing the true culprit.  Although a rare obstetric event, uterine torsion should be considered in the differential diagnosis of placental abruption, particularly when concealed and associated with maternal shock and intrauterine fetal demise. Uterine torsion following an attempt at external cephalic version has also been reported. 

MRI has been described to give a diagnosis of uterine torsion. 

Management: An effort should be made to rotate the uterus to the normal position and then an incision made on the uterus.  If de-torsion is impossible, then the posterior surgical approach is used. A transverse incision is best, curved upward, mimicking the usual anterior wall procedure.

Several cases of torsion have been reported in which the degree of rotation was so severe that the hysterotomy incision at the time of the cesarean delivery was actually performed on the posterior uterine wall. Some surgeons have described these posterior incisions as inadvertent, while others have deliberately performed them when efforts at rotation of the uterus to the normal position proved unsuccessful.

Prophylactic plication of the round ligaments by various techniques has been performed postdelivery with the intent of stabilizing the uterus, possibly preventing recurrence of torsion in the puerperium. The efficacy of this treatment is unknown.

Prognosis: Maternal prognosis is good after surgical treatment.  However, perinatal mortality remains high.   Mortality rates are highest in the fifth to sixth months of pregnancy (17%) and decrease as gestational age advances. Torsion of 180 to 360 degrees historically carries a 36% mortality rate.  Fetal demise has occurred in 71% of cases with torsion of 180 to 360 degrees. 

 

Comments

Torsion of the uterus, as discussed above, is a rare event and laparotomy seems to be the only method of diagnosis.  In the case discussed above, although an attempt was made to conserve the uterus, the speed with which it re-rotated raises speculations about leaving the uterus behind in such cases.  In term uteri, it may be less likely to re-rotate; however, in primigravidas, it may be worth giving a try, specially, as permission for hysterectomy is usually not taken in these cases, as the diagnosis is usually made at the time of laparotomy. 

 

Bibliography:

1.        Carbonne B, Cabrol D et al: Torsion of the pregnant uterus: J Gynecol Obstet Biol Reprod (Paris). 1994;23(6):717-8.(Abstract).

2.        Fabien Demaria, MD, François Goffinet et al: Preterm Torsion of a Gravid Uterus Didelphys Horn of a Twin Pregnancy : Obstetrics & Gynecology 2005;106:1186-1187 © 2005 by The American College of Obstetricians and Gynecologists.

3.        Kathleen E. Cook, ,Sheri M. Jenkins: Pathologic uterine torsion associated with placental abruption, maternal shock, and intrauterine fetal demise : Am J Obstet and Gyny: Vol 192 • NO 6 • June 2005:Copyright © 2005 Mosby, Inc.

4.        Berger H; Sermer M: J Obstet Gynaecol Can.  2006; 28(6):536-9 (ISSN: 1701-2163)

5.        Joh.P.O.Grady: Uterine torsion: http://www.emedicine.com.

  1. Picone, Olivier ; Fubini, Alessandra et al: Cesarean Delivery by Posterior Hysterotomy Due to Torsion of the Pregnant Uterus [Case Report]: Obstetrics & Gynaecology:  Volume 107(2, Part 2) Supplement, February 2006, pp 533-535.

 

 

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