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.
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.
showed fluid in the uterus The foetus was dead and a
diagnosis of abruptio placenta was made.
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
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.
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.
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
MRI has been described to give a diagnosis of uterine
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.
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.
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.
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
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
Cabrol D et al: Torsion of the pregnant uterus:
J Gynecol Obstet Biol Reprod (Paris).
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.
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.
Joh.P.O.Grady: Uterine torsion:
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.