Third Trimester Uterine Torsion: Case Report

Do Not Get Your Uterus Twisted: A Case Report of a 180-Degree Torsion of Term Gravid Uterus and a Review of the Literature

Gravid uterine torsion less than 45 degrees is a common phenomenon of the third trimester. Torsion greater than 45 degrees represents a rare, pathologic, and obstetric emergency. The rotation of the uterus on a longitudinal plane can result in vascular compromise, and it has potential for catastrophic maternal-fetal complications. We report the case of a 22-year-old G3P1011, third pregnancy with history of one full-term live newborn, one spontaneous abortion, and presented at 38 weeks gestation with complaints of abdominal pressure and recurrent transverse fetal presentation. She underwent an external cephalic version (ECV), which resulted in fetal distress necessitating an emergency cesarean section. After successful delivery of the live newborn, an inspection of the uterus identified a uterine torsion of 180 degrees with delivery through a posterior hysterotomy incision. She had no postoperative complications and carried a subsequent pregnancy to term that was delivered via repeat cesarean section five years later. Gravid uterine torsion should be included in the differential diagnosis for patients presenting with abdominal pain and fetal intolerance to labor. A higher suspicion should be held for patients with a known history of uterine abnormalities or those having undergone an ECV. Our case also highlights a safe repeat cesarean section after this rare complication and brief narrative review of existing literature on this rare obstetrical emergency.

Torsion in Uterus: An Obstetrical and Gynaecological Emergency

Uterine torsion is defined as torsion of the uterus along its longitudinal axis greater than 45 degrees. It is observed in all age groups of the reproductive period, in all parity groups, and at all stages of pregnancy. Torsion from 60 degrees to 720 degrees has been described. It is not possible to clarify why it occurs, but numerous abnormalities have appeared with uterine torsion. It is a rare complication that can result in placental abruption and intrauterine foetal death. Pregnancy, giant fibroids, and ovarian cysts are among the most common causes. Vague clinical attributes make diagnosis challenging pre-operatively and can be missed on routine ultrasound. Being a rare life-threatening condition, it necessitates a high level of concern for diagnosis and prompt intervention to optimise results. This review will help the healthcare worker to understand the various presentation of uterine torsion and their management by appropriately and timely diagnosing it.

A Case Report of Uterine Torsion: An Obstetric Emergency During Pregnancy

Uterine torsion is an exceedingly rare obstetric emergency representing pelvic organ torsion, characterized by the uterus rotating more than 45 degrees around the longitudinal axis. This torsion predominantly occurs at the junction of the cervix and uterine corpus. Albeit the infrequent prevalence, this condition can arise in any reproductive group. Oligohydramnios is defined as an amniotic fluid volume of 2 cm or less in the single deepest vertical pocket. During pregnancy, uterine torsion is known to be associated with severe maternal and perinatal consequences encompassing placental abruption, maternal mortality, and intrauterine fetal demise. Here, we present a specific case of a woman who experienced uterine torsion during pregnancy, leading to complications such as uteroplacental and fetoplacental insufficiency, severe fetal growth restriction, and persistent oligohydramnios throughout the pregnancy.

A case report of torsion of the gravid uterus caused by pelvic adhesion

Key Clinical Message

In this case, a patient experienced rare uterine torsion during pregnancy, detected by MRI. Diagnosis before Cesarean is helpful to achieve better outcomes, highlighting the importance of attention in high-risk groups.

Abstract

Uterine torsion during pregnancy is a rare complication and its risk factors and diagnostic modalities have not yet been clearly defined. Here we present a case of uterine torsion due to unexpected pelvic adhesion. A 34-years-old primigravida patient underwent an emergency cesarean section for aggravated maternal preeclampsia symptoms at 34 + 0 weeks of gestation. Intraoperatively, after the baby was out, it was found that the uterus was rotated about 90 degrees to the right by dense pelvic adhesion in posterior uterine wall. In this patient, a rightward vaginal stretch was represented through a retrospective review of magnetic resonance imaging (MRI) before childbirth. To our knowledge, this is the first reported case of uterine torsion during pregnancy with MRI. Diagnosing uterine torsion in advance or paying attention to incisions during operative delivery will lead to better management in this condition and good perinatal outcomes.

Gravid uterine torsion after prone positioning in SARS-CoV2 (COVID-19)-related acute respiratory distress syndrome

A multiparous pregnant patient was admitted to the intensive care unit in her third trimester of pregnancy for prone positioning mechanical ventilation after developing SARS-CoV2 (COVID-19)-related acute respiratory distress syndrome. Repositioning in left lateral tilt was followed by uterine contractions and cardiotocography alterations. Preterm caesarean section was performed based on persistent foetal tachycardia and suspected foetal distress, followed by a per-operative diagnosis of uterine levotorsion. This case report is the first to explore a potential causal link between prolonged prone positioning in late pregnancy and postural gravid uterine torsion and highlights the need for appropriate foetal monitoring during prone positioning mechanical ventilation support.

Posterior classical caesarean section in a myomatous gravid uterus at term: a case report

We present a case of a 30-year-old primigravida, at 38-week gestation, who had a posterior classical uterine incision due to a huge anterior wall leiomyoma associated with uterine torsion and breech presentation. The rarity of this type of uterine incision, the size of the uterine myoma and the uterine torsion prompted this case report.

During caesarean section, the diagnoses of uterine torsion and a huge anterior wall leiomyoma were made. She had safe delivery of the fetus through a posterior classical caesarean section. The patient had an uneventful post-operative period and was discharged home with her baby on the fourth post-operative day.

Uterine torsion and intrauterine growth restriction: Case report and systematic literature review

PURPOSE

Uterine torsion (UT) in pregnancy is a rare condition in obstetric practice. It is defined as a rotation of the uterus of more than 45° around its long axis. Presentations are varied and, most of the time, this condition is recognized at laparotomy or cesarean section (CS). The aim of this study is to summarize the latest evidence about UT in pregnancy.

METHODS

A systematic research of the literature was conducted fetching all papers published from March 2006 to June 2020. We collected data regarding clinical features, treatment, and feto-maternal outcomes. Finally, we reported data of a case of UT associated with intrauterine growth restriction (IUGR) diagnosed and treated at our institution.

RESULTS

According to our search strategy, 38 articles were included. In 66% of the cases, acute symptomatology was present at the onset, most frequently abdominal pain was reported. In one-third of the cases, UT was diagnosed during CS without clinical suspicion. Only in two cases, including our case, IUGR was reported. Most (66%) of the cases presented a 180° torsion. In the majority of the cases, a CS was performed also with a deliberate or accidental posterior hysterotomy. One and six cases of maternal and fetal death were, respectively, reported.

CONCLUSION

UT is an infrequent obstetric condition but should be considered in case of abdominal pain, vomiting, or shock presentation during pregnancy. It could lead to a reduction in uterine blood flow contributing to poor placental perfusion, even though more evidence is needed to clarify this link.

Uterine torsion in a full-term pregnancy presenting as prolonged latent phase and fetal intolerance of labor: A case report

Background

Uterine torsion is defined as torsion of the uterus around its longitudinal axis exceeding 45 degrees. It is a rare obstetric complication. It is a dangerous complication that can lead to placental abruption and intrauterine fetal death. Although rare, early diagnosis is crucial to expedite intervention and optimize outcomes. While the few cases in the current literature have documented acute presentations of uterine torsion, our case is unique in that it had a slower evolution.

Case

A 38-year-old woman, G2P0, was admitted at 37 weeks 0 days of gestation for induction of labor for gestational diabetes mellitus, pre-eclampsia, and maternal BMI of 60. Due to a prolonged latent phase of labor and fetal intolerance of labor, primary cesarean was recommended. Through a sub-umbilical approach, the uterus was dextro-rotated almost 180 degrees and blanched with engorged uterine vessels. A vertical uterine incision was made, and a asphyxiated female infant was delivered via breech extraction. APGAR scores were 2, 7, and 8. The infant required brief respiratory support following delivery. The postoperative course was uncomplicated, with normal recovery time.

Conclusion

Uterine torsion poses significant risk to both mother and fetus. The phenomenon is so rare that epidemiological data are difficult to gather. In our case, the presentation was gradual compared with the acute presentations that have been reported, which may mislead clinicians toward more benign diagnoses. Our case report aims to add to the literature on uterine torsion, providing a unique presentation, clinical features, and treatment.

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Uterine torsion is torsion of the uterus around its longitudinal axis exceeding 45 degrees.

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It is a rare obstetric complication.

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Severe acute uterine torsion can result in placental abruption, intrauterine fetal death, and maternal death.

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This case of uterine torsion presented as prolonged latent phase and fetal intolerance of labor.

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Delivery was achieved via classical cesarean section.

Torsion in the Gravid and Nongravid Uterus: A Review of the Literature of an Uncommon Diagnosis

Importance

Uterine torsion is an uncommon but life-threatening clinical situation that requires a high index of suspicion for diagnosis.

Objective

The aim of this study was to review literature and determine the etiology, presentation, diagnosis, and management of uterine torsion in the gravid and nongravid patients.

Evidence Acquisition

A literature search was undertaken by our research librarian using the search engines PubMed and CINAHL. The search terms used were "uterine torsion" OR (uterus and torsion). The search was limited to the English language, but the years searched were unlimited.

Results

The search identified 177 articles, 91 of which are the basis for this review. There have been 41 cases or gravid uterine torsion, their characteristics, and symptoms published since 2006. Torsion is rare in nongravid patients, but can still occur.

Conclusion and Relevance

Uterine torsion is rare, can affect all ages, and can have significant implications for women. Prompt recognition allows for timely intervention and can mitigate harm.

Torsion of a Large Myomatous Uterus Associated with Progressive Renal Failure and Paralytic Ileus in an 86-Year-Old Woman

Uterine torsion of a nongravid uterus is rare, and proper diagnosis is challenging. Herein, we report a case of torsion of a large myomatous uterus in an 86-year-old woman who was presented with progressive renal failure and paralytic ileus. She was presented with abdominal discomfort, loss of appetite, and oliguria. A large myomatous uterus with broad calcification was identified when she underwent surgery to repair an umbilical hernia one year before the symptoms developed. Computed tomography revealed that one year later, the myomatous uterus significantly increased in size and the calcified lesion of the fibroid was largely displaced. She was also presented with paralytic ileus, and her general condition progressively worsened. Her serum creatinine levels were increased (3.5 mg/dL) and hemoglobin levels were low (8.5 g/dL). Emergency laparotomy revealed that the uterus was rotated 360 degrees clockwise at the level of the isthmus. The uterus was discolored, appearing dark red, and accompanied by broad congestion, and the cervix was elongated. The patient's renal function and ileus recovered after a hysterectomy. In conclusion, torsion of a large myomatous uterus could become life-threatening in an oldest-old woman, and early release of the torsion is necessary to avoid serious complications.

Uterine torsion of 720 degrees in the third trimester of pregnancy and accompanying bladder torsion: a case report

Partial rotation of the uterus not more than 45 degrees to the right is considered to be normal. Since all cases are not reported, the incidence of uterine torsion in pregnancy is not known exactly. In the literature, there have been reports of cases with uterine torsion ranging from 45 to 720 degrees. This is a case report of uterine torsion of 720 degrees with accompanying bladder torsion, developing after two caesarean sections, and developing of uterine atony after the operation.

A Case of Abruptio Placentae due to the Torsion of Gravid Uterus

Torsion of a gravid uterus is a rare obstetric emergency potentially lethal for the fetus and the mother. Some of the cases described in literature are associated with preexisting gynecologic conditions related to pelvic and uterine anatomy, even if most of cases remain unexplained. We report a case of acute 180-degree torsion of uterus at 33 weeks of gestation associated with abruptio placentae in a young Asian woman without apparent risk factors.

[Prelabour uterine torsion complicated by partial abruption and fetal death]

Uterine torsion is a rare obstetrical complication whose diagnosis remains challenging. We report a case of 180 degrees dextrogyre torsion at 36(+5) weeks of gestation complicated by partial abruption and in utero fetal death. Emergency cesarean section was performed through an unintentional posterior hysterotomy. Literature reports a few similar cases. Vertical hysterotomy should be advised in this context avoiding incision on lateral sides associated with increased risk of vascular or ureteral injury.

Uterine torsion mimicking supine hypotension syndrome after regional anaesthesia

A 40-year-old gravida 5 para2 +2 was admitted at 38 weeks +5 days of gestation for elective caesarean section in view of unstable lie. After spinal anaesthesia, when the patient was positioned supine for caesarean section, she developed acute onset breathlessness and dizziness. Blood pressure was unrecordable. She remained symptomatic with hypotension and bradycardia despite lateral tilt and intravenous atropine. On entering the peritoneal cavity, a congested uterus with torsion in a clockwise direction to almost 180° with the posterior wall facing anteriorly was noted. Immediate attempt to detort the uterus was successful. The patient immediately became symptomatically better and the uterine congestion resolved. Uterine incision was given in the anterior lower segment delivering a healthy baby. High index of suspicion and detorsion of the uterus avoided the inadvertent incision in the congested posterior uterine wall which could have resulted in massive postpartum haemorrhage.

Uterine torsion in second trimester of pregnancy followed by a successful-term pregnancy

Uterine torsion is defined as rotation of the uterus of more than 45° on its long axis. It is an unusual complication of pregnancy and for most obstetricians it probably represents a 'once-in-a-lifetime' diagnosis. Fetal mortality up to 12% and occasional maternal mortality are reported. A 22-year-old second gravida presented at 22+ weeks gestation with severe abdominal pain and shock. Laparotomy was done for suspected abruptio placenta, when torsion of the uterus to 180° was diagnosed. Posterior hysterotomy was performed. She conceived the next year and was delivered at term by caesarean section. Uterine torsion is a rare complication of pregnancy and obstetricians should have this complication in mind when performing a caesarean section for undiagnosed severe abdominal pain in pregnancy. Anatomical landmarks should be defined if possible, prior to uterine incision during a caesarean section, to avoid posterior hysterotomy.

A case of torsion of gravid uterus caused by leiomyoma

Uterine torsion during pregnancy is only sporadically reported in the literature. Here we present a case of leiomyoma causing uterine torsion in pregnancy and review the literature on etiology, diagnosis, and management. A 25-years-old primigravida with leiomyoma complicating pregnancy was admitted in our hospital with abdominal pain and uterine tenderness. She underwent emergency LSCS (lower segment cesarean section) for fetal bradycardia. Intraoperatively, the uterus was rotated 180 degrees left to right. Inadvertent incision on the posterior wall was avoided by proper delineation of anatomy. Torsion was corrected by exteriorization of leiomyoma and uterus, and lower segment cesarean was carried out safely. Prompt recognition and management of this condition is necessary for better maternal and fetal outcome.