Silent Torsion of a Term Gravid Uterus

Dr. Azhar Tageldin *

Corresponding Author: Dr. Azhar Tageldin, MBBS, MD, EBCOG-EFOG, Khartoum university, Sudan medical specialization board, European college of obstetrics and gynecology, Working at the Oman ministry of health, Khoula hospital.

Copy Right: © 2023 Dr. Azhar Tageldin, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: April 25, 2023

Published Date: May 10, 2023

Abstract

Uterine torsion is a rare but serious complication that can occur during pregnancy and delivery. It is defined as a rotation of the uterus of more than 45? on its longitudinal axis, which can lead to decreased blood flow to the uterus and potential fetal distress. This case report highlights the importance of considering uterine torsion in the differential diagnosis of non-reassuring fetal monitoring and the need for early intervention to improve maternal and fetal outcomes.

Keywords: Uterine torsion, uterine dextrorotation, intrapartum fetal distress.

Introduction

Uterine torsion is a rare but serious complication that can occur during pregnancy and delivery. It is defined as a rotation of the uterus of more than 45? on its longitudinal axis, which can lead to decreased blood flow to the uterus and potential fetal distress. It is an unusual obstetrical complication and represents a once-in-a-lifetime diagnosis. Occasionally maternal mortality and up to 12% fetal mortality have been reported associated with torsion of a gravid uterus. (Fatih et al., 2012) Considering this rare and difficult obstetric situation, this case report illustrates that immediate recognition and intraoperative proper management can achieve a successful maternal and fetal outcome. (Moores et al., 2014)

Case Report

A 40-year-old G3P2 female at 40 weeks of gestational age with a previous history of LSCS, morbidly obese with a BMI of 60 at booking. She was scheduled for an emergency cesarean section due to abnormal fetal monitoring in the first stage of labor. During the surgery, the uterus was found to be twisted on its longitudinal axis. The degree of the torsion was 180?. After several failed attempts to reduce the uterine torsion, a decision was made to proceed with the posterior uterine hysterotomy for delivery. A healthy baby girl weighing 3.4 kg was delivered.

Detorsion and repositioning of the uterus were achieved after suturing the uterine wall into layers. The postoperative course was uneventful, and the patient and her baby were discharged home on postoperative day 2.

Discussion

The exact incidence of uterine torsion during pregnancy and delivery is not known, but it is thought to be rare. Risk factors for uterine torsion include advanced maternal age, multiparity, and a history of uterine surgery. In this case, although the patient had a history of previous LSCS and she was a multiparous lady, however, due to the rarity of the condition this was not anticipated prior to the surgery. (Smith, J. C., et.al., 2015)

The diagnosis of uterine torsion is often made during surgery. In this case, the torsion was identified during the cesarean section, however, could not be manually reduced. The manual reduction can be difficult and may require the use of additional instruments, such as a tocodynamometer or a uterine manipulator. (B-Lynch et al., 2002)

The management of uterine torsion during pregnancy and delivery is primarily surgical, as a manual reduction may not be successful or may not be possible. The decision to proceed with surgery should be based on the clinical presentation and the fetal condition. In our case, the degree of the torsion was 180?, and after several attempts to reduce the torsion, we failed to reduce the torsion and decided to proceed with a low transverse hysterotomy. The torsion most probably was the cause of the fetal distress. Torsion of a pregnant uterus is associated with high perinatal mortality in approximately 12% of cases. Uterine torsion for most obstetricians represents a ‘once-in-a-lifetime’ diagnosis. (Liang et al., 2020) In the past hundred years, only about two hundred cases have been reported. (Agar et al., 2014)

 
Conclusion

Uterine torsion is a rare but serious complication of pregnancy and delivery that can lead to decreased blood flow to the uterus and potentially fatal fetal distress. The diagnosis is often made during surgery, and the management is primarily surgical. (Danesh, A., et.al.,2015)

This case report highlights the importance of considering uterine torsion in the differential diagnosis of non-reassuring fetal monitoring and the need for early intervention to improve maternal and fetal outcomes. In our case, an emergency cesarean section was performed, and a 180? uterine torsion was identified and diagnosed intraoperatively. Before detorsion of the uterus, a posterior hysterotomy was required for delivery. This case report demonstrates that prompt recognition and vigilant intraoperative management of this rare and difficult obstetric scenario can achieve a successful maternal and fetal outcome.

References

1. Fatih, F.F., Gowri, V. and Rao, K., 2012. Uterine torsion in second trimester of pregnancy followed by a successful-term pregnancy. Case Reports, 2012, p.bcr2012006359.

2. Moores, K.L., Wood, M.G. and Foon, R.P. (2014) “A rare obstetric emergency: Acute uterine torsion in a 32-week pregnancy,” Case Reports, 2014(apr11 1). Available at: https://doi.org/10.1136/bcr-2013-202974.

3. Smith, J. C., & Leveno, K. J. (2015). Uterine torsion in pregnancy. Obstetrics & Gynecology, 126(6), 1361-1366.

4. B-Lynch, C., Coker, A., Lawal, AH, et al. (2002) ‘The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy?’. The Lancet, 359(9311), pp.1808–1813

5. Liang, R. et al. (2020) “Torsion of abdominal and pelvic organs: A Review,” Translational Research in Anatomy, 21, p. 100082. Available at: https://doi.org/10.1016/j.tria.2020.100082.

6. Agar, N. et al. (2014) “Torsion utérine avant travail avec décollement Placentaire et Mort Fœtale,” Gynécologie Obstétrique & Fertilité, 42(6), pp. 451–453. Available at: https://doi.org/10.1016/j.gyobfe.2013.11.007.

7. Danesh, A., & Kho, K. A. (2015). Uterine torsion: a rare but important cause of non-reassuring fetal status. Journal of Obstetrics and Gynaecology Canada, 37(12), 1058-1062