CASE REPORT

CASE REPORT

Third Trimester Uterine Torsion: Case Report

Don Wilson, MD,1 Aisling Mahalingham, MD,1 Sue Ross, PhD1,2
1
Department of Obstetrics and Gynaecology, University of Calgary, Calgary AB
2
Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary AB

Abstract effectuée. Au moment de la césarienne, un diagnostic de torsion

utérine a été établi. La patiente s’est remise et a été retournée à la
Background: Rotation of the gravid uterus is a normal finding in the maison avec son nouveau-né trois jours après l’opération.
third trimester of pregnancy. However, a pathologic rotation of the
uterus beyond 45 degrees—torsion of the entire uterus—is rarely Conclusion : La torsion utérine est une complication de grossesse
seen in obstetrical practice. We report here a case of uterine rarement signalée et potentiellement dangereuse qui se manifeste
torsion from our obstetrical practice and a review of reported principalement au cours du troisième trimestre et qui entraîne des
cases. conséquences maternelles et néonatales indésirables.
Case: The patient, a 36-year-old gravida 3 para 2 at 36 weeks’ J Obstet Gynaecol Can 2006;28(6):531–535
gestation with a singleton pregnancy, was admitted to the
obstetrical unit with uterine cramping and decreased fetal
movement. Her prior obstetrical history included two uncomplicated
INTRODUCTION
term vaginal deliveries, and the current pregnancy had been
otation of the gravid uterus is a normal finding in the
uncomplicated until the date of presentation. After 3 hours’
observation, uterine cramping and tenderness increased, and fetal
tachycardia developed. The presumptive diagnosis was a
concealed placental abruption. The patient was not in labour, so an
R third trimester of pregnancy. However a pathologic
rotation of the uterus beyond 45 degrees—torsion of
emergency Caesarean section (CS) was carried out. At the time of the entire uterus—is rarely seen in obstetrical practice. We
CS, the diagnosis of uterine torsion was made. The patient report here a case of uterine torsion and review of cases
recovered and was discharged home with her baby on the third
postoperative day. reported to date.
Conclusion: Uterine torsion is an infrequently reported and
potentially dangerous complication of pregnancy that occurs mainly THE CASE
in the third trimester with adverse maternal and neonatal
consequences. The patient was a 36-year-old gravida 3 para 2 at 36 weeks’
gestation with a singleton pregnancy. Her prior obstetrical
Résumé history included two uncomplicated term vaginal deliveries,
Contexte : La rotation de l’utérus gravide est une constatation and the current pregnancy had been uncomplicated until
normale au cours du troisième trimestre de la grossesse. the date of presentation. The patient’s pre-pregnancy BMI
Cependant, une rotation pathologique de l’utérus au-delà de
45 degrés (torsion de l’utérus en entier) est un événement was 28.3 kg/m2, and her general health had been excellent
rarement constaté dans le cadre de la pratique obstétricale. Nous throughout pregnancy. She arrived on the obstetrical unit
présentons ici un cas de torsion utérine issu de notre pratique
obstétricale et une analyse des cas signalés.
with uterine cramping and decreased fetal movement.
Cas : La patiente, une femme gravida 3 para 2 de 36 ans en étant On examination, the maternal vital signs were stable. The
e
rendue à la 36 semaine de gestation d’une grossesse unique, a fetus was found to be in a transverse lie, with the fetal head
été admise à l’unité d’obstétrique en raison de crampes utérines et
d’une diminution des mouvements foetaux. Ses antécédents on the maternal left. The uterus was cramping irregularly
obstétricaux comprenaient deux accouchements vaginaux à terme and was mildly tender to palpation. There was no vaginal
sans complications et la grossesse actuelle ne comptait aucune blood or fluid loss. Electronic fetal monitoring was insti-
complication jusqu’à ce moment. À la suite de trois heures
d’observation, la sensibilité et les crampes utérines se sont tuted, and a reassuring fetal heart rate was noted. Vaginal
accrues et une tachycardie foetale s’est manifestée. Le diagnostic examination demonstrated a parous cervix with a firm con-
présumé en était un de décollement placentaire latent. La patiente
ne se trouvant pas en travail, une césarienne d’urgence a été
sistency and no significant effacement or dilatation.
After approximately three hours of fetal monitoring, uter-
Key Words: Uterine torsion in pregnancy, case report, literature
ine cramping increased, and fetal tachycardia between 180
review and 200 beats per minute with marked variability was noted.
Competing Interests: None declared. Uterine tenderness had increased since the time of admis-
Received on February 5, 2006
sion. The presumptive diagnosis was a concealed placental
Accepted on March 15, 2005
abruption.

JUNE JOGC JUIN 2006 l 531

CASE REPORT

As the patient was not in labour, an emergency Caesarean Only one case of uterine torsion was diagnosed before
section (CS) was recommended. The patient consented to labour: an abnormal vaginal examination led the clinicians
the procedure and was taken to the operating room. Under to arrange an MRI, which detected uterine torsion.27 Most
spinal anaesthesia, a Pfannenstiel incision was made, and cases (n = 37) were undetected before the onset of labour or
the lower uterine segment was exposed; a bladder flap was emergency or scheduled CS. In these cases, the diagnosis of
not made. There were no unusual findings at this point in uterine torsion was confounded by other diagnoses, such as
the surgery. A transverse lower segment uterine incision abnormal fetal heart rate,2,3,8,9,14,15,29 failure to progress in
was made, and the baby, a female weighing 2723 g, was labour,8,13,14,16 or suspected abruption.2 Coexisting condi-
delivered by breech extraction. Apgar scores were 7 at one tions included uterine fibroids,4,20,34 adhesions,4,916,22
minute and 7 at five minutes. The placenta was removed adnexal mass,34 fetal malpresentation,5,9,14–19 and traumatic
manually. injury.3 One case was identified during a termination of
pregnancy.28 One woman died,11 but all of the others made
When the uterus was examined again, the uterine incision
a full recovery, although two required a peripartum hyster-
was no longer visible. The uterus was then brought through
ectomy for heavy bleeding,10,17 and one underwent hyster-
the incision, and the hysterotomy incision was found to be
ectomy and oophorectomy because of development of
in the posterior lower uterine segment. It was apparent that
necrosis in the uterus and ovaries.13 Information is available
after delivery the uterus had spontaneously undergone
for only one subsequent pregnancy in which a repeat CS
detorsion of at least 180 degrees; the uterine incision was
was successfully performed.9
symmetrical on either side of the posterior midline of the
uterus. The uterine incision was closed with a double layer Our literature review was limited to English language
of delayed-absorbing suture (polyglactin 910). Close exami- reports cited in PubMed, from 1966 to January 2006. An
nation of the uterus and adnexa revealed no abnormalities. earlier review by Jensen reported 212 cases from a variety of
countries.7 Although the number of cases reported in the
The patient made an uneventful recovery and was dis-
literature is limited, it is possible that this condition is
charged home on the third postoperative day. The patient
underreported.
was advised to undergo CS for any subsequent deliveries
because of the lack of information about the safety of Other authors, such as Jensen,7 have suggested that pelvic
labour following a posterior lower segment uterine incision. pathology could be a cause of uterine torsion. Our review
has not shown this to be the case, but rather that uterine tor-
The infant was initially admitted to the special care nursery sion occurs during a normal pregnancy and within a typical
for transient tachypnea of the newborn but was discharged pelvis.
home in good condition with the mother on the third post-
operative day. Our case shares many features with other reported cases.
Our patient presented with a singleton pregnancy in the
DISCUSSION third trimester. The presumptive diagnosis was concealed
placental abruption because of the fetal heart rate abnor-
The first report of uterine torsion in the human was pub- mality with uterine tenderness in the absence of vaginal
lished by Labbé in 1876.1,2 Since then, uterine torsion has bleeding. Transverse fetal lie (or malpresentation) is com-
been reported rarely, perhaps because of the nonspecific monly reported in association with uterine torsion.5,9,14–19
presentation1,3–7 and generally successful outcome for As in our case, uterine torsion has been discovered inciden-
mothers.7 Nevertheless, it is a potentially dangerous com- tally at CS performed through the posterior lower uterine
plication of pregnancy. segment.2,5,6,20–25
We conducted a review of the literature, using the terms The common risk factors reported in association with uter-
“uterine torsion” and “pregnancy,” that identified 33 rele- ine torsion are often non-specific and therefore not always
vant papers (Table).1–6,8–34 Of the 38 cases of uterine torsion useful in heralding this uncommon complication of preg-
reported, one resulted in spontaneous abortion,1 and six in nancy. Our experience and our literature review indicate
stillbirth.8–13 This fetal mortality rate (18%) is higher than that the possibility of uterine torsion should always be con-
that reported by Jensen in 1992 (12%).7 sidered as part of a differential diagnosis of complications in
The women in these 38 cases ranged in age from 17 to 43 the third trimester of pregnancy. Incorporating into routine
years. The number of previous pregnancies varied from practice the palpation of round ligaments at the time of CS
none to 11, and none of the women had a previous uterine would most likely prevent inadvertent hysterotomy at sites
torsion. One case was a twin pregnancy,14 and the remain- other than the anterior lower segment.
der were singleton pregnancies. Two cases were detected We are unable to provide evidence-based recommenda-
earlier in pregnancy1,28; the remainder in the third trimester. tions for women who have had a uterine torsion and who

532 l JUNE JOGC JUIN 2006

 Third Trimester Uterine Torsion: Case Report

Table. Results of the literature review

Author, date [reference] No. Management Outcome

cases

Jovanovic et al., 19721 1 Myomectomy at time of 2nd laparotomy; pregnancy left Spontaneous abortion after 2nd laparotomy;
undisturbed uneventful maternal recovery
Biswas et al., 19902 2 (1) Correction of uterine torsion prior to lower segment (1) Uneventful postoperative recovery
uterine incision; delivery of viable 2982 g female infant (2) Uneventful postoperative course
(2) Posterior transverse lower segment hysterotomy
for urgent delivery of fetus with bradycardia; 20%
abruption noted; uterus detorted after delivery
Duplantier et al., 20043 1 Emergency CS; undiagnosed 180 degree uterine Uneventful maternal recovery; severe acute
levorotation resulted in posterior lower segment and long-term neonatal morbidity
hysterotomy
Rich & Stokes, 20024 1 Emergency myomectomy via longitudinal upper Normal postnatal examination
segment incision, followed by transverse upper seg-
ment hysterotomy & delivery of viable neonate
Kim et al., 20015 1 Unsuccessful attempt to derotate uterus because of Unremarkable 6-week postpartum
large size; deliberate classical posterior classical examination
hysterotomy with delivery of viable female infant by
internal podalic version & breech extraction for
transverse lie
Rudloff & Joels, 20036 1 Posterior lower segment hysterotomy for irreducible Spontaneous detorsion of uterus after
uterine torsion delivery; unremarkable pospartum course
Smith, 19758 1 Emergency CS demonstrated 175 degree uterine Mother did well; fetus stillborn
dextrorotation, corrected before anterior lower
segment uterine incision made for delivery
Nielsen, 19819 3 (1) Uterine torsion reduced before uterine incision was (1) Healthy mother & infant; mother
made—normal lower segment uterine incision carried underwent repeat CS at 39 weeks three
out years later—no uterine torsion noted
(2) Unintentional incision through right uterine (2) No postoperative complications; patient
sidewall & artery, surgically controlled, followed by underwent repeat CS for live female infant 2
myomectomy years later
(3) CS through right uterine sidewall, otherwise (3) Mild endometritis in puerperium. Mother &
uncomplicated procedure infant discharged home healthy on post op
day 12
Achanna et al., 199610 1 Spontaneous detorsion of uterine horn after delivery of Uneventful postoperative recovery; normal
stillborn female infant; emergent peripartum follow-up examination
hysterectomy of right uterine horn for severe
postpartum hemorrhage
Guie et al., 200511 1 Mother died after a long resuscitation attempt Mother and fetus died
(prior to CS)
Kovavisarach & 1 Emergency laparotomy for suspected uterine rupture; Fetal demise; uneventful maternal recovery
Vanitchanon, 199912 180 degree uterine levorotation noted on opening by 6-week postpartum examination
abdomen, easily corrected; transverse lower segment
uterine incision for delivery of fresh stillborn male
infant; 1000 cc retroplacental blood clot
Cook & Jenkins, 200513 1 After failed induction, patient had hysterotomy and the Full recovery of mother
fetus was delivered. Supracervical hysterectomy with
bilateral oophorectomy was performed
Visser et al., 199314 3 (1) Inadvertent posterior vertical hysterotomy noted (1) Healthy mother & infant
after delivery of placenta & 180 degree uterine (2) Healthy mother & healthy infant twins
levorotation was identified (3) Healthy mother & infant
(2) CS for footling breech presentation of twin A; 80
degree dextrorotation of the uterus noted & easily
corrected prior to lower segment transverse uterine
incision
(3) CS for transverse lie with notation of 130 degree
uterine levorotation
partially corrected; vertical incision to right of uterine
midline.
Koh & Bradford, 197715 1 CS for transverse lie, fetal distress; uterus initially Healthy mother & infant
thought to be 180 degrees dextrorotated - manually
corrected only to discover it had been 180 degrees
levorotated leading to iatrogenic 360 degree
levorotation. Uterine torsion was corrected & classical
CS performed for poorly formed lower uterine segment.
Table continued

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CASE REPORT

Author, date [reference] No. Management Outcome

cases

El-Taher & Hussein, 1 Omental adhesions with parietal peritoneum had to be Uneventful discharge of mother and infant on
200416 divided. Rotated uterus corrected manually with some day 5
difficulty. Low transverse CS performed
Bond et al., 198917 1 Empty uterine cavity at CS—incision with large fundal Transient low grade disseminated
sacculation on left side, & uterus rotated 90 degrees. intravascular coagulopathy in mother. Infant
T-incision into sacculation to reach fetus; supracervical did well, Apgar scores 6 & 9 at 1 & 5 minutes.
hysterectomy for heavy bleeding
Crona & Bachrach, 1 Acute laparotomy with discovery of 180 degree Healthy mother and infant
198418 levorotation of uterus; CS via sagittal incision in upper
posterior uterine segment
Steigrad, 198719 1 CS; manual detorsion at time of CS Healthy mother and infant; uncomplicated
postoperative course
Bolaji et al., 199220 1 Posterior oblique hysterotomy for delivery of viable 3190 g Normal postoperative course for mother and
male infant; myomectomy performed in order to accom- infant
plish uterine detorsion following delivery
Piot et al., 197321 1 Uterus detorted manually with repeat transverse lower Healthy mother and infant
segment incision made for delivery
Pelosi & Pelosi, 1998 22 1 Deliberate posterior lower segment hysterotomy after Healthy mother and infant
failed attempt to derotate uterus; suture plication of round
ligaments to prevent recurrence of uterine torsion in the
puerperium; posterior uterosigmoid adhesions noted at
laparoscopy 3 months later for sterilization
Imrie, 196623 1 Uterus manually detorted to normal position & normal Healthy mother & infant; no postoperative
lower segment CS carried out for liveborn term male infant complications
Barr & Bergman, 1 Elective CS with note made of 180 degree levorotation Spontaneous detorsion of uterus after
198424 after delivery of live female infant; routine closure of delivery; unremarkable pospartum course
posterior lower segment hysterotomy
Torbjorn & Tore, 199225 1 Uterine torsion corrected prior to low transverse incision; Uneventful maternal recovery
delivery of viable 3650 g female infant; planned
sterilization also performed
Fait et al., 199726 1 Suture ligation at two points, above and below intended Uncomplicated postoperative course
transverse lower segment incision; delivery of viable 5040
g female infant; spontaneous uterine detorsion after
delivery
Nicholson et al., 199527 1 Manual levorotation of uterus to anatomically correct Uneventful maternal and neonatal
position with lower segment transverse uterine incision; postoperative course
delivery of viable 3380 g female infant; bicornuate uterus
with rudimentary left horn discovered after delivery
Gupta et al., 199128 1 Laparotomy with right ovarian cystectomy & hysterotomy Benign mucinous cystadenoma on
for pregnancy termination pathology of right ovarian cyst; nonspecific
abnormal vaginal bleeding postoperatively,
but otherwise uneventful recovery
Bakos & Axelsson, 1 CS, with anatomy difficult to ascertain. Inadvertent Healthy mother and infant, no postoperative
198729 posterior low segment CS performed followed by detorsion complications
of uterus. No uterine anomalies detected. Amniocentesis
for fetal lung maturity; CS
Jain & Agrawal, 198630 1 Laparotomy, discovery of bicornuate uterus with torsion of Healthy mother and infant
gravid horn. Live fetus delivered by upper segment CS
Kremer & van Dongen, 1 Unexpected uterine torsion discovered during CS Healthy mother and infant; uncomplicated
198931 postoperative course
Legarth & Hansen, 1 CS; lower uterine segment torsion was discovered, leading Uterine torsion had resolved by 8 weeks
198232 to vaginal torsion postpartum
Mustafa et al., 199933 1 Posterior lower segment hysterotomy for irreducible Healthy mother and infant; uncomplicated
uterine torsion with easy resolution of torsion after delivery; postoperative course
plication of lax uterosacral and round ligaments
Aviram et al., 199534 1 High transverse posterior uterine J-incision for delivery of No maternal or neonatal postpartum
viable 4660 g male infant; two-layer uterine closure; complications
myomectomy of pedunculated 10 cm fibroid; uterine
malposition then corrected

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 Third Trimester Uterine Torsion: Case Report

wish to have future pregnancies. The risk of uterine rupture 15. Koh KS, Bradford CR. Torsion of the pregnant uterus. Can Med Assoc J
1977;117(5):501.
with a prior posterior lower segment incision compared
16. El-Taher SS, Hussein IY. Unexpected torsion of the gravid uterus. J Obstet
with the risk following an anterior lower segment incision Gynaecol 2004 Feb;24(2):177.
remains unknown. In the absence of evidence, we recom-
17. Bond AL, Grifo JA, Chervenak FA, Kramer EE, Harris MA. Term
mend a CS for any subsequent deliveries. Theoretically, a interstitial pregnancy with uterine torsion: sonographic, pathologic, and
repeat CS is safer because it avoids the possibility of a clinical findings. Obstet Gynecol 1989;73(5pt2):857–9.
labour-associated uterine rupture. 18. Crona N, Bachrach I. Pathologic torsion of the pregnant uterus. Acta
Obstet Gynecol Scand 1984;63(4):375–6.
ACKNOWLEDGEMENTS 19. Steigrad SJ. Torsion of the gravid uterus. Aust NZ J Obstet Gynaecol
1987;27(1):66–8.
The woman whose story is told in this case report has pro-
20. Bolaji II, Rafla NM, Mymotte MJ. Classical caesarean section through the
vided signed permission for its publication. posterior uterine wall. Ir J Med Sci 1992;161(2):46–7.
21. Piot D, Gluck M, Oxorn H. Torsion of the gravid uterus. Can Med Assoc J
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