Inevitable Cesarean Myomectomy Following Delivery Through Posterior Hysterotomy in a Case of Uterine Torsion

DOI: 10.5455/medarh.2013.67.75-76
Med Arh. 2013 Feb; 67(1): 75-76
Received: October12th 2012 | Accepted: December 19th 2012

CONFLICT OF INTEREST: NONE DECLARED

case report

Inevitable Cesarean Myomectomy Following

Delivery Through Posterior Hysterotomy in a Case
of Uterine Torsion
Radmila Sparic, Biljana Lazovic
Clinic for Gynaecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia1
Clinical Hospital Center ZemunBelgrade, Internal Medicine Clinic, Belgrade, Serbia2

ackground: Torsion of the pregnant uterus at term is a very infrequent obstetric event.
It is usually associated with the presence of myoma or congenital deformities. Maternal
prognosis is good after surgical treatment; however, prenatal mortality is high. Case report:
We report a case of posterior low transverse hysterectomy in a case of uterine torsion at 38 weeks
gestation, due to a large myoma. At presentation, her cervix was unfavorable and cardiotocography
showed spontaneous deceleration demanding delivery by cesarean section. Following delivery, it
was realized that the incision had been made on the posterior wall of the uterus and that the uterus
was axially rotated by 180 degrees. The mother recovered uneventfully and both mother and the
baby were discharged on the fifth postoperative day. Conclusion: Obstetricians must have uterine
torsion in mind when performing a cesarean section in patients with myomas. Key words: uterine

torsion, pregnancy, cesarean section, myoma.

Corresponding author: Biljana Lazovic, MD. Clinical Hospital Center Zemun-Belgrade, Internal
Medicine Clinic 11080 Belgrade, Serbia. Tel: 062212040. E-mail: lazovic.biljana@gmail.com

1. Introduction
Uterine torsion is a rotation of more
than 45 degrees of the uterus around
its longitudinal axis that occurs at the
junction between the cervix and the
corpus of the uterus. The extent of the
torsion is usually 180 degrees, although
it has been described torsion from 60 to
720 degrees (1). It is infrequent in humans, and majority of the available papers are case reports diagnosed as incidental findings during surgical exploration (2, 3). Uterine torsion was first described by an Italian veterinary surgeon
in 1662 (3). Most reported reviews are
from the veterinary literature, particularly in the cattle (4). The most extensive
review was published by Jensen, including 212 reported cases (1). The cause of

the uterine torsion during pregnancy

is unclear. The earliest reported age for
uterine torsion during pregnancy is in
the sixth gestational week and the latest
in forty third weeks (1). It is associated
with the presence of uterine myomas
or congenital deformities, abnormal fetal presentations, placenta praevia, pelvic tumors or abnormalities, although
there are cases in which none of the
predisposing factors were present (2, 3).
Clinical diagnosis is difficult, since it is
rarely considered and symptoms are either absent or nonspecific (abdominal
pain, vaginal bleeding, shock, cervical
dystocia, painful uterine contractions,
dynamic hypertonia, repeated episodes
of pathological CTG patterns, urinary
and intestinal symptoms) (1, 6).

The diagnosis is often missed, usually made at laparotomy (2, 3). Maternal prognosis is good after surgical
treatment; however, prenatal mortality is high (6).

2. Case report
A 28-year-old nullipara with a diagnosed uterine myoma was referred
to our hospital at 38 weeks gestation. Her prenatal course was uncomplicated. On vaginal examination the
cervix was closed and 2 centimeters
long. Cardiotocography showed decelerations demanding delivery by cesarean section. During surgery, the uterovesical fold of peritoneum could not
be found over the lower segment. As it
was not possible to perform torsion of
the gravid uterus, a low transverse incision was made and a 3150 gram baby
was delivered easily with a 1-minute
Apgar score 7.
Following delivery, it was realized
that the incision had been made on the
posterior wall of the uterus and that
the uterus was axially rotated by 180
degrees. Detorsioning was carried out
by exteriorizing the myoma and the
uterus out of the abdominal cavity. The
uterus was closed in two layers with a
continuous stitch. A 15 cm intramural
myoma on the right fundal region was
found. A standard technique for myo-

Med Arh. 2013 Feb; 67(1): 75-76 case report

75

Inevitable Cesarean Myomectomy Following Delivery Through Posterior Hysterotomy in a Case of Uterine Torsion

mectomy was used with no complications. Following myomectomy, the

uterus was put back into abdomen in
its anatomical position. The mother recovered uneventfully and both mother
and the baby were discharged on the
fifth postoperative day. At a follow up
examination six weeks later, her pelvic
examination was normal.

3. Discussion
Except pathological cardiotocography, our case was clinically asymptomatic for uterine torsion. This is consistent with the Jensens report that in 11%
of the patients no symptoms are present (1). The clinical presentation of uterine torsion is variable and physical examination and ultrasonographic scanning may be insufficient for diagnosis (1). Vaginal examination, as in our
case, only reveals the cervical canal to
be twisted and closed. Ultrasound has
some diagnostic role in cases of regular pregnancy follow up, when changing in placental localization on ultrasound could be a sign of uterine torsion (7). Magnetic resonance imaging
is currently the method of choice for
establishing diagnosis by demonstration of an X shaped configuration of
the torsion site (8, 9). Thus, this kind of
pregnancy complication could be often
misdiagnosed in cases insufficient prenatal care or inaccessibility of modern
diagnostic tools, such as magnetic resonance imaging. Rare affection of difficult clinical diagnosis, the uterine torsion presents both diagnostic and therapeutic dilemma. Once the diagnosis is
established, immediate surgical intervention is advisable. Delayed surgical
intervention could result in increased
maternal morbidity and poor fetal outcome, even fetal demise.
The cause of uterine torsion is usually due to an anatomical aberration
with myomas being the most common
(1, 6, 7). Myomas are observed more
frequently in pregnancy because more
women are delaying childbearing. Also,
there is a high incidence of cesarean
section in women with myomas with a
large proportion being directly related
to the myoma (8). Unlike the torsion
described during labor, that occurring
during pregnancy might be difficult to
recognize. Uterine torsion signs, when
76

present are not specific. Our case was

clinically asymptomatic for uterine torsion. This is consistent with the Jensens report that in 11% of the patients
no symptoms are present (1). Delivery
is either by posterior hysterectomy followed by repositioning of the uterus or
by repositioning of the uterus first before lower segment cesarean section.
Once the diagnosis is established, immediate surgical intervention is advisable. Delayed surgical intervention
could result in increased maternal morbidity and poor fetal outcome, even intrauterine fetal demise (9). Important
current concept of management includes cesarean section for parturient
with this infrequent pregnancy complication. The same treatment is advisable
in all the other cases with viable fetus.
The alternative hysterectomy incision
could be performed transversal through
posterior uterine wall, above the level of
uterosacral ligaments, in cases of failed
uterine detorsion efforts such in our
case. Following closure of the uterine
incision the contracted uterus should
be rotated back to the correct anatomical position. In all the cases of uterine
torsion it is advisable to conduct adjunct surgery to eliminate the possible
etiologic factors. There are some authors who suggest bilateral plication of
the round ligaments as a prophylactic
procedure to provide uterine stability,
thus preventing the recurrence of the
torsion (10). The effectiveness of this
method requires further investigation,
considering that exact etiopathogenesis
of uterine torsion in pregnancy remains
open to speculation. Despite the fact
that the predisposing factors are relatively common, such as myomas, torsion of the uterus is rare. Together with
the fact that in 16% of cases no abnormalities could be found, this data suggests that some additional, yet incompletely recognized factors need be present for uterine torsion to occur (11, 12).
In cases with uterine torsion prior
to fetal viability, the treatment should
be individualized. Uterine detorsion is
the principal treatment, followed by removal of contributing factors, if possible. There are not sufficient data in the
literature to define the safety of leaving the pregnancy to continue. Once
again, if the effectiveness of shortening

Med Arh. 2013 Feb; 67(1): 75-76 case report

of round ligaments gets proven, continuing of the pregnancy in such cases

might be advisable in the future (13).

4. Conclusion
The cause of uterine torsion is usually due to an anatomical aberration
with myomas being the most common.
Myomas are observed more frequently
in pregnancy because more women are
delaying childbearing. Also, there is a
high incidence of cesarean section in
women with myomas with a large proportion being directly related to the myoma. Although uterine torsion is rare,
obstetricians must have this complication in mind when performing a cesarean section in patients with myomas. In
conclusion, during cesarean delivery in
such patients obstetricians should routinely palpate for uterine rotation before incision is made into the lower segment. Anatomical landmarks should be
identified prior to uterine incision thus
checking for torsion of the uterus in patients with myomas. An inappropriate
uterine incision to deliver the fetus may
cause vascular and ureteric injury, causing serious complications.

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