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Twisted fallopian tube in pregnancy: a case report

BMC Pregnancy and Childbirth20011:5

https://doi.org/10.1186/1471-2393-1-5

Received: 27 September 2001

Accepted: 5 November 2001

Published: 5 November 2001

Abstract

Background

Isolated twisted fallopian tube is an uncommon event, isolated twisted fallopian tube in pregnancy is also very rare. The diagnosis is often difficult and established during the operation. The right fallopian tube is most common affected.

Case presentation

We report an uncommon twisted left fallopian tube in pregnancy. A 34-year-old G3P2 28 weeks pregnant woman presented with acute left lower abdominal pain. The clinical and ultrasonographic findings led to diagnosis of twisted left ovarian cyst. Emergency exploratory laparotomy was performed. A twisted left fallopian tube and paratubal cyst was noted and left salpingectomy was performed. The postoperative course was uneventful and the pregnancy continued until term without complication.

Conclusions

Although isolated twisted fallopian tube during pregnancy is very rare, it should be included in the differential diagnosis of acute abdomen in pregnancy. Early surgical intervention will decrease obstetric morbidity and may allow preservation of the fallopian tube.

Background

Isolated twisting of a fallopian tube is an uncommon event. The incidence from previous reports is 1/1,500,000 women [1]. The diagnosis of isolated twisted fallopian tube in pregnancy is also very rare, only 12% of cases are found during this time [2]. The condition is frequently misdiagnosed as acute appendicitis or ovarian torsion [38]. The right fallopian tube is most commonly affected. We report a case of twisted left fallopian tube during pregnancy and review the relevant literature.

Case presentation

A 34-year-old woman, gravida 3, para 2, presented at 28 weeks gestation complaining of constant left lower abdominal pain with intermittent cramping that had been radiating to her left flank for 2 days. It happened after changing the position. She also had nausea and vomiting. Her past medical history was significant for chronic hypertension and β-thalassemia trait. Her prenatal course had been unremarkable except for a 5-cm, hypoechoic left ovarian cyst noted incidentally on 18-week ultrasonography. Her past obstetric history was unremarkable with two uncomplicated vaginal deliveries.

On examination, her temperature was 37.2°C and blood pressure was 130/80 mmHg. The uterine size was consistent with gestational age, and fetal heart beat was 160/min. Abdominal examination revealed tenderness at the left paraumbilicus. The admission hematocrit was 30 %, white blood cell count was 15,000/mm3 with 81.4% neutrophil, platelet count and urine analysis were normal. Ultrasonographic examination demonstrated a hypoechoic cystic mass with the dimensions of 65 mm, 61 mm and 60 mm, in the left adnexal region. Laparotomy was performed for the diagnosis of the twisted left ovarian cyst. A gangrenous, 6 × 6cm paratubal cystic mass was found during the exploration. The cystic mass and the distal two third of the left fallopian tube had twisted 3 times around themselves.

As the right fallopian tube, both ovaries and appendix had no abnormality, left salpingectomy and extirpation of the left paratubal cyst were performed. Histologic examination showed severe congestion and recent hemorrhage in the wall of the fallopian tube and paratubal cyst. Postoperatively the patient required intravenous tocolysis for 2 days which was then weaned. She was discharged on the 5th postoperative day. The rest of the pregnancy was uneventful and she gave birth to a healthy male baby with birth weight 3.910g at the 38th week by cesarean section due to cephalopelvic disproportion. No fetal or maternal complication was observed during the postpartum period.

Discussion

Isolated twisted fallopian tube in pregnancy is a rare event. Regad reported that only 12% of isolated tubal torsion was associated with pregnancy [2]. We have found only 1 case in 120,000 pregnancies from a 10 years period (1991–2000) in our institute.

The etiologies of the development of twisted fallopian tube in this case were paratubal cyst, pregnancy and sudden body position changes. Other etiologies have been proposed [311] including: anatomic abnormalities (long mesosalpinx, tubal abnormalities, hematosalpinx, hydrosalpinx, hydatids of Morgagni), physiological abnormalities (abnormal peristalsis or hypermotility of the tube, tubal spasm from drugs and intestinal peritalsis), hemodynamic abnormalities (venous congestion in the mesosalpinx), Sellheim theory (sudden body position changes), trauma, previous surgery or disease (tubal ligation, pelvic inflammatory disease), and gravid uterus.

The most presenting symptom is pain, which begins in the affected lower abdomen or pelvis but may radiate to the flank or thigh [58, 10, 11]. The onset of pain is sudden and cramp-like and may be intermittent [5, 7, 11]. Other associated symptoms include nausea, vomiting, bowel and bladder complaints, and scant uterine bleeding [58, 10, 11]. The body temperature, white blood cell count and erythrocyte sedimention rate may be normal or slightly elevated [58, 11]. Pelvic examination may reveal a tender, tense adnexal mass associated with cervical tenderness [12]. The present case presented with only left lower abdominal pain and nausea and vomiting.

Because these signs, symptoms and physical findings are associated with other common diseases, the diagnosis is never established before operation [311, 13, 14]. The differential diagnosis includes acute appendicitis, ectopic pregnancy, pelvic inflammatory disease, twisted ovarian cyst, ruptured follicular cyst, urinary tract disease, renal colic, degenerative leiomyoma, and abruptio placenta [3, 5, 7, 8, 10, 11]. There have been reports of using ultrasound in the diagnosis of twisted fallopian tube [15]. The ultrasonographic appearance includes an elongated, convoluted cystic mass, tapering as it nears the uterine cornu and demonstration of the ipsilateral ovary [15]. In this present case, clinical and ultrasonographic findings led to a diagnosis of twisted ovarian cyst.

Many reports indicate that twisted fallopian tube is more common on the right than the left [311, 13, 14]. This may be due to the presence of the sigmoid colon on the left [3, 5, 7, 8, 11], or to slow venous flow on the right side, which may result in congestion [8]. The other reason is that more cases of right-sided pain are operated because of the suspicion of appendicitis [5, 10], whereas left-sided cases may be missed and resolve spontaneously. But the unique aspect of our case that contrasted with other reports [311, 13, 14] was that the left fallopian tube was affected. This may have been related to the left paratubal cyst.

The management of this condition consists of early surgery [5, 8, 11]. Laparotomy is often performed [39, 11, 13], but laparoscopic surgery has recently been described in the management of twisted fallopian tube [10]. A recent report confirmed that laparoscopic surgery is safe for use in the first trimester of pregnancy [16]. If the tube is beyond recovery, salpingectomy is necessary. However, if twisting is incomplete or recent, untwisting may be possible and the tube may be preserved [35, 79, 11]. In our case laparotomy was suitable because of the enlarged 28-week uterus and salpingectomy was performed due to the gangrenous fallopian tube.

The English language literature concerning twisting or torsion of the fallopian tube and pregnancy available from Cumulative Index Medicus from the year 1962 to 1965 and Medline from the year 1966 to 2000 were reviewed. There have been 7 publications reporting 13 cases, including present case (Table 1). All cases occurred in reproductive age (age ranged from 20 the 41 years). The condition occurred in the first trimester in 1/13 (7.7%) case, second trimester 3/13 (23.1%) cases, third trimester 8/13 (61.5%) cases, and intrapartum 1/13 (7.7%) case. All of the cases were not able to be diagnosed as twisted fallopian tube before surgery. All of the cases except present case (92.3%) occurred in the right fallopian tube. There were no associated findings during operation in 4/13 (30.7%) cases, while reported associated findings were paratubal cyst in 3/13 (23.1%) cases, ovarian cyst 2/13 (15.4%) cases, cyst of mesosalpinx 1/13 (7.7%) case, cyst in broad ligament 1/13 (7.7%) case, sactosalpinx 1/13 (7.7%) case, and hydrosalpinx 1/13 (7.7%) case. Most of the cases were treated with salpingectomy of the affected tube. In all of the cases the pregnancies ended with a favorable outcome.
Table 1

characteristic of twisted fallopian tube in pregnancy [5-9], [13], [14].

Author (year)

Age (years)

Gravia & Parity

Gestational age (weeks)

Preoperative Diagnosis

Operative findings

Associated finding

Operation

Pregnancy outcome

Walker PA (1962)[13]

24

G1P0

37

Acute abdomen

Twisted right fallopian tube

No

Right salpingectomy

Term pregnancy (Vaginal delivery)

Lewis EC (1962)[14]

22

-

30

Acute appendicitis

Torsion of right fallopian tube

Cyst in broad ligament

Right salpingectomy

Term pregnancy (Cesarean section)

Chambers JT et al(1979)[5]

        

Case 1

25

G1P0

30

Acute appendicitis

Torsion of right fallopian tube

No

Right salpingo-oophorectomy

Term pregnancy (Vaginal delivery)

Case 2

27

G1P0

36

Urinary tract infection and abruptio placenta

Torsion of right fallopian tube

No

Right salpingectomy

36 week pregnancy (Cesarean section)

Isager-Sally L & Weber T (1985)[6]

        

Case 1

26

G1P0

15

Appendicitis

Torsion of right fallopian tube

Twisted right ovarian cyst

Right salpingo-oophorectomy

Term pregnancy (Vaginal delivery)

Case 2

25

G1P0

39

Fetal indication

Twisted right fallopian tube

Cyst of the mesosalpinx

Right salpingectomy

Term pregnancy (Cesarean section)

Case 3

20

G2P1

32

Fetal indication

Twisted right fallopian tube

Sactosalpinx

Resection of lateral part

36 week pregnancy (Cesarean section)

Case 4

30

G1P0

29

Acute appendicitis

Twisted right fallopian tube

Right ovarian cyst

Right salpingo-oophorectomy

-

McKenna PJ & Gerbert KH (1989)[7]

33

G6P4

32.5

Acute appendicitis

Twisted right fallopian tube

Paratubal Cyst

Right salpingectomy

37 week pregnancy (Vaginal delivery)

Sorem KA etal (1991)[9]

26

G3P2

39 (in labor)

Early uterine rupture or adnexal torsion

Twisted right fallopian tube

No

Right salpingectomy

39 week pregnancy (Cesarean section)

Yalcin OT et al(1997)[8]

        

Case 1

24

-

26

Acute abdomen

Twisted right fallopian tube

Right hydrosalpinx

Right salpingectomy

37 week pregnancy (Vaginal delivery)

Case 2

31

-

34

Torsion of an ovarian cyst

Twist right fallopian tube

Paratubal cyst

Right salpingectomy

39 week pregnancy (Vaginal delivery)

Present case

34

G3P2

28

Twisted left ovarian cyst

Twisted left fallopian tube

Paratubal cyst

Left salpingectomy

38 week pregnancy (Cesarean section)

Conclusions

Although twisting or torsion of fallopian tube during pregnancy is uncommon, it should be included in the differential diagnosis of acute abdomen in pregnancy. Early surgical intervention will decrease obstetric complications and may allow preservation of the tube.

Declarations

Authors’ Affiliations

(1)
Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University

References

  1. Hansen OH: Isolated torsion of the Fallopian tube. Acta Obstet Gynecol Scand. 1970, 49: 3-6.View ArticlePubMedGoogle Scholar
  2. Regad J: Etude Anatomo-Pathologique de la torsion des trompets uterines. Gynecol Obstet. 1933, 27: 519-535.Google Scholar
  3. Blair CR: Torsion of the fallopian tube. Surg Gynecol Obstet. 1962, 114: 727-730.PubMedGoogle Scholar
  4. Dueholm M, Praest J: Isolated torsion of the normal fallopian tube. Acta Obstet Gynecol Scand. 1987, 66: 89-90.View ArticlePubMedGoogle Scholar
  5. Chambers JT, Thiagarajah S, Kitchin JD: Torsion of the normal fallopian tube in pregnancy. Obstet Gynecol. 1979, 54: 487-489.PubMedGoogle Scholar
  6. Isager-Sally L, Weber T: Torsion of the fallopian tube during pregnancy. Acta Obstet Gynecol Scand. 1985, 64: 349-351.View ArticlePubMedGoogle Scholar
  7. McKenna PJ, Gerbert KH: Isolated torsion of the uterine tube in pregnancy. A case report. J Reprod Med. 1989, 34: 187-188.PubMedGoogle Scholar
  8. Yalcin OT, Hassa H, Zeytinoglu S, Isiksoy S: Isolated torsion of fallopian tube during pregnancy; report of two cases. Eur J Obstet Gynecol Reprod Biol. 1997, 74: 179-182. 10.1016/S0301-2115(97)00117-6.View ArticlePubMedGoogle Scholar
  9. Sorem KA, Bengtson JM, Walsh B: Isolated fallopian tube torsion presenting in labor. A case report. J Reprod Med. 1991, 36: 763-764.PubMedGoogle Scholar
  10. Milki A, Jacobson DH: Isolated torsion of the fallopian tube. A case report. J Reprod Med. 1998, 43: 836-838.PubMedGoogle Scholar
  11. Provost RW: Torsion of the normal fallopian tube. Obstet Gynecol. 1972, 39: 80-82.PubMedGoogle Scholar
  12. Krissi H, Orvieto W, Dicker D, Dekel A, Ben Rafael Z: Torsion of a fallopian tube following Pomeroy tubal ligation: a rare case report and review of the literature. Eur J Obstet Gynecol Reprod Biol. 1997, 72: 107-109. 10.1016/S0301-2115(96)02656-5.View ArticlePubMedGoogle Scholar
  13. Walker PA: A case of torsion of the fallopian tube in pregnancy. J Obstet Gynaecol Br Commonw. 1962, 69: 117-118.View ArticleGoogle Scholar
  14. Lewis EC: Torsion of a fallopian tube complicating pregnancy. Br J Clin Pract. 1962, 16: 540-543.Google Scholar
  15. Elchalal U, Caspi B, Schachter M, Borenstein R: Isolated tubal torsion: clinical and ultrasonographic correlation. J Ultrasound Med. 1993, 12: 115-117.PubMedGoogle Scholar
  16. Yen ML, Chen CA, Huang SC, Hsieh CY: Laparoscopic cystectomy of a twisted, benign, ovarian teratoma in the first trimester of pregnancy. J Formos Med Assoc. 2000, 99: 345-347.PubMedGoogle Scholar
  17. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/1/5/prepub

Copyright

© Phupong and Intharasakda; licensee BioMed Central Ltd. 2001

This article is published under license to BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.

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