Uterine torsion was first reported in 1861, but just over 200 cases have been reported in the past 100 years . The etiology of uterine torsion during pregnancy remains unclear. According to reports, the causes of most cases of uterine torsion include congenital or acquired uterine malformations, pelvic tumors or uterine fibroids or adhesions, traction, or abnormal fetal position that may lead to significant uterine asymmetry [7, 12]. For these reasons, we need to screen patients for the above causes in the first trimester and before pregnancy, inform them of the relevant risks, and strengthen education and management during pregnancy to reduce the occurrence of adverse pregnancy outcomes. In addition, pregnancy can exacerbate the congenital and physiological rotation and tilt of the uterus, but most cases still cannot be explained by the above reasons.
In general, symptoms are related to the degree and duration of uterine torsion. Previous reports have shown peritonitis-like symptoms in 16% of patients, urinary tract symptoms in 8%, and asymptomatic symptoms in 11% . Therefore, prenatal diagnosis of uterine torsion is not easy. Uterine torsion is more difficult to suspect in asymptomatic cases . Moreover, most cases are determined only during surgery and sometimes even after the uterine incision has been sutured . The study pointed out that since the normal vagina has an H-shaped structure on magnetic resonance imaging (MRI), an X-shaped structure of the vagina on MRI is a sign of uterine torsion . However, MRI is not an appropriate test in the emergency rescue of mothers and babies. Excessive inspections and time spent on imaging may lead to missed opportunities for rescue efforts.
Although symptoms such as abdominal pain and vaginal bleeding are not specific enough, this case alerts the obstetrician to the possibility of uterine torsion. In this case, we considered the diagnosis of placental abruption and fetal distress based on symptoms, signs and fetal heart rate monitoring. Emergency cesarean section is performed in critical situations without ultrasound evaluation. If the situation is less urgent, we may perform an ultrasound evaluation and compare the previous results, and perhaps a diagnosis of uterine torsion can be confirmed before delivery.
By narrowing the venous lumen, twisting of any uterus-like organ results in a decrease in perfusion. When uterine torsion occurs, the torsional venous lumen narrows, venous blood flow decreases first, and then the blood supply to the uterus decreases, followed by increased pressure in the placental cotyledons leading to fetal distress and placental abruption. Studies have identified factors associated with placental abruption, including maternal asthma, previous cesarean section, cocaine use, endometriosis, chronic hypertension, older maternal age, maternal smoking, use of antiretroviral therapy, low preconception weight, preeclampsia, uterine leiomyoma and cannabis use . Based on this report, uterine torsion, a rare disease, should also be added. Management of perinatal uterine torsion depends on when torsion occurs during pregnancy. In all cases, laparotomy is necessary. When uterine torsion occurs before the fetus is viable, treatment is laparotomy and uterine detorsion.
When the uterus is twisted, the fallopian tubes and ovaries are located anteriorly, there is no normal bladder reflex peritoneum, the lower uterine segment is constricted, the vessels on the surface of the lower segment are extremely hyperemic, and the ureter is closer to the uterus. Agar et al. recommend the use of longitudinal uterine incision in suspected cases of uterine torsion to prevent damage to blood vessels or ureters . However, Albayrak and colleagues have noted that in unexpected situations, when detorsion is not performed, a posterior low percutaneous incision is also a safe option . Similarly, this procedure has also been shown to be practical in this case .
Through this case, we learned that uterine torsion causes serious harm to both mothers and babies. Therefore, we should optimize antenatal care and examination and reduce or advise avoidance of sexual activity and heavy physical labor in the second and third trimesters of pregnancy as much as possible . In patients with a history of uterine leiomyomas, preconception resection or intensive monitoring during pregnancy should be considered based on the size and location of the fibroids . In addition, pregnancy care and timely treatment and monitoring of symptoms such as abdominal pain are needed.