Twisted fallopian tube in pregnancy: a case report

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 [3][4][5][6][7][8]. 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/mm 3 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 5 th 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 38 th week by cesarean section due to cephalopelvic disproportion. No fetal or maternal complication was observed during the postpartum period.
Many reports indicate that twisted fallopian tube is more common on the right than the left [3][4][5][6][7][8][9][10][11]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 [3][4][5][6][7][8][9][10][11]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 [3][4][5][6][7][8][9]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 [3][4][5][7][8][9]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.