INTRODUCTION:

As obstetricians, we are generally more familiar with ovarian torsion than uterine torsion, which remains a rare clinical encounter. Although dextrorotation—the most common form of uterine torsion—is covered in undergraduate medical education, many practicing obstetricians may never encounter it during their careers. Uterine torsion is particularly challenging to diagnose antenatally and is often identified only intraoperatively during caesarean section.

In this case report, we present a term pregnant woman who was asymptomatic for uterine torsion, which was incidentally discovered during a caesarean delivery performed due to suspicious cardiotocography (CTG) findings and failure to progress in labour.

CASE REPORT

A 33-year-old woman, G2P0+1, at 39 weeks of gestation, presented with significant bilateral lower limb oedema. Her antenatal course had been uneventful, with normal anomaly and serial growth scans. In view of the bilateral leg oedema, a preeclampsia (PE) profile was performed and returned within normal limits. She continued routine antenatal follow-up without any further complications while awaiting spontaneous onset of labour.

In line with local hospital guidelines, she was counselled regarding induction of labour if she had not delivered by 40 weeks + 7 days. Her leg oedema continued to progress, prompting repeat PE profiles at each subsequent visit. At her final antenatal visit, an elevated urine protein-to-creatinine ratio was noted. Given that she was already at 40 weeks + 5 days gestation, the decision was made to proceed with induction of labour.

She was admitted the following day (40+6 weeks) and underwent induction at 40+7 weeks. Standard preparatory measures were undertaken, including explanation of the induction process, obtaining verbal consent, per vaginal assessment, and arranging blood grouping and saving. Her Bishop score was 5/13, indicating an unfavourable cervix.

As per hospital protocol, a prostin pessary regimen was initiated, with continuous monitoring via cardiotocography (CTG). Cervical changes were observed and she eventually progressed to 4 cm dilatation. She was then transferred to the labour room for artificial rupture of membranes (ARM) and subsequently augmented with a syntocinon infusion.

Despite satisfactory uterine contractions over a 6-hour period, there was no further cervical dilation. In addition, suspicious features of fetal hypoxia were noted on CTG. Given the unfavourable vaginal findings and biochemical changes suggestive of worsening preeclampsia, a decision was made to proceed with an emergency Caesarean section.

CASE PROCEEDINGS AND DISCUSSION

During the Caesarean section, intraoperative findings were notable for the right fallopian tube and ovary being stretched and located anteriorly over the lower uterine segment and the dome of the bladder. The normal uterovesical peritoneal fold was absent. The broad ligament venous plexuses were tortuous, prominently dilated, and engorged. The uterus was found to be rotated to the left (levorotation), with the posterior uterine wall now facing anteriorly, making detorsion at this stage technically unfeasible.

A posterior lower segment uterine incision was performed cautiously trying to avoid injury to the engorged vessels. The baby was delivered with the assistance of forceps and was found to have two loops of the umbilical cord tightly coiled around the neck. The placenta was located at the upper posterior uterine wall and was delivered smoothly without complication.

The uterus was closed in two layers in the standard fashion. Haemostasis was secured, following which gentle untwisting of the uterus was successfully performed. Both ureters were visualized and confirmed to be intact. The total estimated blood loss was approximately 1.1 liters.

LITERATURE REVIEW

Uterine torsion is defined as a rotation of the uterus of more than 45°, and it is considered pathological when it exceeds this threshold. While dextrorotation of the gravid uterus is a common physiological finding, frequently noted in medical textbooks, pathological uterine torsion remains a rare clinical entity. Dextrorotation accounts for approximately 80% of cases, whereas levorotation is seen in only 20%.

Most case reports have associated uterine torsion with structural abnormalities such as uterine anomalies or fibroids. However, the precise etiology remains unclear. Koh noted that no apparent causative factor is identified in up to 20% of cases.¹

One of the literature review evidences that uterine torsion is not reported frequently. Piot, Gluck, and Oxorn traced the earliest recorded instance to 1662 by an Italian veterinarian, Columbi. In 1863, Virchow reported the first human case during a postmortem examination, and the first case in a living woman was described in 1876 by Labbe, Nesbitt, and Corner². Their 1956 review included 107 cases, excluding their own. Later, in 1992, Jensen (cited by Carbonne) documented 212 cases with varying etiologies.³

The degree of uterine torsion varies, although most reported cases involve rotation around 180°. Severe cases have also been documented; for instance, Van Pall in 1940 reported a 540° rotation associated with uterine necrosis.⁴ The severity of clinically presented case often associates with the degree of twist. Acute torsion may mimic an acute abdomen, presenting with pain, vomiting, shock, and even fetal demise. Differential diagnoses include placental abruption, ectopic pregnancy, pelvic tumor torsion, peritonitis, obstructed labour, and abdominal hemorrhage.

However, uterine torsion can be entirely asymptomatic, as in our case. Piot [2] reported that pain is the most common symptom (95%), followed by shock, vaginal bleeding, and signs of obstructed labour. Imitation of intestinal impediment and urinary symptoms are correspondingly described frequently.

Several predisposing factors have been proposed, including:

· Fetal malpresentation (particularly transverse lie)

· Uterine fibroids

· Congenital uterine anomalies

· Pelvic adhesions

· Ovarian cysts

· Abnormal pelvic anatomy

· Uterine suspension procedures

· Placenta praevia

Uterine asymmetry is considered a significant contributing factor, though a definitive causal mechanism remains undetermined. Diagnosis is usually made intraoperative during laparotomy or Caesarean section. Suspicion should be raised when the fallopian tubes and ovaries are observed anteriorly, the uterovesical peritoneal fold is absent, or when engorged and tortuous vessels are found over the lower uterine segment.

Additional preoperative clues may include:

· A change in the placental site compared to previous ultrasound findings

· Abnormal uterine vessel course on Doppler imaging

· On MRI, a characteristic “X-shaped” configuration of the vagina (instead of the normal “H-shape”) ⁶

Management involves surgical intervention. Detorsion followed by Caesarean delivery is the standard approach. If detorsion is not feasible, delivery can be achieved through a posterior low transverse uterine incision.⁷ Conservative management is generally not an option since diagnosis is seldom made prior to surgical exploration. Mustafa et al. advocated for bilateral round ligament plication post-delivery to prevent recurrence, reduce dyspareunia, minimize posterior adhesions, and help maintain the uterus in an anteverted position.⁸ In rare early-detected cases, detorsion with bilateral round ligament plication may allow the pregnancy to continue to term.⁹ However, an elective Caesarean section is typically advised in subsequent pregnancies due to the unknown risk of uterine rupture following a posterior uterine incision.

Maternal mortality associated with uterine torsion ranges from 10% to 20%, while perinatal mortality is approximately 30%.¹

Several case reports reflect variable presentations and management strategies:

· De Loris described torsion in a myomatous uterus with a premature breech fetus.¹⁰

· Picone reported a club-footed premature infant delivered via posterior hysterotomy due to torsion.¹¹

· A recent report documented a 360° torsion at 27 weeks managed via a vertical uterine incision.¹²

· A rare case of uterine torsion was also reported in a non-pregnant woman with leiomyosarcoma.¹³

Most reports confirm that uterine fibroids are the predominant predisposing factor. Uterine torsion tends to occur in the late second or third trimester, particularly between 28–32 weeks or at term. At term, as in our case, Pelosi highlighted that a deliberate posterior caesarean hysterotomy is an option when detorsion is not possible. Additionally, round ligament plication may prevent immediate postpartum recurrence.¹⁴ In our case, the fetus was delivered through a posterior uterine incision due to irreducible torsion; however, round ligament plication was not performed, which may be considered a missed opportunity for preventing recurrence.

CONCLUSION:

Uterine torsion is a rare condition that frequently goes unnoticed in obstetric practice. The increased awareness of its potential presentation, stressed the value of early intraoperative detection, and illustrated suitable management techniques like in this case report. We hope that this report will help others to expand their knowledge and to achieve greater clinical awareness. In the future, the knowledge and awareness will lead to prompt diagnosis of this rare encounter resulting in best maternal and fetal outcome.

Conflict of interest: There was no conflict of interest among the authors.

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Received on 19.01.2025 Revised on 27.04.2025

Accepted on 05.08.2025 Published on 01.10.2025

Available online from October 04, 2025

Research J. Pharmacy and Technology. 2025;18(10):4769-4772.

DOI: 10.52711/0974-360X.2025.00686

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