Keywords : Torsion uterus, ovarian cyst
A 20-year-old primigravida married since 1 year, was admitted with 36 weeks pregnancy along with a mass and acute pain in the abdomen. In early pregnancy she visited local doctors for the confirmation of pregnancy. Thereafter she had no antenatal checkup. At 35 weeks of pregnancy she noticed an excessive enlargement of the abdomen but she did not visit any doctor. On the day of admission she had a sudden severe pain in the abdomen which was associated with vomiting and fainting. She went to a local doctor who after initial resuscitation referred her to this hospital. Her complaints were continuous pain all over the abdomen, aggravated by movements and associated with vomiting. She was afebrile, pale, and normotensive with tachycardia. Symphysio fundal height was 42cm. Abdomen was tender, fetal heart sounds were present and regular, ultrasound examination revealed 37 weeks fetus with active heart beat, 2.5 kilogram in weight. There was a huge cystic mass with internal echoes and thin septations, measuring 19x15cm in size lying above the uterus in the epigastric region
Her hemoglobin was 9.0 gm%. She underwent emergency laparotomy. On exploration, she had dual pathology i.e. huge ovarian cyst without any torsion while the full term pregnant uterus was found twisted at lower uterine segment (Fig. 1). The uterus was untwisted; a live baby boy was delivered by lower segment caesarean section. The baby was hypoxic at the time of birth, resuscitated by the pediatrician. The ovarian cyst was having benign features, 20x18cm in size, and 7.5 kg in weight (Fig. 2). The other tube and ovary were normal. Right salpingo-oophorectomy was done. Her postoperative period remained uneventful. She was discharged on the 8th postoperative day. Histopathology report of the removed tumor was serous cystadenoma.
Uterine torsion is the twist of the uterus at the junction between the cervix and the corpus more than 45 degrees around its long axis and mostly the degree of twist is 1800. Rarely does torsion of pregnant uterus occurs to such an extent that the uterine circulation is arrested leading to acute maternal symptoms and also threatenfetal survival. Thus it is usually associated with abruptio placentae. The risk factors for uterine torsion are abnormal fetal presentation i.e. transverse lie, uterine distention due to the leiomyoma, mullerian anomalies, pelvic adhesions and large neoplasms distorting the uterine shape or position. In this case the associated factor was large ovarian cyst. The incidence of the ovarian tumor in pregnant women is 1/10001 deliveries.
Torsion of the full term pregnant uterus is a rare obstet- ric event2 and rarely diagnosed before surgery3. It can be asymptomatic or may present with acute onset of abdominal pain, distention, gastrointestinal disturbances, urinary dysfunction and vaginal bleeding. In this case the patient had torsion of full term pregnant uterus with huge ovarian cyst. Ovarian cysts are usually asymptomatic but once there are complications like complex masses, torsion, rupture or hemorrhage, surgical intervention is required1. She was suspected as a case of torsion of ovarian cyst with full term pregnancy but the diagnosis of uterine torsion was made at the time of operation as the uterus was rotated at its long axis with marked edema and venous engorgement. This patient was not in labor but literature review from different case reports show that even with good uterine contractions there is no cervical dilatation4, or women have acute abdominal pain and shock due to placental abruption5. According to the case report by Cook6, acute uterine torsion was associated with placental abruption, maternal shock and fetal demise as in that case labor was induced and uterine torsion was diagnosed late. So on laparotomy the uterus and ovaries were found necrotic.
In our case the women was 36 weeks pregnant and had huge ovarian cyst. On laparotomy, there was huge right sided ovarian cyst occupying the whole abdomen; uterus was displaced to the left side with a twist of 180 degree at its pedicle. The baby was alive and uterus was having no evidence of necrosis. In this case the patient had early surgery so the lives of baby and mother were saved. Guie et al7 also reported that prompt surgical treatment is fundamental for the reduction of fetal mortality and possible maternal mortality with this condition.
