Management
Treatment of torsion depends on the gestational age. When torsion is discovered at surgery prior to the period of presumed fetal viability, promptly returning the uterus to the normal position is the principal treatment.
Contributing pathology of the uterus or adnexa is removed, if possible. Whether the pregnancy should be allowed to continue is unclear. The risk of repeat torsion or other potentially serious complications is not known. Whether any procedures should be performed to fix the uterus in the usual anatomic position at the time of surgery and which procedure to attempt is also uncertain. In various clinical case reports, plication of the round ligaments has commonly been performed. In these unique circumstances, care must be individualized and establishing fixed guidelines for management is impossible. In instances in which the fetus is of sufficient maturity to be considered viable, the best treatment is delivery by cesarean.
Several cases of torsion have been reported in which the degree of rotation was so severe that the hysterotomy incision at the time of the cesarean delivery was actually performed on the posterior uterine wall. Some surgeons have described these posterior incisions as inadvertent while others have deliberately performed them when efforts at rotation of the uterus to the normal position proved unsuccessful. A number of case reports state that the uterus cannot be rotated into the normal position until it is emptied.
Too few reports are available to permit an accurate assessment of the long-term sequelae of delivery via a posterior hysterotomy incision. It seems reasonable that an effort at rotation to the normal position should precede the incision of the uterus. If de-torsion is impossible, then the posterior surgical approach is used. A transverse incision is best, curved upward, mimicking the usual anterior wall procedure. As noted, prophylactic plication of the round ligaments by various techniques has been performed postdelivery with the intent of stabilizing the uterus, possibly preventing recurrence of torsion in the puerperium. The efficacy of this treatment is unknown.
Abruptio placentae has been described in association with acute torsion. In theory, direct compression of the uterine, and perhaps the ovarian, veins due to the acute rotation of the uterus leads to increased back pressure in the placental cotyledons, predisposing to placental separation. Whether this mechanism is correct is speculative; however, the association is clear.
Because potentially serious sequelae are possible, establishing the correct diagnosis of uterine torsion early, before complications ensue, is the challenge for clinicians. Based on a review of the available literature, the trimester of pregnancy at the time the uterine torsion is diagnosed has a profound bearing on maternal morbidity and mortality. No maternal mortalities are reported in cases occurring before 20 weeks gestation. However, the rate of maternal death is reported to be 17% in the interval from 20-28 weeks, 10% in the late third trimester weeks, and 9% at term.
In considering these data, remember that these statistics are derived from a compilation of case reports or events that transpired over many years and occurred in many different institutions. Thus, these reported risks are almost certainly not representative of maternal risk in modern, fully equipped hospitals with current diagnostic equipment. Nonetheless, these data are a reminder that serious sequelae of torsion are possible.
Because of the potential for problems and the fact that the diagnosis is usually not established until a surgical exploration has been performed, full medical record documentation is mandatory. The chart should reflect the steps taken in evaluation and diagnosis and the basis on which the intraoperative decisions concerning the fate of the pregnancy and the uterus were made. In many, if not most, cases, patient counseling is by necessity retrospective.
Uterine torsion is a rare obstetric complication. Nonetheless, because of its associated risks, torsion should be included in the differential diagnosis when nonspecific abdominal pain occurs during pregnancy and in instances of dystocia or acute fetal jeopardy during labor. If uterine torsion is discovered at laparotomy, the surgeon should search for a pathologic process responsible for the malrotation. If delivery is required, the type of myometrial incision performed is individualized but a posterior wall hysterotomy may be necessary. A uterine fixation procedure may electively be performed after delivery of the fetus.