Hindawi Publishing Corporation

Case Reports in Obstetrics and Gynecology

Volume 2014, Article ID 801616, 3 pages
http://dx.doi.org/10.1155/2014/801616

Case Report
A Case of Abruptio Placentae due to
the Torsion of Gravid Uterus

S. Zullino, S. Faiola, A. M. Paganelli, and E. Ferrazzi

Vittore Buzzi Children’ Hospital, Via Castelvetro 32, 20154 Milan, Italy

Correspondence should be addressed to S. Zullino; sarazullino@hotmail.it

Received 12 October 2014; Revised 18 November 2014; Accepted 19 November 2014; Published 4 December 2014

Academic Editor: Eliezer Shalev

Copyright © 2014 S. Zullino et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Torsion of a gravid uterus is a rare obstetric emergency potentially lethal for the fetus and the mother. Some of the cases described in
literature are associated with preexisting gynecologic conditions related to pelvic and uterine anatomy, even if most of cases remain
unexplained. We report a case of acute 180-degree torsion of uterus at 33 weeks of gestation associated with abruptio placentae in
a young Asian woman without apparent risk factors.

1. Introduction abdominal surgery in the past. The course of pregnancy was

regular including fetal growth.
Torsion of gravid uterus is a rare, potentially serious, unex- At the admission in our hospital the patient appeared
pected, obstetric emergency and it is almost always diagnosed pale, exhausted, unable to walk, and maintaining an upright
during caesarean section [1]. Uterine torsion is defined as a position. She had nausea and episodes of vomiting. At triage
rotation on its long axis greater than 45 degrees. blood pressure was 90–60 mmHg, heart rate was 120 beats
When the uterus rotates on its longitudinal axis, the blood per minute, and temperature was 37.1∘ C. Abdominal pain
supply is dramatically altered due to a vascular obstruction was deep, diffuse, with no signs of peritonitis or lateral renal
involving at first the veins and after the arteries. This sequence colic. Uterine growth was appropriate for gestational age and
is the cause of acute or subacute abdominal pain, fetal the organ was tender on palpation. On vaginal examination
distress, and abruptio placentae in the most severe cases. cervix was closed and there was no vaginal bleeding or
There are no reported cohorts of uterine torsions, but only abnormal vaginal discharges.
the description of single cases [2–9]. The majority of reported Ultrasonography showed a single fetus in transverse
cases of uterine torsion during pregnancy concern patients lie, with a normal amniotic fluid. Placental location was
with uterine leiomyomas [2]. clearly “anterior” with vast subchorionic hypoechogenic area
We report a case of acute uterine torsion at 33 weeks of interpreted as a sign of abruptio placentae. Placental tissue
gestation in a singleton pregnancy without uterine myomas. was hyperechogenic and thicker than normal. Fetal heart rate
at ultrasound examination was 90 beats per minute. It was not
2. Case Presentation possible to visualize and interrogate uterine arteries in their
typical anatomical sites by Color Doppler and Pulsed Wave
A 25-year-old Asian woman, gravida 2, para 1, reported to our Doppler.
hospital at 33 weeks of gestation with severe abdominal pain. An emergency caesarean section under general anes-
She had a BMI of 24 and a negative obstetric history in the thesia was performed. Abdomen was opened by standard
previous pregnancy. The abdominal pain had started three Stark incision. Peritoneal cavity contained approximately 100
hours prior to admission, like a vague posterior abdominal milliliters of coagulated blood. Hysterotomy was done on “the
colicky pain. The patient and her husband did not relate lower uterine segment.” At amniorrhexis the amniotic fluid
physical efforts prior the onset of the pain. She did not have was clear. A male fetus in transverse lie was delivered by
2 Case Reports in Obstetrics and Gynecology

breech extraction. The fetus was alive but pale and hypotonic. bleeding in case placental abruptio is also present, shock, and
A large quantity of fresh clots leaked from the uterus during urinary or intestinal symptoms. Sometimes this condition
the afterbirth. The placenta showed a large subchorionic could be even asymptomatic [9].
haematoma. The uterus was ischemic and extremely floppy. The modification of placental site compared to the previ-
At exteriorization of the uterus we observed the anterior ous scan on ultrasound and the abnormal position of ovarian
crossing over of the proper ovarian ligaments. At that time and uterine vessels across the uterus on Doppler evaluation
we realized that the uterus was rotated by 180 degrees. can help to suspect the torsion.
We performed the counterclockwise detorsion of the uterus The magnetic resonance imaging could be helpful but it
and confirmed a low transverse incision of the posterior is not feasible in emergency situation when fetal distress is
wall of the organ. In a matter of seconds after detorsion suspected [2, 4].
the myometrium reverted to a normal colour and consis- The management of torsion of gravid uterus consists in
tency. We also observed a superficial bleeding laceration of emergency laparotomy. As described above, it is frequent
the left part of the posterior wall that probably was the to diagnose the condition only after the extraction of the
cause of the hemoperitoneum. There were no myomas or fetus. In unexpected cases posterior low transverse incision
uterine malformations. The posterior uterine incision was is usually performed. In such patient with a posterior Hys-
closed by a standard two-layer suture. The uterus, after the terotomy an elective caesarean section is advisable for future
administration of uterotonic, was properly contracted and pregnancy, because the risk of uterine rupture during labour
it was then replaced into the abdomen. The estimated loss through the posterior scar is not known.
of blood was 1100 milliliters. The placenta was sent for Proposed methods to prevent a recurrence of uterine
pathologic examination that confirmed the clinical diagnosis torsion in future pregnancies, as plication of round ligament
of abruptio. or uterosacrals, are not validated [10].
Maternal conditions were stable after two hours. Hae- As regards neonatal and maternal complications, Jensen
moglobin concentration decreased from 10.8 grams/liter has reported 13% of perinatal mortality [3] and there is one
at admission to 8.5 grams/liter. White blood cell count reported case of maternal death in the last fifty years [5].
was 19.000/milliliter, almost halved from admission values Even if rare, the severity of this pathology requires
(31.000/milliliter). C-reactive protein had always been nega- knowledge of its existence and awareness of how to handle
tive. Analysing the previous reports and ultrasound images in this emergency. This is the only manner to preserve maternal
the patient’s pregnancy record, we confirmed that a posterior and newborn’s health.
placental position had been observed at 22 weeks’ scan,
exactly the opposite of the anterior position we have seen by Conflict of Interests
ultrasound at the time of hospital admission.
The newborn at birth weighted 2200 grams, Apgar score The authors declare that there is no conflict of interests
was 1, 3, and 5 at 1, 5, and 10 minutes, cord pH was 6.61, and regarding the publication of this paper.
base deficit was 28 millimol/liter.
A severe acute cerebral haemorrhage was diagnosed. References
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