ACTA REVIEW

Uterine torsion in pregnancy

JOHNG R 0 N K J E R JENSEN
From the Departments of Obstetrics and Gynecology, Hjmring Hospital, Hjerrring, Denmark

Actti Ohstet Gynecol Scnnd 1992; 71 : 26G265

Torsion of the pregnant uterus is defined as rotation more than 45" around the long axis
o f the uterus. Uterine torsion is observed in all age groups of the reproductive period, in
all parity groups, and at all stages o f pregnancy. Torsion from 60" t o 720" has been
described. I t is not possible to clarify why uterine torsion occurs, but numerous ab-
normalities have appeared with uterine torsion; most often, abnormal fetal presentation,
myoma uteri and uterine malformations. The most usual symptoms of uterine torsion are
birth obstruction, abdominal pain, vaginal bleeding, shock, and urinary and intestinal
symptoms. Elcvcn percent arc asymptomatic. The treatment in the earlier months of
pregnancy is immediate laparotomy and detorsion of the uterus and, if practicable,
adjunct surgery t o climinatc the possible etiologic factors. Near term or during labor
ccsarcan section is carried out, and elimination of the possible etiologic factors.
The fetal and maternal mortality rates since 1976 arc 12% and 0% respectively.

k'q words: LIICTLIS,torsion; pregnancy, human

Suhmitted Srpternher SO, 1991

Accepted Juriuury 13, 1992

Uterine torsion is defined as rotation of more than ( 5 ) , have been drawn upon extensively in the review
45" around the long axis of the uterus (1). The tor- of the literature before 1969.
sion is always on the transition between cervix and
corpus uteri (2).
Torsion of the pregnant uterus is a rare phenom- Occurrence
enon in the human. Careful review of the world's
literature reveals 212 reported cases of torsion of the Maternal age, parity, and month of gestation seem
pregnant uterus. In 1956, Nesbitt and Corner (3) to play no rBle in the production of the torsion. Five
collected 107 cases of uterine torsion in pregnancy; percent of the women were younger than 20 years of
Hart and Van 0 s (4) produced a 1967 update of 33 age, and 5 percent older than 41. The rest o f the
new cases, and Legerlotz ( 5 ) described 10 new cases cases were equally distributed in the age groups
in 1960. I n 1966, Nickell's thesis (6) dealt with 24 21-30 and 31-40. Thirty-six percent of the women
cases o f uterine torsion in pregnancy where abnor- were primiparous. Six percent occurred in 1st tri-
malities could not be found in the pelvis. All other mester, 26% in 2nd trimester, 49% in 3rd trimester
publications concerning uterine torsion in pregnancy before the term, and of the cases 18% at term. In
since 1956 have been case reports. The present arti- 1% of the cases the gestational age was unknown.
cle adds 62 new cases of uterine torsion in preg- The earliest age uterine torsion in pregnancy is re-
nancy, 44 cases occurring since 1969 (7-43), and 18 corded occurred in the 6th week (45), and the latest
cases before 1969 (44-56), not included in the earlier time at delivery, in the 43rd week (57). T h e majority
articles (3, 4, 5 , 6). The present article surveys the of the torsions occurring at term do so during the
total of 212 cases of uterine torsion in pregnancy first stage of labor.
described in these reports. The references Nesbitt The degrec of torsion is most often 180", but cases
and Corner ( 3 ) , Hart and Van 0 s (4), and Legerlotz with torsion from 60" (13) to 720" ( 4 6 3 4 , have been

Actu Uhsrer Gyrrecol Srund 71 (1YY2)

 Uterine torsion in pregnuncy 261

Titble 1. Degree of torsion ot the uterus according to pelvic pathology

Pathology m a i cases Degree ot torsion More than Unknown

one complete
No. Percent Yo" o r less >YO" to 180" >180" to 360" turn

Abnormal presentation 54 23 12 40 2 0 0
Myomatous uterus SO 21 20 27 1 0 2
Uterine malformations 26 11 5 12 5 2 2
Pelvic adhesions 16 7 8 6 2 0 0
Other 63 27 17 40 4 2 0
None 34 16 I0 19 2 3 0

Total 243 - 72 144 16 7 4

described. Breaking down the total of 212 cases by gerates the congenital and physiologic rotations and
degree of torsion yields the following: 590" 31%; obliquities of the normal uterus.
>90"-5 180" 58'X ; > 180°-5360" 6% ; more than one Many pathological findings appear with uterine
complete turn 3 % ; degree of torsion unknown 2 % . torsion. A breakdown of cases according to pelvic
In 62%) of the cases with known torsion direction, pathology is shown in Table I. In some cases there is
the torsion was from left to right, and in 38% from more than one pathologic finding, and that is why
right to left, or 2/3 and 1/3. In 9 % , the torsion the total number makes more than 212. Seventy-two
direction was not recorded. percent of the abnormal fetal presentations were
The longest time a case of uterine torsion has transverse lie. The uterine anomalies were mainly
persisted is 25 years (56). In that case, labor was double o r bicornuate uterus. Of the cases with other
unsuccessfully induced at home by a midwife em- pathologic findings, abruptio placentae was seen in
ploying medical herbs. Delivery did not take place, 4%, ovarian tumors, loose suspended uterus, pla-
and the woman did not seek help. The fetus died and centa previa and loose abdominal wall in each 3'%,
was autolysed in uterus. sudden movement (mother) 2%, long or rigid cer-
vix, abnormal pelvis or spine, polyhydramnios,
twins, hyperactive fetus, interstitial pregnancy and
Etiology fetal anomaly each in l'Yo, and fimbrial cysts in less
than 1%). In 16%, no abnormalities could be found.
It is not possible to clarify why uterine torsion in In 2% of the cases, it was not mentioned whether
pregnancy occurs. In most cases of torsion of the there were any abnormalities.
uterus there is obvious asymmetry due to congenital Despite the fact that the predisposing factors are
or acquired deformities o r from the traction of pelvic relatively common, torsion of the uterus is rare,
tumors or adhesions. Furthermore, pregnancy exag- suggesting that additional influences must be

Tdhle 11. Symptoms recorded in cases of torsion o f the uterus according to degree of torsion

Degree of Total Symptoms mentioned by authors

torsion cases
Ob- Other No
structed symp- symp-
Pain Shock Intestinal Urinary Blceding labor 10ms tomb
~ ~ _ _ _ _
NO. NO. % NO. 'Yo No. 'XI NO. Yo NO. 'Yo NO. Yo No. 'Yo

90" or less 66 43 65 4 6 10 I S S 8 6 9 7 11 13 20 9 14
>9O0-180" 122 91 75 22 18 17 14 10 8 13 11 19 16 35 29 14 I1
> I80"360" 14 14 100 6 43 7 SO 0 0 1 7 3 21 3 21 0 0
More than one
complete turn 6 6100 6 100 0 0 2 33 1 17 6 100 0 0 0 0
Unknown 4 4100 2 so 0 0 0 0 0 0 0 0 0 0 0 0

Total 212 158 75 40 19 34 16 17 8 21 10 35 12 51 24 23 11

Acta Ohsier Gynecoi Scund 71 (1992)

262 J . G. Jensen

Table 111. Maternal mortality in torsion o f the uterus by time of publication

Year Total cascs Maternal outcome Per cent cases
with torsion
Recovery Fatal Unknown Per cent mortality > 180"

187&1899 7 4 2 1 29 0
1900k1929 46 38 8 0 17 13
1930-1959 74 66 8 0 11 16
1960L1990 8.5 83 1 I 1 1

Total 212 191 19 2 9 8

brought to bear upon the uterus. The fact that there torsion: spiral running urethra and rectum, twisted
arc no pathologic findings in some of the women vagina and an arteria uterina pulsating in fornix an-
points further in that direction. Robinson and Du- terior o r posterior. Other signs are a ligamentum
vall (59) have designated such influences as 'activa- teres uteri, ligamentum suspensorium ovarii and
ting factors', and have incriminated certain irregular tuba uterina crossing the front of uterus, the ovaries
bodily movements, posture and positions; irregular are dislocated, and the cervix can be dislocated,
contractions of the abdominal muscles; functional inside the cervix canal a constriction ring can be felt
variations in the size, anatomy, position, and mobil- and the fetal heart action may be affected. Collum
ity of the bladder and rectum; variations in the at- and orificium cervicis are only affected modestly in
tachment of the placenta; fetal movements; and the delivery or may even suddenly become longer or
even uterine contractions as occasional activating constricted.
factors. The confusion in diagnosis between torsion of the
uterus and other surgical conditions is not serious
since laparotomy will be carried out in any case. But
Diagnosis and clinical manifestations to mistake torsion for a non-surgical entity o r for an
obstetric complication usually managed vaginally
The diagnosis of torsion of the uterus is seldom may well, however, prove disastrous to the paticnt.
definitely established prior to laparotomy. Fre-
quently mentioned preoperative diagnoses are
abruptio placentae, placenta previa, rupture of ute- Maternal mortality
I-us,abnormal fetal presentation, degeneration hem-
orrhage, or torsion of a pelvic tumor. Since 1960, only 1 woman has died as a result of
In general, symptoms are related to the degree uterine torsion (lS), table 3 .
and duration of torsion of the uterus; and may be The stage of pregnancy at the time of uterine
designated as acute, subacute, chronic, or may be torsion seems to have a bearing upon maternal prog-
intermittent. The symptoms in cases of torsion of the nosis. There has been no case of maternal death due
uterus are shown in Table I1 according to the degree to uterine torsion before the 5th gestational month.
of torsion. Although obstructed labor was only men- In the S t h 4 t h month the mortality was 170/0, in
tioned in 12% of the cases, it must have been present 7th-8th month lo%, and at term 9%. In 1 % o f the
in 100%. Intestinal complaints such as nausea, vom- cases the outcome is unknown. The maternal out-
iting, diarrhea, abdominal distention and tender- come is greatly influenced by the degree of uterine
ness, and 'peritonism' were present in 16% of the torsion. A t torsion at 590" 2% died, at >00"-~180"
cases. The urinary symptoms included urgency, fre- 7"/0 died, at >180"-5360" 36% die, and at torsion
quency, nocturia, oliguria, and hematuria, and were more than one complete turn 67% die. In 2O/" the
mentioned in 8 % of the cases. Other symptoms than outcome is not on record.
those mentioned in Table II were seen in 24%. Of Before 1960, 18 women had torsion of more than
these hypertonic uterus, hypertonic contractions, or 180", and 8 of these women died, corresponding to
irregular contractions were seen in 9%, premature- 44% (3,4). Since 1960, only 1 woman had torsion of
ly ruptured membranes in S%, and less frequent more than 180" (4), and she survived. The decline in
pre-eclampsia, ruptura uteri, dizziness, fever and advanced cases of uterine torsion was also reflected
faintness. In 11% no symptoms were present. In in a decline of cases with shock. Before 1960,26% of
2 % , the symptoms were not recorded. the women had shock; since 1960, 9 % .
There are four pathognomonic signs in uterine

Acta Ohstet Gynecol Scand 71 (1992)

 Uterine torsion in pregnancy 263

Perinatal mortality nancies. When detorsion is not possible before in-

cision in uterus, longitudinal section should be
It is difficult to accurately assess the absolute per- made.
inatal loss in the 212 cases of torsion of the uterus. Nothing indicates that shortening of ligamentae
Many of the reports indicate 'recovery' without spe- teres uteri is necessary to prevent uterine torsion in
cifically referring to the fetal outcome. The mortality later pregnancies. There has only been one case with
figures must be regarded as absolute minimum per- new torsion in a later pregnancy (60) and the liga-
centages, since they are based on the assumption ments have only been shortened in 4 cases. The
that 'recovery' refers to a favorable outcome for the woman who experienced uterine torsion twice had in
fetus as well as for the mother unless the fetus is her first pregnancy one large and several smaller
specifically mentioned. In the period 1876-1 899 50% myomata uteri, which were not removed during the
of the fetuses died, in 1900klY29 30% died, in 1930- cesarean section because she was in poor condition.
1959 31% died, and in 1960-1990 24% died. In the One case was treated with external detorsion and
period 1976-1990 the mortality was 12%. abdominal truss in the 3rd trimester followed by
The most significant factor bearing upon fetal out- vaginal delivery; mother and child did well (17).
come is the degree of uterine torsion. The perinatal However, this procedure should not be used because
mortality was 20% for torsion at <90", 25% at >go"- of the risk of worsening the torsion.
i180", 71% at >180"-5360", and 83% at more than On grounds of necrosis of uterudadnexae and le-
one complete turn. In 2% of the cases the degree of sions of an arteria uterina, hysterectomy was carried
torsion was unknown, and 25"/0 of these fetuses out in 16% and adnexectomy in 7%.
died. The stage of the pregnancy also seems to influ-
ence the fetal outcome. The perinatal mortality was
19% before the 5th gestational month, 50% in Conclusion
5 t h 4 t h month, 35% in 7th-8th month, and 19% at
term. In 1 % the stage of pregnancy was unknown, Uterine torsion must be considered as differential
and 50% of these fetuses died. diagnosis in cases of long-lasting and obstructed de-
livery and in cases of long-lasting or intense abdom-
inal pain in pregnancy. Whether the diagnosis is
Treatment made before laparotomy is not vitally important as
long as the intervention is carried out quickly, be-
The treatment of uterine torsion depends upon what cause all cases of uterine torsion will presumably end
time in the pregnancy the torsion occurs. In all cases, with laparotomy, and if the fetus is viable, with
laparotomy is imperative. When uterine torsion oc- cesarean section. The position of the uterus should
curs before the fetus is viable, the treatment is lapa- always be known before the incision into the uterus.
rotomy and detorsion of the uterus. If necessary,
pelvic tumors and adhesions should be removed. In
one case (47) ligamentae teres uteri were shortened
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Acta 0bstc.t G y n e m l Scurid 71 (1YY2)