Uterine torsion due to a fibroid, emergency myomectomy and transverse upper segment caesarean section

Abstract

A 37-year old woman booked at nine weeks of gestation in her third pregnancy. Fourteen years previously she had had an uncomplicated emergency lower segment caesarean section at 37 weeks for fulminating pre-eclampsia. Two years later, she had a normal delivery at term without complication. She had laser treatment to the cervix in 1987 for CIN 1. There was no other gynaecological history of note.At booking, a singleton pregnancy of nine weeks of gestation was confirmed on scan. The uterus was retroverted but although the ultrasound report commented on the presence of an 11cm anterior wall fibroid, this was not documented in the woman's case notes. A senior radiographer performed her routine anomaly scan at 19 weeks of gestation. All was well and the placenta was noted to be posterior. Again, the fibroid was noted but was not documented in the notes. She was followed-up regularly by both the midwife and the hospital antenatal clinic. She remained well and symptom free. Throughout the antenatal period from 28 weeks onwards the presentation was thought cephalic and the uterine size compatible with her dates. At 37 weeks the head was reported as being engaged, with three-fifths of the head palpable per abdomen. At 39 weeks of gestation she was seen in the antenatal clinic by a senior member of staff who found that the head was now two-fifths palpable and recommended that the woman could have a trial of labour.She was seen at term plus four days in the antenatal clinic. The symphysis -fundal height was appropriate for her dates, but the fetus had a transverse lie. A caesarean section was booked for the following day. However, she went into labour during the night. At 2cm dilatation, an emergency caesarean section was performed under a spinal anaesthetic. The abdomen was opened by a Pfannensteil incision. The uterus was found rotated to the left by 180 degrees. The rotation was corrected manually without difficulty. A large anterior wall fibroid was found extending from the upper segment to the previous caesarean scar in the lower segment. The whole of the anterior aspect of the lower segment was covered with fibroid and dense bladder adhesions. It was impossible to feel the lower extent of the fibroid. The anaesthetist continued with the operation under a spinal anaesthetic. A longitudinal incision was made in the upper segment over the fibroid to enucleate the fibroid. A myomectomy was performed. The uterus was opened transversely during the dissection and the opening enlarged to deliver the baby. The decidua was sutured with interrupted sutures of polyglactin polymer and the myometrium closed in three layers with a continuous stitch of the same material, the deepest layer being repaired transversely and the more superficial layers longitudinally. The operation lasted for 75 minutes. Blood loss was estimated to be 600ml. Her haemoglobin concentration fell by 0.4gldL. A prophylactic antibiotic was administered. She recovered well and was discharged home on her sixth post-operative day. Postnatal examination showed no ...

Torsion utérine au cours d’une grossesse gémellaire

“…La valeur diagnostique exacte de ce signe n'a pour l'instant pas été étudiée de façon précise et l'utilisation d'une IRM en cours de travail (comme dans notre observation) semble illusoire. Toutefois, il est bien évident que seul un diagnostic ou au moins une suspicion avant l'incision peuvent limiter le risque de réaliser une hystérotomie postérieure fortuite pourvoyeuse de complications ou bien même une incision sur la face latérale de l'utérus devant un manque d'observation de la part du chirurgien avec une potentielle lésion des pédicules utérins et des uretères [9]. En pratique devant tout diagnostic de torsion utérine, il faut réali-ser si possible avant l'extraction une détorsion de l'utérus afin d'éviter une hystérotomie latérale ou postérieure pouvant léser les pédicules utérins, ainsi que les uretères.…”

“…En pratique devant tout diagnostic de torsion utérine, il faut réali-ser si possible avant l'extraction une détorsion de l'utérus afin d'éviter une hystérotomie latérale ou postérieure pouvant léser les pédicules utérins, ainsi que les uretères. En cas d'impossibilité de rotation utérine, il est préfé-rable de réaliser une hystérotomie verticale [9,10]. Des cas d'hystérotomie postérieure ont toutefois été décrits, soit en cas de non-diagnostic de la torsion, soit en cas d'échec de détorsion.…”

A rapidly growing uterine fibroid postpartum

“…Most obstetricians advise against myomectomy at the time of caesarean section, 3 unless the myoma is pedunculated 2,4 . Three cases have been described where myomectomy was performed to achieve delivery 5,6 …”

“…2,4 Three cases have been described where myomectomy was performed to achieve delivery. 5,6 Most uterine fibroids either stop growing or decrease in size postpartum. One study of 32 patients with leiomyomas showed that the size at six weeks postpartum did not differ significantly from the size during pregnancy, 7 but another of 34 women who underwent ultrasound scans four weeks after delivery showed that the myomas became smaller, shrinking back to their initial size at the commencement of pregnancy.…”

Torsión uterina causada por un leiomioma gigante

“…El dolor abdominal es la manifestación más frecuente y puede oscilar entre una molestia leve y un dolor agudo con estado de shock. Se han descrito también otros síntomas asociados a la torsión uterina como sangrado vaginal, clínica urinaria ó gastrointestinal (4).…”