Surprise Finding of Uterine Torsion During a Routine Scheduled Repeat Cesarean Section: A Case Report.

Introduction: This article describes a case of asymptomatic uterine torsion in the setting of macrosomia and polyhydramnios. While other causes have been reported in the literature, there are no existing cases of uterine torsion associated with fetal macrosomia and polyhydramnios. Case: This patient had an asymptomatic uterine torsion discovered incidentally during a scheduled repeat cesarean section. A congested vascular lower uterine segment was noticed on entrance into the abdomen. After exteriorization of the uterus, 180° torsion was discovered. If torsion is identified prior to hysterotomy, an attempt can be made to perform detorsion. If unsuccessful, a posterior hysterotomy can be performed to avoid the bilateral uterine vessels. In our case, the torsion was not discovered until after exteriorization of the uterus, so an unintended posterior classical (vertical) uterine hysterotomy was performed to avoid the bilateral uterine vessels. Conclusion: While prior cases of uterine torsion have had other etiologies for increased size of the gravid uterus, including large fibroids, twins, and malpresentation, the likely cause in this case was fetal macrosomia and polyhydramnios. Uterine torsion should be considered as part of the differential diagnosis for abdominal and pelvic pain in pregnancy, especially with any risk factors, although it may be asymptomatic. Ultrasound, MRI, and, in select cases, CT (outside of pregnancy) can be helpful imaging modalities to evaluate for uterine torsion, but it is often not detected. The finding of a congested vascular lower uterine segment should raise the surgeon's index of suspicion for uterine torsion. Surgical management of uterine torsion in pregnancy includes reducing the torsion when possible or performing a posterior hysterotomy when attempts at reduction are not successful. Prophylactic shortening of the round ligament after delivery may be considered to prevent recurrence, but this technique is not yet validated.