Parulekar SV

Torsion of the gravid uterus is not a very common condition. Some degree of dextrorotation is usually seen in pregnancy due to the presence of the sigmoid colon on the left and posterior aspect of the uterus. It is also the normal direction of the uterine muscle fibers. Usually the rotation is mild (less than 40 degrees) and asymptomatic. Rotation greater than 45 degrees is uncommon. Of those cases, about 5, 25 and 70% cases occur in the first, second, and third trimester respectively. The earliest occurrence of uterine torsion in pregnancy has been at 6 weeks, and the latest at 43 weeks. There is a predisposing factor in about 20% cases, such as uterine leiomyoma, bicornuate uterus, adnexal mass or pelvic adhesions due to a past pelvic surgery or other causes. Congenital weakness at the junction of the uterine corpus and cervix has also been proposed as a cause. Vehicular accidents and external cephalic version have also been listed as possible causes. Chronic torsion is seen much more often than acute or subacute torsion. Levorotation of the uterus is less common. It would be seen in case of situs inversus with the sigmoid colon on the right and posterior aspect of the uterus and any of the other conditions listed above. A very high degree of suspicion in the antenatal period may bring to attention a few cases. Acute symptoms like abdominal pain, nausea, vomiting, diarrhea,  vaginal bleeding, dystocia, urinary symptoms like urgency, frequency, nocturia and hematuria may draw attention to the presence of the condition. However chronic asymptomatic type is far more common than the acute or subacute type. On palpation of the maternal abdomen, the round ligament may be felt passing across the abdomen. Uterine artery pulsations may be palpable in the anterior fornix. A speculum examination may show a distortion of the vagina and cervix.  The diagnosis of the chronic type can be confirmed by performing a magnetic resonance imaging scan, which would show an X-shaped vagina rather than the usual H-shaped one. However such cases are extremely rare. Most of the asymptomatic rotations escape detection, since there is no way of diagnosing them when the women deliver vaginally. The condition comes to light only when a cesarean section is performed. In those cases the rotation must be corrected manually before making uterine incision, or the broad ligament and its contained structures would get cut in case of rotation of 90 degrees, and posterior wall of the uterine lower segment in case of rotation of 180 degrees. Such cases have been reported periodically over the years. The maternal morbidity in such cases is serious and entirely unjustifiable.

Pendulous abdomen due to poor muscle tone and divarication of recti is another condition that can affect the obstetric outcome. It can cause transverse lie, face presentation, dystocia, and injury to the fetal neck. It is related to excessive stretching of abdominal wall during past pregnancies and lack of abdominal wall exercises subsequently. Concurrent occurrence of levorotation of the uterus and pendulous abdomen causing transverse lie is extremely uncommon. We have one such case reported in this issue. What makes it even more interesting is that the authors have included photographs of the operative findings, which are not found in the literature published so far. I believe that our readers will find this case report interesting as well as educative.