GYN/OB-4. Torsion of the gravid uterus with umbilical cord prolapse and subsequent posterior hysterotomy.

Pathologic torsion of the gravid uterus has been defined as rotation greater than 45 degrees on its long axis. It is a rare finding in human pregnancies. The etiology of uterine torsion is unclear, however, a predisposing factor exists in many cases. These include fetal malpresentation, uterine anomalies, adnexal tumors, uterine leiomyomata, or pelvic adhesions. The incisional approach is highly variable, chosen based upon the underlying pathology, the degree of rotation, and whether or not the torsion is correctable. Some incisions have been described prior to the discovery of uterine torsion. A 30-year-old grand multiparous female presented at term with spontaneous rupture of membranes. The maternal cervix was not initially palpable. The fetus was noted to be in a transverse lie, confirmed sonographically. Reevaluation of the cervix revealed an umbilical cord prolapse. Following emergent cesarean delivery of the neonate and placenta, the uterus was exteriorized and noted to be dextrorotated 180 degrees. The transverse incision was present in the posterior wall of the lower uterine segment. Diagnosis of uterine torsion is often difficult prior to laparotomy. Historically, 25% of cases have been discovered only after the delivery of the fetus, causing an inadvertent entry into the posterior uterine wall as occurred in our patient. Of those cases discovered prior to uterine incision, 57% of uteri were restituted before delivery of the infant. The remaining 43% were not correctable, and required a deliberate posterior wall incision. Every effort should be made to identify and correct any degree of uterine rotation prior to hysterotomy. However, a posterior incision has been documented as a safe alternative should correction be impossible. Our case illustrates the first reported patient with fetal transverse lie in association with umbilical cord prolapse and uterine torsion.

Wayne Henry Friedman, MD, Anthony B. Royek, MD, Lynn Leaphart, MD, and Todd Robinson, MD. Department of Obstetrics and Gynecology, Mercer University School of Medicine, Memorial Health University Medical Center, Savannah, GA.