Acute abdomen in a term pregnancy due to isolated tubal torsion. Perinatoloji Dergisi 2020;28(3):-
- Istanbul Health Science University Umraniye Research and Training Hospital Obstetrics and Gynaecology Department Istanbul TR
- Istanbul Health Science University Umraniye Research and Training Hospital Pathology department Istanbul TR
- Istanbul Health Science University Umraniye Research and Training Hospital Obstetrics and Gynaecology, Perinatology Department Istanbul TR
Aysegul Ozel, Istanbul Health Science University Umraniye Research and Training Hospital Obstetrics and Gynaecology, Perinatology Department Istanbul TR, [email protected]
Gönderilme Tarihi: 01 Eylül 2020
Kabul Edilme Tarihi: 12 Ekim 2020
Erken Baskı Tarihi: 12 Ekim 2020
Çıkar çakışması bulunmadığı belirtilmiştir.
Due to isolated tubal torsion in pregnancy is a rare condition we want to present this case.
Here we present a 23-year-old primigravida at 37 gestational week women with acute right lower abdominal pain. The clinical and Magnetic resonance imaging (MRI) findings led to diagnosis of acute appendicitis. Emergency exploratory laparotomy and cesarean section were performed. A torsioned right fallopian tube and Morgagni cyst was noted and right salpingectomy was performed.
Although isolated tubal torsion during pregnancy is very rare, it should be
included in the differential diagnosis of acute abdomen in pregnancy. Early surgical intervention will decrease obstetric morbidity.
Acute abdomen, pregnancy, isolated tubal torsion
GirişTorsion of the fallopian tubes is a rare cause of acute abdominal pain. The incidence of tubal torsion reported 1 in 1.5 million women and, only 12% of cases being identified during pregnancy [1,2]. Etiology of tubal torsion may include hydrosalpinx, hematosalpinx, previous tubal surgery, cyst of Morgagni, adhesions, tubal abnormalities, medications which increase the tubal mobility (hormones etc.), and tubal trauma. It can also occur with healthy tubes. Other known ethiological factors include varicose veins around tubes [3,4].
It is hard to diagnose tubal torsion, because it is hard to differentiate it from other acute abdominal pain causes such as acute appendicitis, pelvic inflammatory disease, ovarian torsion, renal colic, pyelonephritis, diverticulitis etc. Definitive diagnosis of tubal torsion is usually decided peroperatively.
This case was operated with the initial diagnosis of acute appendicitis with preterm pregnancy however peroperatively it was understood that right tubal torsion was the cause of the abdominal pain.
OlguA 23-year-old healthy primigravida, with medical history of gestational diabetes-using 10 units of insulin detemir (long-acting insulin) per day- presented with pruritis at a gestational age at 36 weeks and 2 day. Her vital signs, hemogram, urinary parameters were normal but, liver function parameters were increase (Alanine aminotransferase levels increase to 296 U/L, Aspartate aminotransferase levels increase to 179 U/L). The patient was admitted to inpatient service with a preliminary diagnosis of cholestasis and gestational diabetes. A single live fetus at 37 weeks of gestation with normal amniotic fluid and placenta were revealed by sonographic examination. The umbilical artery Doppler findings were normal. The nonstress test showed normal accelerations and variability of the fetal heart rate without uterine contractions. After high level of serum bile acids, treatment of ursodeoxycholic acid was started.
On the fifth day of her hospitalization, the patient complained of absence of appetite and abdominal pain in the right lower quadrant. Physical examination revealed abdominal enlargement compatible with pregnancy age and costovertable angle sensitivity and no specific tenderness. Urinary ultrasound and complete urinalysis were planned , however due to localized pain in the right lower quadrant, loss of appetite and leukocytosis in the new complete blood count with a raised C- reactive protein, the patient was consulted to the general surgery with a preliminary diagnosis of acute appendicitis. MRI was recommended and implemented. MRI results interpreted as acute appendicitis by the radiologist. The patient was informed and emergency exploratory laparotomy and cesarean section was planned. After the delivery of a healthy 3000gr, 9/10 apgar score baby via cesarean section, an observation was made: the right fallopian tube had twisted four times around itself (figure 1), and the distal tip of the tube was adherent to the back of the uterus with a necrosis measuring 6*3 cm in size. We also noticed a 20 mm cyst of Morgagni which was located at the fimbriatic ends. Salpingectomy was performed. Due to distal part of the appendix was edematous and inflamed, general surgeon invited and consulted preoperatively. Appendectomy was performed. Tubal hemorrhage and necrosis were confirmed by histopathological examinations. However, the histopathology report did not indicated that part of the appendix showed primary inflammation (figure 2 a,b).
Postoperative recovery was uneventful, insulin and ursodeoxycholic acid were stopped after the c- section. The blood sugar levels and liver function tests were normal.
TartışmaTubal torsion is seen rarely during pregnancy. Approximately 31 isolated tubal torsion cases during pregnancy seem to have been reported from 1936 till today in English literatures [5-8].
This case doesn’t have any previously known etiological factors, but in the peroperative observation there was a cyst of Morgagni on the right side. Morgagni cysts are Wolffian duct remnants are located at the ends of the fallopian tubes. These are usually asymptomatic. and rarely undergo torsion with fallopian tube .
The unspecific clinical findings make it difficult to identify an isolated tubal torsion preoperatively. Nausea, vomiting and lower abdominal pain are the most important symptom of tubal torsion. The case in this report had abdominal pain in her right lower quadrant, loss of appetite and white blood cells were slightly elevated. Acute appendicitis, ovarian torsion, ruptured ovarian cyst, tuboovarian abscess, salpingitis, urolithiasis, degenerated leiomyoma and ablatio placenta can mimic the symptoms and findings of tubal torsion. Acute appendicitis is frequently confused with right tubal torsion as in this case. Tubal torsion occurs usually on the right side. Probable reason of tubal torsion occurs usually on the right side is small intestine and appendix can easily move but on the left side sigmoid colon is attached to the mesentery. As a second reason, it may be due to slow venous drainage on the right side, resulting in congestion [10,11].
Although the imaging in tubal torsion cases are usually nonspecific, MRI is helpful in cases where the diagnosis remains unclear, especially in young or pregnant patients with undetermined sonographic findings. It is also the safe option because of great contrast of soft tissue and lack of radiation for pregnant women. One of the reasons why the present case was misdiagnosed is that we did not perform a preoperative ultrasonography for patient’s pain in the right lower quadrant. Secondly, because of the emergency condition of the patient, we weren’t able to examine MRI images. We recognized a cystic dilatation at the right adnexial side on the MRI images after surgical intervention (figure 3).
The technical approach in surgical intervention is also an important issue in a pregnant woman. However, laparosccopic approach was found safety in a recent study by Walsh et al. which focused on appendectomies in pregnancy. We opted an open surgical approach due to the patient was at 37 th gestational week. We also prefer salpingectomy rather than detorsion as in most cases reported in the literature [2,7] because of the fallopian tube was edematous with hemorrhaged infarction and necrosis .
SonuçIt is so difficult to establish a final diagnosis preoperation in tubal torsion. Aggressive management including early surgical invention is indicated in such cases to prevent obstetric complications. Imaging techniques may be suggestive but not conclusive. Therefore, a pregnant patient with acute abdomen should first be evaluated with the clinical findings.
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||Dosya / Açıklama
The right fallopian tube had twisted four times around itself
The histopathological image of right tubal hemorrhage and necrosis (H&EX10).
The histopathological image of the appendixPeriappendicitis is seen secondary tubal torsion associated peritoneal inflammation.
Dilated and cystic structure on the right adnexial area (white arrow) was interpreted as torsioned right tuba after surgical intervention retrospectively.