Torsion of a hydrosalpinx in pregnancy: an unusual cause of acute abdomen in pregnancy
Torsion of a hydrosalpinx in pregnancy: an unusual cause of acute abdomen in pregnancy |
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Key words: pregnancy, acute abdomen, torsion
Introduction
Torsion of the fallopian tube is uncommon and even more so in pregnancy. About
12% of cases are associated with pregnancy. [1,2] It presents as an acute abdomen
and it is usually misdiagnosed as appendicitis or ovarian torsion [3—8].
Diagnosis of torsion of fallopian tube during pregnancy is difficult and delays
surgical intervention. An adnexal mass is usually misdiagnosed in a gravid woman
and is found to be the fallopian tube intra-operatively and treated during pregnancy.
We present a case of torsion of fallopian tube in pregnancy.
Case report
A 23year old primigravid at 23 weeks gestation was referred by her GP on account
of flu-like symptoms. Clinically, she was not febrile, but dehydrated, with
proteinuria and ketonuria. At booking scan, she had a small right ovarian cyst
measuring 34x18mm. She had no abdominal signs or symptoms. She was admitted
into hospital with a tentative diagnosis of urinary tract infection. Serum biochemistry
and urine microscopy were normal.
Over the next 24 hours, she looked clinically unwell and complained of nausea,
no vomiting and significant lower abdominal pain. On examination, her vital
signs remained stable but there was generalised abdominal tenderness and guarding
in the right iliac fossa.
An ultrasound scan on admission revealed a right ovarian mass measuring 880x539x413mm.There
was associated right renal pelvis dilatation. An assessment of torsion of right
ovarian cyst was made and she had an emergency laparotomy.
At laparotomy, there was a gangrenous hydrosalphinx on the right tube. The right
tube had also twisted twice on its axis [fig1]. The left tube and both ovaries
were normal. A partial right salpingectomy was performed.[fig 2]
The post-operative period was uneventful. The rest of her antenatal care was
uneventful and she was delivered of a live female baby following induction of
labour at term. Her postnatal period was uneventful.
Discussion
Torsion of the fallopian tube is a rare cause of acute abdomen in pregnancy.
The first case described was
by Bland-Sutton in 1890[3]. The right fallopian tube is commonly affected than
the left [4,5]. This may be due to the presence of the sigmoid colon on the
left and the slow venous drainage on the right, which may result in congestion
[6]
The condition is associated with the following:
1. Anatomical abnormalities eg hydrosalpinx, tubal abnormalities
2. Physiological abnormalities from hypermotility of the tube or tubal spasms
from drugs
3. Haemodynamic abnormalities from venous congestion/pelvic congestion
4. Gravid uterus
5. Trauma, previous surgery or disease
This patient was gravid, prone to venous congestion and was found to have hydrosalphinx.
Hydrosalphinx was found in18% of cases of torsion of the fallopian tube. [2].
The most common presenting complaint is lower abdominal pain radiating to the
thigh or flank. Other symptoms include nausea, vomiting, bowel and bladder complaints
and scant uterine bleeding [5,6]. Body temperature, ESR, and white blood cell
count may be normal or slightly elevated [5,6]. Unless a unilateral mass has
been diagnosed by ultrasound scan, it is unlikely that a preoperative diagnosis
will be made. Pelvic examination may reveal a tender adnexae with cervical excitation
tenderness. This case presented with nausea and lower abdominal pain.
The management of this condition in pregnancy consists of early diagnosis and
surgery. Abnormalities suggesting a tortion can be detected by colour doppler
transvaginal ultrasonography due to changes in the normal blood flow to the
tubes and ovaries. Other diagnostic criteria include transvaginal abdominal
ultrasound [8,9] and culdosynthesis. The latter may suggest intraperitoneal
bleeding but has been replaced by laparoscopy.
Laparoscopy can be used either as diagnostic or conservative treatment inform
of laparoscopic salpingectomy. Laparoscopy is safe in the first trimester of
pregnancy. If torsion is recent or incomplete, it can be untwisted and preserved
[1,11]. Some suggest that if the tube cannot be salvaged, a salpingectomy should
be performed and this decreases the likelihood of an embolus travelling down
the ovarian vessels which could complicate untwisting treatment [12]. With proper
care to exclude malignancy, laparoscoy is the surgical procedure of choice in
the second
Conclusion
Although torsion of the fallopian tube is uncommon in pregnancy, it should be
considered as a differential diagnosis of acute abdomen in pregnancy.
References
Correspondence to:
Mr I.I. Bolaji MB, FRCOG, FRCPI, MD
Department of Obstetrics and Gynaecology
Diana, Princess of Wales Hospital, Scartho Road,
Grimsby DN33 2BA
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