Maternal collapse in COVID-19: A rare case of uterine torsion, placental abruption and fetal death in utero in third trimester

ABSTRACT

Background: Uterine torsion is defined as a rotation of the uterus on its long axis of greater than 45 degrees and is a rare cause of placental abruption. It is a life-threatening and rare condition, with only 41 cases being described since 2006 and a fetal mortality rate of up to 71%. Case A 27-year-old Para 1 at 32-week gestation presented to a tertiary hospital via ambulance in hypovolemic shock with abdominal pain secondary to uterine torsion and placental abruption. Examination demonstrated severe haemodynamic shock, a distended abdomen, tender uterus and fluctuating GCS. Bedside ultrasound-confirmed fetal death. A dedicated COVID emergency theatre and team were assembled to receive the patient, given the patient was of unknown COVID status. Massive transfusion protocol was activated with immediate transfer to theatre for laparotomy. An infra-umbilical midline incision was performed under general anaesthetic revealing a Couvelaire uterus, torted 180 degrees at the level of the lower segment. Detorsion was performed, follow by classical caesarean section of a cephalic stillborn fetus. A complete placental abruption was evident with a large retroplacental clot, with an otherwise normal uterus. Discussion: Our patient did not have any known predisposing factors to developing uterine torsion (fetal malposition, fibroid uterus or adhesions). This case highlights the importance of including uterine torsion as a differential diagnosis for abdominal pain and is an example of the safe and effective use of pandemic protocols for emergency surgery in a patient of unknown infective status.