A Rare Cause of Acute Abdomen in 3rd Trimester of Pregnancy: Isolated Tubal Torsion

Isolated tubal torsion is a rare gynecologic emergency, the incidence is reported to be approximately 1/1.500.000 [1]. The 12 to 20% of patients are observed in pregnancy [2]. In the evaluation of adnexal masses; ultrasonography (USG) is the gold standard although a definitive diagnosis is diagnosed after surgical exploration [3]. In this case; we aimed the presentation of which is operated with the diagnosis of adnexal torsion and intraoperative detected isolated tubal torsion in the third trimester of pregnancy

Isolated tubal torsion is a rare gynecologic emergency, the incidence is reported to be approximately 1/1.500.000 [1]. The 12 to 20% of patients are observed in pregnancy [2]. In the evaluation of adnexal masses; ultrasonography (USG) is the gold standard although a definitive diagnosis is diagnosed after surgical exploration [3]. In this case; we aimed the presentation of which is operated with the diagnosis of adnexal torsion and intraoperative detected isolated tubal torsion in the third trimester of pregnancy

Case Report
A 26 years old, primigravid woman admitted to the emergency department with a sudden onset of severe right iliolumbar abdominal pain, nausea and vomiting. At abdominal examination, there were defense and tenderness but no vaginal bleeding or uterine contractility. Obstetric USG examination revealed an average of 30 weeks, single, viable fetus and in the field of right adnexal 74 mm size, anechoic structure cyst was detected. In Doppler, the periphery of the cystic was not identified blood flow. Operation was decided in patients being considered with Adnexal Torsion (AT). The risks and complications that may develop in the mother and fetus were explained to the family depending on the process to be made. After obtaining her family, the patient was operated. Right pararectal incision was made to reach adnexal field in a shorter time and for situated less uterine manipulation. The incision was applied parallel to the linea alba, 8 cm mediolateral of the umbilicus and approximately 5 cm in length. In observation of abdomen; right ovary was normal size and appearance, right fallopian tube approximately 8 cm in length, oedematous and counterclockwise, twice torsion were found ( Figure 1). Right fallopian tube was detorsioned after than about 5 cm in length linear incision was made to antimesenteric area and tubal cyst was ekstip. Location of the incision was sutured ( Figure 2). Maintenance tocolysis was not applied for about decreasing post-operative pain, without contractions in Non-Stress Test (NST) and cervical changes in gynecological examination. Post-operative pathology result was serous cystadenoma. She delivered vaginally a healthy baby, spontanuesly. The baby was 3150 g of weight, 48 cm of length and had an APGAR score of 8 and 9 at the first and fifth minute, respectively.

Dıscussıon
Isolated tubal torsion is seen rarely in pregnancy and is important with due to non-specific acute abdominal pain symptoms [4]. Sorem et al. reported 1/1.500.000 years as the incidence in women [5]. The

Abstract
Isolated tubal torsion is rare event during pregnancy. The clinical symptoms are often nonspecific and the diagnosis is difficult, especially in the pregnant abdomen. The diagnosis is usually established during the operation performed for acute abdomen. Early diagnosis and treatment is necessary and early gestationel weeks laparoscopy may be a considerable diagnostic tool in these cases. We report a case of isolated tubal torsion in the third trimester of the prgnancy with pararectal incision.  80% of cases were observed in the reproductive period and 12% were in pregnant women [6]. Cause of tubal torsion is not known exactly but several theories have been proposed. Etiology factors include; long mesosalpinx, hydro/hematosalpenks, tubal mass/neoplasm, adnexal mass (ovarian/paraovarian), abnormal tubal peristaltism, periovulatuar spasm, adnexal venous congestion, Sellhe theory (pointing to a sudden change in body position), trauma, Pelvic İnflammatory Disease (PID), pelvic adhesions, tubal ligation and enlarging uterus / uterine mass [7,8]. The presence of adnexal masses in pregnancy is a risk factor known for torsion. Yen et al. have reported adnexal masses often due to torsion between 60-80 mm. and 94% of these occurred before the 20. gestational weeks [9]. In our case, risk factors that may cause torsion were the growing uterus due to pregnancy and the presence of tubal cyst. In patients, a blunt-continuous or paroxysmal, unilateral, pungent lower quadrant abdominal pain is the most common presenting symptom. However, nausea, vomiting and urinary symptoms such as urgency may be accompanied with together [10]. In the differential diagnosis ovarian cyst rupture or torsion, appendicitis, PID, fibroid degeneration, intestinal pathologies, maternal hydronephrosis, hepatobiliary pathology and placental abruption should be considered in pregnant women [11]. Tubal torsion is frequently seen on the right side than the left [2]. This condition is described the left fallopian tube have less mobility due to its proximity to the sigmoid mesentery, different venous flows of left and right sides and surgeons opening the abdominal pain on the right side with preliminary diagnosis of acute appendicitis [12]. In recent years, parallel to technological developments MRI imaging is seen as an alternative to surgery in advanced centers [13]. Despite the advanced imaging methods, if torsion is not excluded, early surgical intervention is recommended regardless of the gestational age. The preferred surgical technique is a major concern for pregnant abdomen. Suspicious pathology and depending on the skill of operator, laparoscopic (L/S) or an open approach (e.g., laparotomy) may be preferred [14]. Walsh et al. reported less length of hospital stay and risk of preterm birth in a meta-analysis who evaluated 637 patients underwent laparoscopic appendectomy in the first and second trimesters of pregnancy [15]. In the third trimester of pregnancy L/S experience is very limited. Laparoscopy is used in a safe manner in the first and second trimesters. But, there are no prospective studies of laparoscopy and laparotomy on the advantage over each other in the 3rd trimester of pregnancy [16]. Therefore, surgical technique were determined by the preference of the operator. In our case, pararectal incision was used as an alternative to midline incision and salpingotomi was performed. After the operation, any tocolysis was not applied and term delivery occurred.
In conclusion; in this case report pararectal section were mentioned be an alternative to a midline incision and L/S, early detection of isolated tubal torsion in the third trimester of pregnancy. Pararectal incision has some advantages such as less incision, interventio n in less time, less uterine manipulation in the surgical area. However; there is also the disadvantage to evaluate the contralateral adnexae and to require surgical experience.