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References
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Isolated Fallopian Tube Torsion
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7
Abstract
Isolated Fallopian tube torsion is an extremely
rare condition in pregnancy. Less than 50
cases have been published. Risk factors
include mechanical, anatomical, physiological, and pathological conditions. The specicity of this condition is that more than 90%
develop on the right side, probably due to the
protective effect of the sigmoid colon on the
left side. Clinical presentation is the same as
for adnexal torsion; sometimes, even with
abdominal ultrasound, the preoperative distinction between adnexal and Fallopian tube
torsion is impossible. Differential diagnosis is
comprehensive as for adnexal torsion. The
condition appears predominantly on the right,
so it is commonly misdiagnosed as acute
appendicitis. Therefore, MRI is useful in such
presentations. Suspicion of Fallopian tube torsion is an indication for operative intervention. Laparoscopy is the abdominal entry of
choice. Detorsion is the procedure of choice
even when ischemic changes are present.
Without restoration of vitality after detorsion,
salpingectomy is indicated.
and a half times twisted and removed by Henry
Morris, whom he assisted. The specimen is preserved in the Museum of the Royal College of
Surgeons. Hansen reported the rst pediatric case
in 1922 [2].
The rst known description during pregnancy
was by J Praeger (Klinikum Chemnitz) in 1899
[3]. He found dark-red cystic swelling, which
turned out to be a left Fallopian tube, with a pedicle twisted twice in the direction of the hands of
a watch. The ovary was not involved. Contents of
the cyst were bloody uid and detritus. Recovery
was complete, and pregnancy was not interrupted. Pozzi’s case in pregnancy in 1900 and
two cases by Pinard in 1901–1902 followed [4].
Before them, in 1893, Martin described IFTT
from ectopic tubal pregnancy [5]. One of the rst
reviews that included pregnant women was by
Hamilton Bell in 1904 [4]. McKerrow, in 1934
[6] and later Savage (Department of Obstetrics,
School of Medicine, University of Maryland
Baltimore, Maryland, USA) in 1936 [7], collected 13 published cases (some included torsion
of both ovary and tube) and added his own.
7.1 Historical Perspective
Sir John Bland-Sutton, in 1890, described the
rst isolated Fallopian tube torsion (IFTT) in
adults [1]. It was caused by hydrosalpinx three
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
G. Augustin, Acute Abdomen During Pregnancy, https://doi.org/10.1007/978-3-031-26021-6_7
7.2 Incidence
Torsion of the Fallopian tube (FT) hydatids of
Morgagni could cause acute abdominal pain in
adolescents, in 25% of adnexal torsions in this
subgroup. However, the condition is an uncommon cause of adnexal torsion in adults [8–11].
173
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The incidence of IFTT from previous reports
was 1/1,500,000 [8, 12]; however, the incidence
appears to be higher. West Hertfordshire NHS
Trust claimed 1/125,000in 3 years. Régad, in
1933, collected 201 cases in the general population with an incidence in pregnancy of 12%
[13]. IFTT in pregnancy involves 12–20% of all
cases of IFTT [13–15]; others 1/120,000 pregnancies (1991–2000) [14]. The literature since
1900 revealed 60 cases [7, 10, 14–66], including ectopic pregnancy with IFTT. The incidence of IFTT of the normal FT during
pregnancy could be increased compared to the
general population [6, 7, 67–70]. Others found
torsion of hydrosalpinx during gestation
[63–66].
The distribution across trimesters is [8]:
First trimester 13.3%
Second trimester 20%
Third trimester 60%
Intrapartum 6.7%
7.3 Etiopathogenesis
7 Isolated Fallopian Tube Torsion
• anatomic abnormalities: long mesosalpinx, tubal abnormalities, hematosalpinx, hydrosalpinx, varicose veins in
mesosalpinx, hydatid of Morgagni,
ectopic tubal pregnancy, paratubal cyst,
• physiological abnormalities: abnormal
peristalsis or hypermotility of the tube
(autonomic dysfunction), tubal spasm,
and intestinal peristalsis,
• hemodynamic/hormonal abnormalities:
venous congestion in the mesosalpinx
(progesterone effects of edema and
increased tissue vascularity),
• Sellheim theory: sudden body position
changes,
• trauma, previous abdominal/gyneco-
logic surgery, or disease: tubal ligation,
PID, tubal endometrioma,
• gravid uterus: direct mechanical cause
and progesterone effects of edema and
increased tissue vascularity,
• external cephalic version [43],
• normal Fallopian tube.
7.3.1 Risk Factors
It is a fact that the Fallopian tube, when distended
with simple uid and blood, pus, or even when
gravid, does twist its pedicle.
(Sir John Bland-Sutton, 1904)
IFTT in the general female population can occur
at any age, mostly under 30. Risk factors are
divided into two categories. Intrinsic factors
include congenital anomalies or acquired FT
pathology (hydrosalpinx, hematosalpinx, neoplasm, surgery, autonomic dysfunction, and
abnormal peristalsis). Extrinsic factors include
changes in the neighboring organs such as neoplasm, adhesions, pregnancy, mechanical factors,
movement or trauma to the pelvic organs, or pelvic congestion [71]. Broader classication of
causes and theories for IFTT in the general and
pregnant population includes [8–10, 14, 35, 37,
40, 41, 72]:
7.3.2 Pathophysiology
The anatomical theory hypothesizes that the
tubes tend to stretch and elongate with fetal
growth during pregnancy. The ovaries come to
lie in closer relation to the fundus of the uterus.
Since the tube is longer than the covering peritoneum, it assumes convolutions or spirals, and
this appearance persists to puberty and sometimes in adulthood. These spirals are considered
a predisposing factor and play a part in IFTT.
A mechanical theory is that IFTT is a
sequential mechanical event in general and
pregnant populations. The process begins with
the mechanical blockage of the adnexal veins
and lymphatic vessels by an ovarian tumor,
pregnancy, hydrosalpinx, or pelvic adhesions
after tubal infection or pelvic operation. This
obstruction causes pelvic congestion and local
edema with subsequent enlargement of the FT,
7.5 Clinical Presentation
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which induces partial or complete torsion [73].
Torsion pronounces venous stasis and subsequent edema. Hypoperfusion determines
hypoxic tissue ischemia and whether the degree
of twisting is severe enough to exceed arterial
blood pressure. The late step represents complete blood stasis and ischemic necrosis. At this
stage, cellular damage is usually irreversible,
and reperfusion determined by the untwisting is
not followed by restitutio ad integrum. A
twisted FT undergoing necrosis can cause
severe infection similar to perforated appendicitis [74]. There can be torsion of the FT accompanied by a paratubal cyst coiling 2.5 times
around the ovary, causing ovarian congestion
and enlargement [75].
The trauma applied to a pelvic organ is tangential and thus has a twisting movement.
Symptoms often appear after unaccustomed
trauma. The abdominal musculature contractions impact the ovaries; this causes the right
ovary to twist to the left and the left ovary to the
right.
Excessive FT peristalsis and associated
venous engorgement are common with premenstrual tension. Therefore, IFTT is most common
in the week preceding menstruation. The veins
supplying the adnexal region are longer than the
arteries and twist around them when they become
congested. Also, overaction of the autonomic
nervous system causes abnormal FT peristalsis at
this time of the cycle.
Anchoring adhesions, particularly to the mbriated end of the tube when longitudinal forces
cannot be transmitted, result in excessive peristalsis, and the perpendicular or diagonal forces
result in FT twisting. Uterine positional changes,
e.g., retroversion to anteversion, cause FT positional changes, making it prone to abnormal
movements with possible torsion, particularly
with anchoring adhesions.
IFTT in pregnancy is more common on the
right side with incidence of 90% [8–10, 18, 22,
23, 25, 28, 29, 31, 32, 36–38, 40–44, 72, 75],
while only 10% are on the left side [14, 17, 24,
30, 34, 35]. Possible explanations are:
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• the left-sided Fallopian tube is less
mobile due to its proximity to the sigmoid mesentery [10, 37, 41],
• slow venous ow on the right side,
which may result in congestion,
• hypermobility of the cecum and ileum
[10],
• cases of right-sided pain are commonly
operated on because of the suspicion of
acute appendicitis [9, 37], whereas leftsided cases may be missed and resolve
spontaneously.
7.4 Classication
From published cases, classication of IFTT,
depending on whether ectopic pregnancy is present, can be proposed:
• IFTT with normal intrauterine pregnancy,
• IFTT with tubal ectopic pregnancy [16, 50,
76],
• IFTT with ectopic tubal pregnancy and normal intrauterine pregnancy,
• The classication helps in treatment decisionmaking (see Sect. 7.8.2).
7.5 Clinical Presentation
The most common presenting symptom is pain,
which begins in the affected unilateral lower
abdomen or pelvis (typically at the level of the
right uterine angle) and may radiate to the ank
or thigh [9, 10, 32, 33, 37, 40, 41, 72]. The onset
of pain is sudden and cramp-like. Most commonly, the pain is constant but may be intermittent if partial or total detorsion occurs [22, 33, 37,
41]. Pain duration is usually less than 48h, but
can last up to 10days [36]. During labor, the pain
unrelated to uterine contractions is present [8], or
persistent pain is present after (induction of)
labor [28]. Other symptoms include nausea,
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7 Isolated Fallopian Tube Torsion
vomiting, bowel, and bladder complaints, such as
urgency but no associated dysuria [9, 10, 14, 17,
22, 37, 40, 41]. Some patients recall previous epi-
sodes of similar symptomatology, mostly less
intense, indicating recurrent IFTT [42]. Some
may have similar episodes after operative
detorsion [77]. There is no disturbance of bowel
action.
Most commonly, physical examination reveals
good general condition and an afebrile state with
stable vital signs [17, 22]. Low-grade fever in
15% of patients indicates necrotic changes of the
FT [23, 78]. In almost all patients, abdominal
tenderness is present, and guarding can develop
in advanced cases [8, 40, 41]. Average fundal
height corresponds to the period of gestation. The
uterus is relaxed with a regular fetal heart without
uterine contractions. Tenderness occurs in the
lower abdominal quadrant, on the side of IFTT.A
tender adnexal mass may be palpable. Pelvic
examination may reveal palpable tender, tense
adnexal mass associated with cervical tenderness
[79]. The vaginal examination shows a closed
cervix without any evidence of bleeding or any
abnormal discharge. If scant uterine/vaginal
bleeding occurs before or with abdominal pain,
ectopic pregnancy or IFTT should be suspected
[80]. The bowel sounds are normal. Varicose
veins in the mesosalpinx can rupture and mimic
ectopic pregnancy, or concomitant ectopic pregnancy may be present [16], causing massive
bleeding with symptoms and signs of hemorrhagic shock [81].
It is feasible that an IFTT may occur with subsequent spontaneous detorsion. The patient will
complain of transient lower abdominal pain, and
a denite diagnosis is challenging.
7.6 Dierential Diagnosis
With symptoms, signs, and physical ndings
similar to other common diseases, the diagnosis
of IFTT is rarely established preoperatively [8–
10, 37, 40, 41, 43, 44, 72]. The correct preopera-
tive diagnosis in pregnancy before 1936 was 0%
[7]; until 2009, it was 37% [78]. The preoperative
diagnosis of IFTT of normal-sized FT with a nor-
Table 7.1 Differential diagnosis of isolated Fallopian
tube torsion during pregnancy [9, 10, 22, 36, 37, 41]
Acute appendicitis
Intestinal perforation
Colonic diverticulitis
Ectopic/heterotopic pregnancy
Pelvic inammatory disease
Twisted ovarian cyst
Ruptured follicular cyst
Degenerating leiomyoma
Placental abruption
Urinary tract disease
Renal colic
mal appearance of the ovaries is extremely difcult. The differential diagnosis is presented in
Table7.1.
7.7 Diagnosis
7.7.1 Laboratory Findings
White blood cell count and erythrocyte sedimentation rate are mostly normal or slightly elevated
[10, 17, 22, 37, 40, 41]. Granulocytosis could be
present with a normal white blood cell count
[17]. A high white blood cell count indicates
IFTT with necrosis [23]. Urinalysis is commonly
normal [17, 22].
7.7.2 Abdominal Ultrasound
Transabdominal and transvaginal ultrasound
(US) is mandatory [17, 82]. First, the status of the
fetus and the placenta should be checked [17],
then the pathology searched. The US shows an
elongated, convoluted cystic mass with good posterior enhancement (Fig.7.1), tapering as it nears
the uterine corn, with normal ipsilateral ovary
[82], free uid, a dilated tube with thickened
echogenic walls, and internal debris or a convoluted echogenic mass [75, 83, 84]. The US ndings of IFTT are not pathognomonic and are
quite variable [24], especially in the second and
third trimesters of pregnancy, where the adnexa
are more difcult to visualize. An IFTT is often
misdiagnosed as ovarian torsion. The paraovarian
7.7 Diagnosis
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Fig. 7.1 Two ovoid masses with a thin hypoechoic
“bridge” in between. Left-sided mass is anechoic with a
small echoic focus posteriorly, while the right-sided mass
was hypoechoic with uniform low-level echoes within.
They had an appearance of a single bilobed structure with
good posterior enhancement. A cyst measuring 3cm in
diameter (red arrow) is noted adjacent to the right ovary
(blue arrow). The right ovary appears slightly enlarged
and partly hypoechoic. (Reproduced with permission
from [75])
and paratubal cysts are difcult to diagnose when
a mass is close to the ipsilateral ovary [85].
However, a clear interface is seen between the
ovarian surface and the cyst in most cases, making diagnosis possible. US Whirlpool sign of
IFTT is diagnostic [86]. Acute adnexal pain with
conrmed pelvic cystic structure and normal
ipsilateral ovary strongly suggests tubal or paratubal cyst torsion [78]. Varicose veins in the
mesosalpinx can rupture and mimic ectopic/heterotopic pregnancy. Transabdominal US rules out
hepatobiliary and urologic pathology.
High impedance, reversal, or absence of reverse
end-diastolic vascular ow of the tubal wall can be
found on spectral Doppler analysis. However,
these ndings can be difcult to interpret [85].
7.7.3 Abdominal CT
CT ndings in the general female population
(rarely used in pregnancy) with IFTT include an
adnexal mass, a twisted appearance to the FT,
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Fig. 7.2 Abdominopelvic CT shows a 44×25mm-sized
homogenous cystic mass (arrow) occupying the right
lower quadrant. (Reproduced with permission from [46]
dilated tube greater than 15mm, a thickened and
enhancing tubal wall, and luminal CT attenuation >50 Hounseld units consistent with hemorrhage (Fig. 7.2). IFTT or adnexal torsion’s
secondary signs include free intrapelvic uid,
peritubular fat stranding, enhancement and
thickening of the broad ligament, and regional
ileus [83, 87].
7.7.4 Abdominal MRI
MRI accurately diagnoses IFTT in pregnancy
and is an excellent alternative to diagnostic
exploration [29]. By combining an excellent softtissue contrast with a large eld of view, MRI
allows further differentiation of cystic lesions
and their relations with intestinal and internal
genital structures. T2-weighted MRI ndings of
dilated and tortuous FT in the presence of a normal ovary (Fig.7.3) give a clue towards the possibility of IFTT [45]. Excluding bleeding in the
dilated FT on T1-weighted images excludes ectopic tubal pregnancy. MRI conrms the Whirlpool
sign from color Doppler US, helping in an early
preoperative diagnosis [45, 86].
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7 Isolated Fallopian Tube Torsion
Fig. 7.3 Transabdominal sonography (upper left) and
T2-weighted MRI (clockwise starting from upper right:
axial, coronal, and sagittal view) of the segmental dilation
(white arrow) of the distal left tube. Note the proximity of
7.8 Treatment
It is important to distinguish between ovarian torsion and IFTT even if both require a surgical
approach. The preoperative knowledge of a normal ovarian structure and vascularization by 2D
and Doppler US help preserve a normal-looking
ovary or partially damaged due to the adjacent
tubal torsion. Thus, it would be possible to pre-
the normal-appearing sigmoid colon (asterisk) and ipsilateral ovary (arrowhead). (Reproduced with permission
from [45] under the CC BY 4.0)
serve ovarian function while avoiding premature
loss of the corpus luteum gravidarum in early
pregnancy cases and other adverse obstetric
sequelae [37, 43]. Second, the preoperative
knowledge of a normal ovary reduces patients’
preoperative anxiety related to eventual oophorectomy. On the other hand, if the patient does not
want any more children, operative sterilization
could be performed during the emergent opera-
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