Rarely, sacculation may form as extensive lower uterine segment dilatation due to persistent entrapment of the pregnant uterus in the pelvis (Fig. 3-7). In these extreme cases, sonography and MR imaging are typically required to deine anatomy (Gottschalk, 2008; Lee, 2008). Cesarean delivery is necessary when sacculation is marked, and Spearing (1978) stressed the importance of clariying the distorted anatomy. An elongated vagina passing above the level of a fetal head that is deeply placed into the pelvis suggests a sacculation or an abdominal pregnancy. The Foley catheter is frequently palpated above the level of the umbilicus! Spearing (1978) recommended extending the abdominal incision above the umbilicus and delivering the entire uterus from the abdomen before hysterotomy. This will restore correct anatomical relationships and prevent inadvertent incisions into and through the vagina and bladder. Unfortunately, this may not always be possible (Singh, 2007). As a inal caveat, a true uterine diverticulum has been mistaken for uterine sacculation (Rajiah, 2009).
he uterus commonly rotates to the maternal right during pregnancy. Rarely, uterine rotation exceeds 180 degrees to cause torsion. Most cases of torsion result from uterine leiomyomas, miillerian anomalies, fetal malpresentation, pelvic adhesions, or laxity of the abdominal wall or uterine ligaments. Jensen (1992) reviewed 212 cases and reported that associated symptoms may include obstructed labor, intestinal or urinary
Anterior wall complaints, abdominal pain, uterine sacculation hypertonus, vaginal bleeding, and hypotension.
Most cases of uterine torsion are found at the time of cesarean delivery. In some women, torsion can be conirmed preoperatively with MR imaging, which shows a twisted vagina that appears X-shaped rather than its normal H-shape (Nicholson, 1995). As with uterine incarceration, during cesarean delivery, a severely displaced uterus should be repositioned anatomically before hysterotomy. In some cases, an inability to reposition or a failure to recognize the torsion may lead to a posterior hysterotomy inci sion (Albayrak, 2011; Picone, 2006;
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