Ahmed Abdeltawab
Isolated torsion of the fallopian tube is a rare cause of acute abdomen in women of reproductive age, with an estimated annual incidence of approximately one per 1.5 million women. Its occurrence during pregnancy is rarer still, with fewer than 50 cases published. We present a 25-year-old primigravida at 27+6 weeks of gestation who was admitted to Farwaniya Hospital, Kuwait, with persistent right iliac fossa pain refractory to conservative management, associated with nausea and dysuria, on a background of recurrent urinary tract infection. Laboratory investigations showed leucocytosis and mild anaemia. Transabdominal ultrasound with colour Doppler identified a small simple right adnexal cystic lesion with preserved ovarian vascularity, and pelvic magnetic resonance imaging demonstrated an encysted fluid collection in the right iliac fossa of probable adnexal origin, together with a nondistended, normal-appearing appendix showing no features of inflammation. Following failure of conservative treatment and after counselling of the patient and her husband, diagnostic laparoscopy was performed. The right fallopian tube was gangrenous, twisted repeatedly upon itself and configured as a true knot, and salpingectomy was performed. Both ovaries and the appendix were macroscopically normal. Histopathology confirmed haemorrhagic infarction with epithelial necrosis of the tubal mucosa. The postoperative course was uneventful and the pregnancy continued to term, with spontaneous vaginal delivery of a healthy female neonate at 40+3 weeks of gestation. This case illustrates the diagnostic difficulty of isolated tubal torsion in pregnancy, in which urinary symptoms and non-specific imaging readily divert attention towards pyelonephritis, and supports laparoscopy as a safe and definitive diagnostic and therapeutic option in the second trimester. The intraoperative finding of a true knot is unusual and is documented here with annotated operative imaging.