Acute Uterine Torsion Masquerading as Fibroid Degeneration in a High-Risk Pregnancy: A Case of Diagnostic Surprise.

Uterine torsion during pregnancy is a rare and life-threatening condition that is frequently misdiagnosed due to nonspecific symptoms and imaging limitations. This case report describes a 32-year-old third gravida (G3, P0+2) with recurrent pregnancy loss, having a 16.9 cm uterine fibroid and hypertrophic cardiomyopathy (managed with bisoprolol), who presented at 24 weeks with severe abdominal pain. Although her vitals were stable, a markedly elevated C-reactive protein (CRP) (245 mg/dL) raised concern for acute pathology. Initial ultrasound incorrectly localized the fibroid to the left, but exploratory laparotomy revealed a 180-degree uterine torsion with contralateral fibroid position, revising the diagnosis from fibroid degeneration to this rare emergency, leading to detorsion and myomectomy. At 30 weeks' gestation, cervical insufficiency (a short cervix measuring 0.5 cm with funneling) was successfully managed with an Arabin pessary and weekly 500 mg injections of hydroxyprogesterone, prolonging the pregnancy to 34 weeks and resulting in an outlet forceps delivery of a healthy 1.9 kg infant. This case highlights the importance of surgical exploration when clinical suspicion contradicts imaging findings, the feasibility of pregnancy-preserving surgery for uterine torsion, and the effectiveness of combined mechanical-hormonal therapy for cervical insufficiency following complex uterine interventions. Multidisciplinary care was critical to manage overlapping high-risk factors, including fibroids, cardiac disease, and preterm cervical changes, ultimately leading to a favorable outcome.