A Case Report and Review: Extreme Uterine Torsion Complicated by Couvelaire Uterus and Intrauterine Fetal Demise.

Uterine torsion is an extremely rare obstetric emergency with potentially severe maternal and fetal outcomes. We describe the case of a 36-year-old multiparous woman who arrived with sudden, severe abdominal pain and hemodynamic instability. Ultrasound confirmed intrauterine fetal demise (IUFD). Emergency laparotomy revealed an extreme uterine torsion exceeding 360°, along with complete placental abruption and a Couvelaire uterus. Stepwise detorsion was necessary to restore proper uterine anatomy. After partial detorsion and identification of both adnexa, an anterior upper vertical uterine incision was made to enable delivery of the fetus and placenta. Hemorrhage was managed using uterotonics, tranexamic acid, fibrinogen concentrate, and temporary intrauterine tamponade. Despite the high bleeding risk, uterine preservation was successfully achieved. The patient recovered well postoperatively without significant complications. This case adds to the limited literature on severe uterine torsion and highlights the diagnostic and surgical challenges involved in high-degree torsion complicated by placental abruption and Couvelaire uterus. It emphasizes the importance of anatomy-guided intraoperative decision-making and early, structured hemorrhage control. However, no definitive conclusions about the best surgical approach can be drawn from a single case.