Konstantinos Zacharis, Stavros Kravvaritis, Theodoros Charitos, Eleni Chrysafopoulou, Anastasia Fouka
Department of Obstetrics and Gynecology, General Hospital of Lamia, Lamia, Greece
Correspondence: Konstantinos Zacharis; firstname.lastname@example.org
Ovarian torsion is caused by rotation of the ovary or adnexa with the vascular pedicle on its axis resulting in arterial and venous obstruction. Here we report a case of a pregnant woman presented to the emergency department in early second trimester with acute abdomen. History revealed the presence of an ovarian mass detected by ultrasonography 6 months before pregnancy. Sonographic examination showed right adnexal mass with abnormal Doppler velocimetry and thus immediate laparotomy was decided. Right salpingo-oophorectomy was performed and post-operative course of the patient was uneventful. According to this case, adnexal torsion should not be eliminated from differential diagnosis when it comes to pregnant women with acute abdomen.
Keywords: Adnexal torsion, pregnancy, gynecologic emergency, acute abdomen
The incidence of adnexal torsion during pregnancy is about 1-10 in 10000 pregnancies1. Torsion clinical symptoms during pregnancy are non specific and may be confused with other acute abdomen conditions such as appendicitis, renal colic, ectopic pregnancy2. Therefore diagnosis is challenging and may be delayed3. Most of the ovarian torsions are diagnosed during the first trimester of pregnancy4. However, in some cases, adnexal torsion may occur at an advanced gestational age. We hereby report a case of a spontaneous pregnancy complicated by adnexal torsion at early second trimester and how the patient was managed.
A 25-year-old primigravida woman (G1P0) attended to our emergency department at 13 weeks of gestational age, complaining of nausea and acute lower abdominal pain that started before 6 hours. From the medical history, patient reported the presence of a cystic mass in right adnexa in a routine transvaginal ultrasound check carried out 6 months earlier.
General examination did not revealed signs of hemodynamic instability; her blood pressure was 110/75 mm Hg, pulse rate was 92 bpm, basal body temperature was 36.7˚C, but the patient was irritable. On abdominal examination, right iliac fossa tenderness, rigidity, and rebound tenderness were elicited.
On investigating, patient’s white blood cell count was 18.770 K/μL (NEU: 83.6%), hematocrit value was 36.3%, CRP was 3.8mg/L, blood group was 0 positive, with normal coagulation profile, liver and kidney function tests.
Accordingly, transabdominal ultrasonography demonstrated one viable in utero fetus compatible with 13 weeks and 4 days-gestation and with normal amniotic fluid index and a normal placenta. Furthermore, a mass of 59 x 55 mm was seen in the right adnexal region and no blood flow was detected on color and power Doppler ultrasound of the right ovary (Figure 1). Thus, the diagnosis of adnexal torsion was confirmed.
Figure 1. Ultrasound finding of right adnexal mass with abnormal Doppler velocimetry
Informed consent was obtained and patient was taken up for exploratory laparotomy under spinal anesthesia after 3 hours of admission to hospital. Emergency laparotomy revealed pelvic fluid collection, pregnant uterus, a twisted twice, edematous, necrotic appearing right adnexal mass of 11.5 cm (Figure 2). Detorsion of the right adnexa was carefully performed, but no improvement in color or decrease of edema of the ovary was observed. Right sided salpingo-oophorectomy was done and fetus viability was confirmed post-operatively by transabdominal ultrasonography.
Figure 2. Peroperative findings shows pregnant uterus and a twisted right adnexa
Histopathology of the specimen showed an ovary with hemorrhagic infarct and a mature cyctic teratoma composed of tissue derived from all three germ layers (mesoderm, endoderm and ectoderm). Post-operatively, the patient was strictly followed up and she was discharged on postoperative day 5. The pregnancy continued uneventfully.
Ovarian torsion is a rare, life threatening condition and may lead to adnexal tissue ischemia, necrosis and ovarian loss5. Risk factors for adnexal torsion are precnancy, ovarian tumors and ovarian hyperstimulation syndrome6. Torsion of the right adnexa is more common due to hypermobility of the right utero-ovarian ligament which is longer than the left7.
The clinical symptoms of ovarian torsion are similar for both pregnant and non pregnant women including abdominal or pelvic pain, nausea and vomiting8. Early diagnosis requires thorough medical history, clinical assessment, and a gray-scale ultrasound combined with Doppler9.
When possible, laparoscopic detorsion is the preferred surgical intervention for adnexal torsion during pregnancy. Although salpingo-oophorectomy is performed in some cases.2, 4, 8. A retrospective case-control study performed by Daykan Y. and colleagues, indicated that detorsion of the adnexa with or without additional surgical procedures during pregnancy did not impact on gestational age of delivery and did not affect maternal and fetal complication rates10.
It is important to identify and report cases of adnexal torsions during pregnancy, due to their challenging diagnostic and therapeutic management.
Informed consent was obtained.
The authors declare no conflicts of interest.
KZ and EC wrote the first draft. SK, TC and AF critically reviewed and amended the draft. All authors approved of the final draft.
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