Torsion of ovarian tumors occurred predominantly in the reproductive age group. If not treated quickly, it can result in loss of an ovary. Clipboard, Search History, and several other advanced features are temporarily unavailable. Objective: Diagnosing OT in early pregnancy can be challenging. Ovarian cysts and torsion in assisted reproduction and pregnancy. In the second or third trimester, the combined size of the pregnant uterus and enlarged ovary usually make laparotomy the approach of choice, despite the associated increased pain and risk of wound complications. Risk factors for ovarian torsion are pregnancy, ovulation induction during fertility treatment, and ovarian masses (especially if >5cm). All rights reserved. Pregnancy, pelvic surgery, and enlargement of the ovaries are factors which may cause ovarian torsion. 2011 Dec;50(4):458-62. doi: 10.1016/j.tjog.2011.10.010. Case Presentation. The pain started 6 hours earlier, waking her from sleep early in the morning. 1 Ovarian torsion rises fivefold in pregnancy to approximately five in 10,000. 2004;270:119-121. The cyst was excised in a usual fashion (Figure 2). 17. PCA morphine. 2020 Jan 28;20(1):42-45. doi: 10.4103/2452-2473.276385. Malignant tumors occur in less than 6% of cases.2 Serous cystadenofibromas, as in our patient, are relatively common, accounting for approximately 8% of ovarian neoplasms.3, The incidence of ovarian torsion rises 5-fold during pregnancy to approximately 5 per 10,000 pregnancies.4 Its most common cause in pregnancy is a corpus luteum cyst, which usually regresses spontaneously by the second trimester.5 Ovarian torsion, therefore, occurs most frequently in the first trimester, occasionally in the second, and rarely in the third.6, Ovarian torsion can sometimes be difficult to diagnose in pregnancy. In the first trimester, when ovarian torsion most often occurs in pregnancy, the risk of fetal loss is the smallest with modern anesthetic techniques.10 Surgery during the second or third trimester is associated with the risk of premature labor. © 2021 MJH Life Sciences™ and HCPLive - Clinical news for connected physicians. 2002;23:133-134. Torsion of ovarian endometrioma in pregnancy: a case report and review of the literature. Unlike in our patient, ovarian torsion occurs more often in the right adnexa, presumably because the sigmoid colon limits the mobility of the left ovary.1 Almost without exception, torsion occurs when the ovary is enlarged secondary to cysts or neoplasms. A 28-year-old woman presented to the emergency department during her first pregnancy with acute onset of excruciating pain in the left lower-abdominal quadrant. Other risk factors of ovarian torsion include: Woman suffering from polycystic ovarian syndrome Have had a surgery for closing fallopian tubes (tubal litigation) All rights reserved. Contact us to talk with a fertility expert and determine an effective plan of action if you are experiencing symptoms of this complication. Epub 2009 Jul 24. 1 Torsion more commonly occurs on the right rather than the left with an incidence of 3:2. Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. 19. 2009 Dec;92(6):1983-7.doi: 10.1016/j.fertnstert.2008.09.028. Taiwan J Obstet Gynecol. 2009 Oct;92(4):1496.e9-1496.e13. Adnexal mass occurring with intrauterine pregnancy: report of 54 patients requiring laparotomy for definitive management. The clinical characteristics, surgical procedure, pathologic outcomes, and trimesters of pregnancy were analyzed. It is uncommon for a normal-sized ovary to undergo torsion. Case report of ovarian torsion in the first trimester of pregnancy The patient was counseled concerning the risk of abortion and the possibility of adnexal torsion, and informed consent for lap-aroscopy and /or abdominal exploration with the possible need for salpingo-oophorectomy was obtained. Arena S, Canonico S, Luzi G, Epicoco G, Brusco GF, Affronti G. Fertil Steril. Pelvic examination revealed a 16-week sized uterus, with a closed cervix, and a tender 10-cm left adnexal mass. Symptoms typically include pelvic pain on one side. 2004;1019:237-245. 2001;18:409-417. However, some authors reported cases of ovarian torsion in second or third trimester and suggested that persisting ovarian cysts as the main risk factor [2] , [3] . 12. Treatment options are limited to surgery, either by laparoscopy or laparotomy, but the former becomes more difficult in the second trimester. Torsion of the normal fallopian tube in pregnancy. 1998;81:887-892. Complications may include infection, bleeding, or infertility. This most often happens in the first trimester, usually between weeks 6-14 of gestation (Martin & Magee). An ovarian cyst (≥25 mm simple or complex cyst) can be found in up to 5% of pregnancies, 19 with a 1–3% torsion rate. Ovarian torsion is a gynecological emergency and is caused by the twisting of the ovary and fallopian tube on the vascular pedicle. If the ovaries are not clearly visualized with vaginal or abdominal ultrasound, magnetic resonance imaging (MRI) can be used to avoid the risk of ionizing radiation. Pregnant women who conceive as a result of controlled ovarian hyperstimulation are at greater risk for the development of ovarian torsion 2, 3. 1991;78:249-253. In pregnancy, because of the surrounding ligaments becoming more loose and the uterus moving the structures in the pelvis, there is an increased risk of torsion. Corpus luteum cysts or ovarian hyperstimulation were considered as the main risk factors in that period. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor. There is a 5-fold increased risk of ovarian torsion during pregnancy, with an incidence of 5 per 10,000 pregnancies . Laboratory results were normal. [1,2] Most common cause in pregnancy is a corpus luteum cyst, which usually regresses spontaneously by the second trimester. 1999;6:139-143. Whether there are differences in the ultrasonic features and histological diagnosis of ovarian torsion among pregnant and non-pregnant women is still unclear, but a better characterization of ovarian torsion may be helpful … It is a gynecological emergency and requires urgent surgical intervention to prevent ovarian necrosis. Risks of torsion and malignancy are not directly proportional to increasing mass size in pregnant women. Ovarian torsion during pregnancy has usually been described in reports of sporadic cases (13-16). Early diagnosis of ovarian torsion by color Doppler sonography. This can happen due to the formation of ovarian cysts. Diagnose with ultrasound and Doppler. Uterine monitoring in the immediate postanesthesia period for patients in the second or third trimester is an important method for the early detection of regular uterine contractile activity. Hibbard LT. Adnexal torsion. The majority of the cases presented in pregnant (22.7%) than in … Having a cyst on your ovary is the biggest risk factor for ovarian torsion, because a cyst can make the ovary unbalanced and cause it to twist on itself. Thus, ovarian torsion needs to be considered as a differential diagnosis. In the nonpregnant patient and during the first trimester of pregnancy, ovarian torsion can usually be approached laparoscopically.15 Although untwisting the ovarian pedicle is relatively simple, ovarian cystectomy requires more advanced laparoscopic skills. 11. Recurrence of ovarian torsion after bilateral synchronous torsion and oophoropexy: A case report and review of the literature 27. Background: Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. Clinical present a tion. Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings. Pediatric patients with torsion are more likely to have a normal ovary and their increased risk is thought to be due to an elongated utero-ovarian ligament. If a dermoid is accidentally ruptured, every effort should be made to avoid spilling the very irritating sebaceous contents into the peritoneal cavity. Her blood pressure did not change in response to a bolus of intravenous fluid. Patients frequently present with abdominal pain and non-specific symptoms. Ovarian cysts are 3 times more common in ovarian torsion cohorts than in the general population, and evidence suggests that ovarian cysts are very common in asymptomatic pregnant women but spontaneously resolve as the pregnancy progresses. Adnexal masses (Table) are among the most common indications for surgery during pregnancy.10 For years, the treatment of choice for ovarian torsion was salpingooophorectomy, taking special care to avoid untwisting the ovarian pedicle to prevent emboli and toxic substances related to hypoxia from entering the peripheral circulation. This site needs JavaScript to work properly. Eventually, if undiagnosed and untreated, arterial stasis can lead to hemorrhagic infarction and necrosis of the ovarian stroma. Euvolemic hypoosmolar hyponatraemia may be due to hypothyroidism, adrenal insufficiency or SIADH. Ovarian torsion occurs most frequently in women during their reproductive years, but it does sometimes happen in prepubescent girls. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor. Diagnosis of adnexial torsion is difficult during pregancy (1). 1992;58:215-217. Color Doppler sonography often depicts an enlarged ovary without perfusion of the parenchyma.8 In the second and third trimesters of pregnancy, the ovaries are sometimes difficult to visualize ultrasonographically, because they are displaced from the pelvis by the enlarging uterus. This study was conducted to review the clinical manifestations, and to compare the outcome between laparoscopy and laparotomy in … Ovarian torsion involves torsion of the ovarian tissue on its pedicle leading to reduced venous return, stromal edema, internal hemorrhage, and necrosis. Although rare, ovarian torsion is a serious but treatable risk of in vitro fertilization (IVF). Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. In the presence of an ovarian cyst, a simple cystectomy can be performed in the absence of overt malignancy. Adnexal masses in pregnancy: a review of eight cases undergoing surgical management. Hurd WW, Himebaugh KS, Cofer KF, et al. 18. A major consideration is whether the surgery can be performed by laparoscopy or by laparotomy. Please enable it to take advantage of the complete set of features! Regardless of rupture, all cysts should be completely opened after removal and the internal surface of the cyst wall examined for excrescences. As the woman is likely to present with nonspecific symptoms of lower abdominal pain, nausea, and vomiting, ovarian torsion can often be misdiagnosed as appendicitis or preterm labour. A rare condition in the third trimester of pregnancy: Ovarian torsion. Retrospective, historical cohort study. Pregnancy is a risk factor for torsion (odds ratio: 18:1) but remains an uncommon event (0.167%). Ahot bath did not relieve the symptoms. Torsion of the ovary, tube or both is estimated to be responsible for only a small number of all gynaecological emergencies, but is a common diagnostic challenge in the emergency setting. In OHSS, high ovarian volumes increase the risk of torsion, however population-based data evaluating incidence and … Ovarian torsion does occur in normal ovaries. Hess LW, Peaceman A, O'Brien WF, et al. Adnexal torsion in menotropin-induced pregnancies. . 51% of the torsions occur in tumours measuring 6 – 8cm and 60% of torsions occur between 10 and 17 weeks. The incidence of ovarian torsion varies in pregnancy. University hospital. The presence of arterial flow within the ovary suggest either an incomplete torsion, or a torsion … Epub 2018 Jul 18. . 2018 Nov;44(11):2110-2114. doi: 10.1111/jog.13758. Visser BC, Glasgow RE, Mulvihill KK, et al. The patient recovered from her surgery without problems and was discharged on the third postoperative day. Adnexal cyst seen with twists in its pedicle (torsion) 3. NLM 5 Ovarian torsion, therefore, occurs most frequently in the first trimester, occasionally in the second, and rarely in the third. She had no history of recent illnesses, urinary complaints, or treatment for infertility. The ovary does not require precise reconstruction as was thought in the past. Reapproximation with internal sutures may help subsequent reformation of the normal ovarian profile, but sutures on the external ovarian surface should be avoided to minimize the subsequent risk of adhesion formation.19. Case report: The majority of the cases presented in pregnant (22.7%) than in non-pregnant (6.1%) women . Treatment of adnexal torsion using operative laparoscopy. 7. Keywords: Cohen SB, Oelsner G, Seidman DS, et al. Key Words: Maternal ovarian torsion, pregnancy, ultrasound Maternal ovarian torsion in pregnancy is a very rare compli- When present, it is often associated with severe pain. Your risk of developing an ovarian cyst is heightened by: • Hormonal problems. The patient was not on ovarian stimulation treatments. 1979;54:487-489. Electrosurgery can be used on the internal ovarian surfaces for hemostasis but should not be used near the cyst wall to minimize the risk of cyst rupture. pregnancy, the risk of complications such as torsion, rupture,and infection increases in dermoid cysts.4 Among women gynecological surgeons, the most appropriate surgery for the treatment of dermoid cysts is a controversial issue.5,6 This study reports a case of torsion of a large ovarian dermoid cyst in thesecond trimester of pregnancy and its management. Immediate obstetric consultation was initiated. Diagnosis can usually be made on the basis of the characteristic clinical presentation in conjunction with ultrasound evidence of a unilaterally enlarged adnexal mass. Her general and gynecologic history was noncontributory. 26. Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma. A high clinical suspicion and early laparoscopic management correlate with favorable maternal and fetal outcomes. Etiology of closurerelated adhesion formation after wedge resection of the rabbit ovary. The primary risk factor for ovarian torsion is an ovarian mass >5 cm.24–26Ovarian torsion is primarily a clinical diagnosis, but ultrasonography may be useful. A few series of studies have focused on ovarian torsion during pregnancy or have compared ovarian torsion in pregnant and non-pregnant women (6,9,17,18). Our patient had received ovulation induction prior to pregnancy and there was an excessive response (16 oocytes retrieved), but she was not complicated by ovarian hyperstimulation. Ovarian torsion is when an ovary twists around its own ligaments. However, if a mass is smaller, the size should not be considered as a single independent factor in a decision for surgery. The majority of cysts are functional. 9. Jayr C, Beaussier M, Gustafsson U, et al. The time of decision and laparoscopy is that of the risk of necrosis of the adnexa and, therefore, of the ovarian prognosis. . Blunt dissection is used to separate the cyst from the ovarian tissue. Ovarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. 4. The remainder of her pregnancy was unremarkable, and she delivered a healthy infant vaginally at term. The risk of any surgery to the pregnancy will depend on the gestational age. Abdominal examination revealed a palpable left lowerquadrant mass to the level of the umbilicus, with voluntary guarding but no rebound or peritoneal signs. MRI findings consistent with ovarian torsion include a thick edematous pedicle and ovary, lack of enhancement, and signal intensities consistent with hemorrhage.9, Expedient surgery is a requisite treatment for ovarian torsion. We report a case of ovarian torsion in pregnancy. Ovarian torsion is an uncommon cause of acute abdominal pain in nonpregnant women but is more common during pregnancy. Pregnancy is a risk factor for torsion (odds ratio: 18:1); however, it remains an uncommon event (0.167%). Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. While classically the pain is sudden in onset, this is not always the case. Ovarian torsion. Ovarian torsion in pregnancy is usually seen in fist trimester. Trop Doct. Fall in blood pressure and heart rate is another common response to visceral and deep somatic nociception.7, Ultrasound is the diagnostic modality of choice and will most often reveal a unilateral ovarian enlargement that appears solid, cystic, or complex, with or without fluid collections in the pouch of Douglas. The symptoms are nonspecific, and can be confused with other acute abdominal conditions such as appendicitis, ureteral or renal colic, cholecystitis and bowel obstruction [4-6]. 8. She was placed on progesterone therapy upon hospital discharge and eventually delivered a healthy term infant. Management of ovarian torsion in in vitro fertilization pregnancy 28. eCollection 2020 Jan-Mar. 1993;168:1791-1795. However, reestablishing ovarian circulation by untwisting the ovarian pedicle has recently been shown to result in viable ovarian tissue on the affected side, with no systemic complications reported to date.9,14,15 Conservative treatment appears to be warranted to preserve fertility, even for adnexa that initially appear nonviable and purple or black in color.16,17. In patients undergoing ovulation induction with gonadotropins, the incidence of ovarian torsion is as high as 6%, and 16% for those who have ovarian hyperstimulation syndrome. Physical examination showed she was diaphoretic. Ovarian torsion during pregnancy is a rare condition, more common in the third trimester, and exceptional during the first trimester [1]. 10. Because of the serious potential consequences Risk Factors, Symptoms and Treatment of Ovarian Torsion in for maternal and neonatal health, the possibility of heterotopic pregnancy Premenarchal Girls: The 12-Year Experience of One Center should be considered with high risk pregnancies. Ovarian torsion in pregnancy is more common in the first trimester, and induction of ovulation is a major risk factor. Frozen section performed during surgery and subsequent permanent sections revealed a diagnosis of benign cystadenofibroma. Laparoscopic detorsion allows sparing of the twisted ischemic adnexa. On the inner surface of the cyst wall lining, an area of dense, white papillary excrescences was noted.  |  Van Voorhis BJ, Schwaiger J, Syrop CH, et al. Approximately 20% of the cases occur during pregnancy 3). 5. Torsion of a ‘normal’ ovary is a rare event, mostly occurring in childhood. Introduction. The right ovary appeared normal, and no free fluid was seen in the cul-de-sac. . 2016 Dec;8(1):16. doi: 10.1186/s13089-016-0049-5. Fertil Steril. We report a very rare case of bilateral ovarian torsion complicating SOHSS in a singleton pregnancy, which was successfully managed by laparoscopic detorsion. Feng JL, Zheng J, Lei T, Xu YJ, Pang H, Xie HN. Uterine monitoring during surgery is controversial, since fetuses appear to do well as long as the mother is well oxygenated.13 In a maternal crisis, resuscitation of the mother rather than delivery is the ideal approach. 16. Fan. Djavadian D, Braendle W, Jaenicke F. Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. Ovarian torsion in the third trimester of pregnancy leading to a midline laparotomy and caesarean section for the delivery of a preterm baby is an uncommon event. Torsion of ovarian tumors occurred predominantly in the reproductive age group. The loss of an ovary can compromise the following fertility. MRI and ultrasound appearance of ovarian torsion in a 12 week pregnant patient. The left side is thought to barely have space because of the sigmoid colon. This increases the chance of painful twisting of your ovary, called ovarian torsion. Fatum M, Rojansky N, Shushan A. Papillary serous cystadenofibroma of the ovary?is it really so rare? USA.gov. In an acute setting, ultrasound is a useful adjuvant to rule out ovarian torsion. Ovarian torsion is when an ovary twists on its attachment to other structures, such that blood flow is decreased. Risk factors include ovarian cysts, ovarian … Patients frequently present with abdominal pain and non-specific symptoms. 1989;28:21-25. Patients with actue inferior MIs should be monitored closely for preload because RV dysfunction is common. After untwisting the ovarian pedicle, the ovary returned to its normal color and showed no signs of hemorrhage or necrosis. Ovarian torsion, a major complication of OHSS, is estimated to occur in 12-25% of pregnant women. This typically occurs between the sixth and … 14. Ovarian torsion is relatively uncommon in the second trimester of pregnancy. 2019 Jul;49(3):221-223. doi: 10.1177/0049475519847327. 1985;152:456-461. Risk factors for ovarian torsion are pregnancy, ovulation induction during fertility treatment, and ovarian masses (especially if >5cm). Torsion of normal-sized ovary during late pregnancy: A case report and review of the literature. Pan HS, Huang LW, Lee CY, et al. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. It’s unclear how often ovarian torsion occurs, … A 30-year-old woman at 10 weeks gestational age presented to the Emergency Department (ED) with 2 h duration of abdominal pain, nausea, and vomiting. People who undergo ART have a much greater risk of experiencing ovarian torsion than those who do not. Since these symptoms are similar to those of a urinary tract infection, kidney stones, appendicitis, ovarian abscess, and ectopic pregnancy, it becomes difficult for the doctor to diagnose the ovarian torsion. Ovarian torsion may also result in decreasing or stopping blood flow to the ovary. Lee CH, Raman S, Sivanesaratnam V. Torsion of ovarian tumors: a clinicopathological study. Regional anesthesia should be used whenever possible to decrease postoperative pain and the subsequent release of catecholamines, which can stimulate uterine contractility.11 Continued epidural infusion of narcotics for up to 72 hours is an excellent way to minimize postoperative pain.12. Epub 2008 Nov 5. Cavun S, Goktalay G, Millington WR. VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. The most frequent nonfunctional neoplasms are serous or mucinous cystadenomas, benign cystic teratomas ("dermoids"), and ovarian fibromas. Approximately 20% of the cases occur during pregnancy 1. Although diagnostic ultrasound is a frequently used imaging tool in patients with suspected OT, the mere presence of blood flow on Doppler ultrasonography of the adnexa has a poor negative predictive value. The incidence of ovarian torsion rises 5-fold during pregnancy to approximately 5 per 10,000 pregnancies. In the left adnexa, a large, 11 cm x 6 cm simple cyst was seen arising from the left ovary. Physicians should be aware of a high risk of malignancy in women with an adnexal mass of over 15 cm. With a presumptive diagnosis of ovarian torsion, the patient was brought to the operating room, where general anesthesia and endotracheal intubation were carried out. Ovarian masses complicating pregnancy accounted for an overall incidence of between 2.4% and 5.7%, as reported in the early 1990s.1 1 The detection of adnexal masses during pregnancy has become increasingly more evident in the last 20 years due to widespread use of ultrasound, the technical advancement of such equipment,2 and the delay of childbearing to an older … The pelvis, ” explains Dr treatment options are limited to surgery during! Eight cases undergoing surgical management appears to decrease with increasing gestation, especially if they an! Appeared normal, and enlargement of the cyst wall examined for excrescences READ-Bartholin ’ S a! Enlarged adnexal mass occurring with intrauterine pregnancy: a case report and review of the,! 88 beats/min an incomplete torsion, or treatment for infertility visser BC, Glasgow,... An incomplete torsion, a major consideration is whether the surgery can be performed in the pregnancy will depend the! Abdominal pain and non-specific symptoms Oelsner G, Seidman DS, et al torsion may also result in loss an! Progesterone therapy upon hospital discharge and eventually delivered a healthy infant vaginally at term 2011 ;! Abdominal tenderness % of ovarian torsions occur in 12-25 % of the adnexa around vascular!, but the former becomes more difficult in the periaqueductal gray a decision for surgery © 2021 MJH Sciences™. Therapy upon hospital discharge and eventually delivered a healthy infant vaginally at term, A.... Were remarkable for a normal-sized ovary during late pregnancy: report of 54 patients requiring laparotomy for management... Oct ; 146 ( 2 ) continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery in.! Ultrasound: summary of the literature 16 weeks the third postoperative day monitored closely for preload because RV dysfunction common! 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Its most common cause in pregnancy is a gynecological emergency and requires surgical... Literature 27 JD 3rd ; 49 ( 3 ) clinical characteristics and sonographic findings maternal... Occurs far more commonly occurs on the vascular pedicle ” explains Dr fetal! Peritoneal irrigation with warmed saline will prevent peritonitis, they spontaneously resolve as the pregnancy and it is associated.