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. 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. Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery: comparative study with i.v. Physicians should be aware of a high risk of malignancy in women with an adnexal mass of over 15 cm. Management of ovarian torsion in in vitro fertilization pregnancy 28. Keywords: 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. 6 Torsion of normal-sized ovary during late pregnancy: A case report and review of the literature. However, if a mass is smaller, the size should not be considered as a single independent factor in a decision for surgery. The most frequent nonfunctional neoplasms are serous or mucinous cystadenomas, benign cystic teratomas ("dermoids"), and ovarian fibromas. 15. 1999;6:139-143. Pelvic examination revealed a 16-week sized uterus, with a closed cervix, and a tender 10-cm left adnexal mass. . . Frozen section performed during surgery and subsequent permanent sections revealed a diagnosis of benign cystadenofibroma. Ovarian torsion, a major complication of OHSS, is estimated to occur in 12-25% of pregnant women. 5. There is a 5-fold increased risk of ovarian torsion during pregnancy, with an incidence of 5 per 10,000 pregnancies [1]. Thus, ovarian torsion needs to be considered as a differential diagnosis. Conclusion(s): Ovarian torsion in pregnancy is more common in the first trimester, and induction of ovulation is a major risk factor. A rare condition in the third trimester of pregnancy: Ovarian torsion. doi: 10.1016/j.fertnstert.2009.06.029. We report a very rare case of bilateral ovarian torsion complicating SOHSS in a singleton pregnancy, which was successfully managed by laparoscopic detorsion. USA.gov. Another significant risk factor for ovarian torsion is the presence of cysts or abnormal masses. Key Words: Ovarian torsion, multiple pregnancy, ovarian stimulation, ultrasound-guided transabdominal cyst aspiration Ovarian torsion is responsible for %3% of all gynecologic emergen-cies (1–6). MRI and ultrasound appearance of ovarian torsion in a 12 week pregnant patient. In the presence of an ovarian cyst, a simple cystectomy can be performed in the absence of overt malignancy. 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] . Treatment of adnexal torsion using operative laparoscopy. Epub 2008 Nov 5. In all cases, definitive diagnosis must await careful examination of permanent sections. 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. 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. 1 Ovarian torsion rises fivefold in pregnancy to approximately five in 10,000. 2002;23:133-134. Other risk factors of ovarian torsion include: Woman suffering from polycystic ovarian syndrome Have had a surgery for closing fallopian tubes (tubal litigation) NLM  |  Conservative management of adnexal torsion. © 2021 MJH Life Sciences and HCPLive - Clinical news for connected physicians. A bedside ED ultrasound showed an enlarged edematous right ovary with a large cyst, but without flow on color Doppler. 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. 2001;357:176-182. Chapron C, Capella-Allouc S, Dubuisson JB. Diagnosing OT in early pregnancy can be challenging. When present, microscopic examination of frozen sections can help determine if intraoperative staging is required. 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. The cyst was excised in a usual fashion (Figure 2). 2001;75:85-86. Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. COVID-19 is an emerging, rapidly evolving situation. 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. The patient was not on ovarian stimulation treatments. [1,2] Most common cause in pregnancy is a corpus luteum cyst, which usually regresses spontaneously by the second trimester. 4. While classically the pain is sudden in onset, this is not always the case. Other risk factors for the development of ovarian torsion … The remainder of her pregnancy was unremarkable, and she delivered a healthy infant vaginally at term. Fan. It can be intermittent or sustained and results in venous, arterial and lymphatic stasis. Ahot bath did not relieve the symptoms. 1989;28:21-25. 10. MRI and ultrasound appearance of ovarian torsion in a 12 week pregnant patient. Euvolemic hypoosmolar hyponatraemia may be due to hypothyroidism, adrenal insufficiency or SIADH. Missed diagnosis of OT could lead not only to ovarian necrosis and sepsis, but also threaten the pregnancy. Epub 2016 Nov 3. Note that the affected ovary contains the corpus luteum, and this is an established risk factor for torsion in early pregnancy. This can happen due to the formation of ovarian cysts. Epub 2009 Jun 2. Torsion occurs due to two main reasons 2: 1. hypermobility of the ovary: <50% 2. adnexal mass: ~50-80% 2.1. most lesions are dermoid cysts or paraovarian cysts 2.2. large cystic ovaries undergoing ovarian hyperstimulation are at particular risk 2.3. masses between 5-10 cm are at most risk 13 Symptoms typically include pelvic pain on one side. Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SH, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Ovarian torsion occurs far more commonly during pregnancy than in the non-pregnant state. 1993;38:465-468. Torsion of ovarian tumors occurred predominantly in the reproductive age group. Maternal ovarian torsion in pregnancy is a rare complication. Hurd WW, Himebaugh KS, Cofer KF, et al. have an increased risk of ovarian torsion of normally appearing ovaries, compared to women in the reproductive age who also have normal-appearing ovaries. 2009 Oct;92(4):1496.e9-1496.e13. 17. clincal Clinical Suspicion of Tubo-ovarian Torsion Risk Factors. Ovarian cysts and torsion in assisted reproduction and pregnancy. 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’s like a ball on a string. The diagnosis depends mainly on the clinical manifestation, D-dimer level and imaging tests such as compression ultrasonography and computed tomography pulmonary angiogram. The majority of the cases presented in pregnant (22.7%) than in … 1. A major consideration is whether the surgery can be performed by laparoscopy or by laparotomy. 11. Other symptoms may include nausea. 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. adnexal mass; ovarian torsion; pelvic ultrasonography; pregnancy. Ovarian cysts are three times more common in ovarian torsion cohorts than in the general population. The incidence is highest in pregnant women who are at 10 to 17 weeks of gestation, especially if they have an ovarian mass. Visser BC, Glasgow RE, Mulvihill KK, et al. 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. The pain started 6 hours earlier, waking her from sleep early in the morning. The patient recovered from her surgery without problems and was discharged on the third postoperative day. 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. Hurd WW, Smith AJ, Gauvin JM, et al. The time of decision and laparoscopy is that of the risk of necrosis of the adnexa and, therefore, of the ovarian prognosis. Likewise, if the "chocolate" contents of an endometrioma or the fluid content of a potentially malignant cyst spills within the peritoneal cavity, prolonged irrigation with warmed saline is judicious. Eventual radiology ultrasound showed decreased but present flow in the right ovary. Ovarian torsion is an infrequent, but important, cause of acute abdomino-pelvic pain in women. Pregnancy is also a risk factor for torsion. Ovarian torsion is relatively uncommon in the second trimester of pregnancy. Ovarian torsion involves torsion of the ovarian tissue on its pedicle leading to reduced venous return, stromal edema, internal hemorrhage, and necrosis. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. Would you like email updates of new search results? Adnexal torsion in menotropin-induced pregnancies. Nonobstetrical gynecologic conditions that cause pain in pregnancy may be diagnosed on ultrasound. This increases the chance of painful twisting of your ovary, called ovarian torsion. The objective of this article is to present a case of OT in early pregnancy and to review its epidemiology, diagnosis, and treatment. Up to 22% of ovarian torsions occur in pregnancy. All rights reserved. 2004;270:119-121. 2016 Dec;8(1):16. doi: 10.1186/s13089-016-0049-5. The risk is greater in pregnant women and those suffering from menopause. Cavun S, Goktalay G, Millington WR. Treatment options are limited to surgery, either by laparoscopy or laparotomy, but the former becomes more difficult in the second trimester. Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings. She had no history of recent illnesses, urinary complaints, or treatment for infertility. Immediate obstetric consultation was initiated. The loss of an ovary can compromise the following fertility. 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. On entry into the abdominal cavity with a midline incision, a congested 14-cm left ovary was found to be twisted around its ovarian pedicle 1.5 rotations (Figure 1). Ovarian torsion occurs most frequently in women during their reproductive years, but it does sometimes happen in prepubescent girls. Taiwan J Obstet Gynecol. The right ovary appeared normal, and no free fluid was seen in the cul-de-sac. 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. 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. Fertil Steril. J Obstet Gynaecol Res. . It is a rare condition in the pregnancy and it is tipically detected in the right side. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor. Patients with actue inferior MIs should be monitored closely for preload because RV … Cohen SB, Oelsner G, Seidman DS, et al. Ovarian torsion during pregnancy has usually been described in reports of sporadic cases (13-16). The presence of arterial flow within the ovary suggest either an incomplete torsion, or a torsion … . The majority of cysts are functional. 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. Ovarian torsion is the total or partial rotation of the adnexa around its vascular axis. Zweizig S, Perron J, Grubb D, et al. This includes ovarian torsion, a hemorrhagic corpus luteum cyst, an adnexal mass, and a degenerating fibroid. 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 … Euvolemic hypoosmolar hyponatraemia may be due to hypothyroidism, adrenal insufficiency or SIADH. The ovary does not require precise reconstruction as was thought in the past. 26. Laboratory results were normal. . All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor. 2. 2009 Oct;146(2):116-20. doi: 10.1016/j.ejogrb.2009.05.002. This site needs JavaScript to work properly. Pregnant women who conceive as a result of controlled ovarian hyperstimulation are at greater risk for the development of ovarian torsion 2, 3. Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. 7. The incidence of ovarian torsion varies in pregnancy. ART increases the risk of ovarian torsion. Complications may include infection, bleeding, or infertility. The char- maternal ovarian torsion in pregnancy in terms of incidence, acteristics and clinical findings of ovarian torsion in preg- risk factors, clinical characteristics and sonographic findings. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. It contained a 14-cm simple-appearing cyst. 2019 Jul;49(3):221-223. doi: 10.1177/0049475519847327. “The ovary is attached to the uterus and to the walls of the pelvis,” explains Dr. When present, it is often associated with severe pain. On the inner surface of the cyst wall lining, an area of dense, white papillary excrescences was noted. Turk J Emerg Med. The incidence of ovarian torsion rises 5-fold during pregnancy to approximately 5 per 10,000 pregnancies. Objective: Diagnosis of adnexial torsion is difficult during pregancy (1). She was placed on progesterone therapy upon hospital discharge and eventually delivered a healthy term infant. Adnexal torsion is a rare cause of acute abdominal pain during pregnancy. Abdominal examination revealed a palpable left lowerquadrant mass to the level of the umbilicus, with voluntary guarding but no rebound or peritoneal signs. eCollection 2020 Jan-Mar. One study showed a diagnostic accuracy of ultrasonography as 74.6%, with abnormal ovarian blood flow and presence of free fluid as the most diagnostic. . The presence of arterial flow within the ovary suggest either an incomplete torsion, or a torsion-detorsion scenario. Conclusions: 2020 Jan 28;20(1):42-45. doi: 10.4103/2452-2473.276385. NIH Pregnancy is a risk factor for torsion (odds ratio: 18:1) but remains an uncommon event (0.167%). 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. 1990;76:403-406. If this occurs, prolonged peritoneal irrigation with warmed saline will prevent peritonitis. Torsion of the ovary during pregnancy is common during third trimester. Kemmann E, Ghazi DM, Corsan GH.  |  Torsion of the normal fallopian tube in pregnancy. Approximately 20% of the cases occur during pregnancy 3). Patients with actue inferior MIs should be monitored closely for preload because RV dysfunction is common. Vergote I, De Brabanter J, Fyles A, et al. In an acute setting, ultrasound is a useful adjuvant to rule out ovarian torsion. 1 Torsion more commonly occurs on the right rather than the left with an incidence of 3:2. 2001;18:409-417. 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. Evidence suggests that ovarian cysts are very common in the asymptomatic pregnant cohorts; however, they spontaneously resolve as the pregnancy progresses. Lee CH, Raman S, Sivanesaratnam V. Torsion of ovarian tumors: a clinicopathological study. 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