n ovarian torsion in our hospital from January 2012 to June 2018. Up to 22% of ovarian torsions occur in pregnancy. A bedside ED ultrasound showed an enlarged edematous right ovary with a large cyst, but without flow on color Doppler. 1. 2019 Jul;49(3):221-223. doi: 10.1177/0049475519847327. 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. Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings. Torsion of normal-sized ovary during late pregnancy: A case report and review of the literature. The right ovary appeared normal, and no free fluid was seen in the cul-de-sac. Approximately 20% of the cases occur during pregnancy 1. The patient underwent emergent laparoscopic surgery, during which the necrotic right ovary was removed. 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. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Another significant risk factor for ovarian torsion is the presence of cysts or abnormal masses. 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. . Ovarian torsion, also sometimes termed adnexal torsion or tubo-ovarian torsion, refers to rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle.. Other symptoms may include nausea. 1 Ovarian torsion rises fivefold in pregnancy to approximately five in 10,000. Retrospective, historical cohort study. In OHSS, high ovarian volumes increase the risk of torsion, however population-based data evaluating incidence and … In one study, preterm labor occurred in 26% of women who had surgery during the second trimester and in 82% of those who had surgery during the third trimester.10, Several approaches can minimize the risk of premature labor. 1999;6:139-143. Pre-menarchal girls have an increased risk of ovarian torsion of normally appearing ovaries, compared to women in the reproductive age who also have normal-appearing ovaries. Pregnancy also results in an increased risk of torsion due to an enlarged corpus luteum. VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. 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). Vergote I, De Brabanter J, Fyles A, et al. ALSO READ-Bartholin’s Glands Cyst: Causes and Symptoms. Early diagnosis of ovarian torsion by color Doppler sonography. Other risk factors of ovarian torsion include: Woman suffering from polycystic ovarian syndrome Have had a surgery for closing fallopian tubes (tubal litigation) 18. Nonobstetrical gynecologic conditions that cause pain in pregnancy may be diagnosed on ultrasound. The majority of the cases presented in pregnant (22.7%) than in non-pregnant (6.1%) women . 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 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. The presence of arterial flow within the ovary suggest either an incomplete torsion, or a torsion … 6 Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery: comparative study with i.v. 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). Diagnose with ultrasound and Doppler. Background: Risk factors for ovarian torsion are pregnancy, ovulation induction during fertility treatment, and ovarian masses (especially if >5cm). 3. Diagnosis can be difficult and is mainly based on clinical symptoms and imaging techniques such as ultrasound and MRI. It is a gynecological emergency and requires urgent surgical intervention to prevent ovarian necrosis. It can be intermittent or sustained and results in venous, arterial and lymphatic stasis. (Fertil Steril 2009;92:1983–7. It’s unclear how often ovarian torsion occurs, … 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. Ovarian torsion is an uncommon cause of acute abdominal pain in nonpregnant women but is more common during pregnancy. 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. Her general and gynecologic history was noncontributory. 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. Keywords: 16. 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. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor. Blunt dissection is used to separate the cyst from the ovarian tissue. Evidence suggests that ovarian cysts are very common in the asymptomatic pregnant cohorts; however, they spontaneously resolve as the pregnancy progresses. Introduction. Ovarian torsion is relatively uncommon in the second trimester of pregnancy. 1 Torsion more commonly occurs on the right rather than the left with an incidence of 3:2. 6. 2016 Dec;8(1):16. doi: 10.1186/s13089-016-0049-5. Treatment options are limited to surgery, either by laparoscopy or laparotomy, but the former becomes more difficult in the second trimester. We report a very rare case of bilateral ovarian torsion complicating SOHSS in a singleton pregnancy, which was successfully managed by laparoscopic detorsion. Diagnosis can usually be made on the basis of the characteristic clinical presentation in conjunction with ultrasound evidence of a unilaterally enlarged adnexal mass. Pelvic examination revealed a 16-week sized uterus, with a closed cervix, and a tender 10-cm left adnexal mass. Complications may include infection, bleeding, or infertility. 19. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. It remains to be determined if these precautions avoid the detrimental effect of intraoperative rupture on stage I ovarian cancer.18. While classically the pain is sudden in onset, this is not always the case. Case report: Epub 2009 Jun 2. Color flow Doppler was not available. Thirty-three pregnant and 72 nonpregnant patients diagnosed with surgically proven ovarian torsion were assessed during the study period. Rupture is inevitable in some ovarian cysts, particularly in endometriomas and functional cysts, such as luteomas. clincal Clinical Suspicion of Tubo-ovarian Torsion Risk Factors. This increases the chance of painful twisting of your ovary, called ovarian torsion. Zweizig S, Perron J, Grubb D, et al.  |  . Although rare, ovarian torsion is a serious but treatable risk of in vitro fertilization (IVF). If ovarian torsion is diagnosed and treated quickly, the chances of a successful recovery are quite high. Due to this reason, in most of the cases, the diagnosis is made late, causing severe damage to the ovary. 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. 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. Case Presentation. Recurrence of ovarian torsion after bilateral synchronous torsion and oophoropexy: A case report and review of the literature 27. Ovarian torsion is a gynecological emergency and is caused by the twisting of the ovary and fallopian tube on the vascular pedicle. University hospital. Patients with actue inferior MIs should be monitored closely for preload because RV … 2. 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. Conclusion(s): Ovarian torsion in pregnancy is more common in the first trimester, and induction of ovulation is a major risk factor. Visser BC, Glasgow RE, Mulvihill KK, et al. 13. 2018 Nov;44(11):2110-2114. doi: 10.1111/jog.13758. Regardless of rupture, all cysts should be completely opened after removal and the internal surface of the cyst wall examined for excrescences. Hurd WW, Himebaugh KS, Cofer KF, et al. 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. The majority of cysts are functional. 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). 1998;81:887-892. Conservative management of adnexal torsion. Turk J Emerg Med. Diagnosis of Ovarian Torsion. have an increased risk of ovarian torsion of normally appearing ovaries, compared to women in the reproductive age who also have normal-appearing ovaries. Epub 2016 Nov 3. 17. Cavun S, Goktalay G, Millington WR. Ovarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. Eventual radiology ultrasound showed decreased but present flow in the right ovary. Background: Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. Key Words: Maternal ovarian torsion, pregnancy, ultrasound Maternal ovarian torsion in pregnancy is a very rare compli- Immediate obstetric consultation was initiated. Adnexal torsion in menotropin-induced pregnancies. To find the risk factors of torsion and malignancy for adnexal tumors during pregnancy. The clinical characteristics, surgical procedure, pathologic outcomes, and trimesters of pregnancy were analyzed. The pain started 6 hours earlier, waking her from sleep early in the morning. The loss of an ovary can compromise the following fertility. 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. Djavadian D, Braendle W, Jaenicke F. Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. Laboratory results were normal. ART increases the risk of ovarian torsion. She was placed on progesterone therapy upon hospital discharge and eventually delivered a healthy term infant. In all cases, definitive diagnosis must await careful examination of permanent sections. The incidence of ovarian torsion rises 5-fold during pregnancy to approximately 5 per 10,000 pregnancies. Epub 2019 May 8. Ovarian torsion is a medical emergency. 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] . The decision to proceed to surgery during pregnancy is somewhat complex, since the well-being of both mother and fetus must be taken into account. Ovarian torsion, a major complication of OHSS, is estimated to occur in 12-25% of pregnant women. Risk factors for ovarian torsion are pregnancy, ovulation induction during fertility treatment, and ovarian masses (especially if >5cm). Laparoscopic management of twelve consecutive cases of ovarian torsion: Four years experience 29. Kemmann E, Ghazi DM, Corsan GH. 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 … Taiwan J Obstet Gynecol. The majority of the cases presented in pregnant (22.7%) than in … 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. Ovarian torsion involves torsion of the ovarian tissue on its pedicle leading to reduced venous return, stromal edema, internal hemorrhage, and necrosis. J Obstet Gynaecol Res. Crit Ultrasound J. 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]. 1992;58:215-217. A major consideration is whether the surgery can be performed by laparoscopy or by laparotomy. Arena S, Canonico S, Luzi G, Epicoco G, Brusco GF, Affronti G. Fertil Steril. The left side is thought to barely have space because of the sigmoid colon. The presence of arterial flow within the ovary suggest either an incomplete torsion, or a torsion-detorsion scenario. Surgical intervention for maternal ovarian torsion in pregnancy. 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. Torsion of a ‘normal’ ovary is a rare event, mostly occurring in childhood. Fertil Steril. All rights reserved. Pregnancy is a risk factor for torsion (odds ratio: 18:1) but remains an uncommon event (0.167%). This includes ovarian torsion, a hemorrhagic corpus luteum cyst, an adnexal mass, and a degenerating fibroid. adnexal mass; ovarian torsion; pelvic ultrasonography; pregnancy. Missed diagnosis of OT could lead not only to ovarian necrosis and sepsis, but also threaten the pregnancy. She reported no vaginal bleeding or discharge, nausea, vomiting, fever, diarrhea, or constipation. Adnexal torsion is a rare cause of acute abdominal pain during pregnancy. Objective: Diagnosing OT in early pregnancy can be challenging. However, if a mass is smaller, the size should not be considered as a single independent factor in a decision for surgery. 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. 11. 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. The risk of any surgery to the pregnancy will depend on the gestational age. Etiology of closurerelated adhesion formation after wedge resection of the rabbit ovary. . 2009 Oct;146(2):116-20. doi: 10.1016/j.ejogrb.2009.05.002. Note that the affected ovary contains the corpus luteum, and this is an established risk factor for torsion in early pregnancy. The incidence is highest in pregnant women who are at 10 to 17 weeks of gestation, especially if they have an ovarian mass. Euvolemic hypoosmolar hyponatraemia may be due to hypothyroidism, adrenal insufficiency or SIADH. Hess LW, Peaceman A, O'Brien WF, et al. Diagnosing OT in early pregnancy can be challenging. 1989;28:21-25. Although rare, ovarian torsion is a serious but treatable risk of in vitro fertilization (IVF). All rights reserved. 8. Laparoscopic detorsion allows sparing of the twisted ischemic adnexa. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. 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. There is a 5-fold increased risk of ovarian torsion during pregnancy, with an incidence of 5 per 10,000 pregnancies [1]. In an acute setting, ultrasound is a useful adjuvant to rule out ovarian torsion. Contact us to talk with a fertility expert and determine an effective plan of action if you are experiencing symptoms of this complication. USA.gov. 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. Symptoms typically include pelvic pain on one side. 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