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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 52-53

Ovarian cyst with torsion during pregnancy


Department of OBG, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Smita Kumari
Department of OBG, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Adenexal torsion is partial or complete rotation of adenexa around its pedicle. Ovarian torsion occurs predominately in the reproductive age group. Diagnosis is based on the clinical and the radiological findings with color Doppler imaging showing decreased or absent blood flow in the ovarian parenchyma depending on the degree of torsion. If diagnosed early cystectomy can be done, however if the ovary becomes gangrenous oophorectomy may be required. Here we report a case of torsion of left ovarian cyst in 21 yrs old primigravida in her second trimester of pregnancy who presented in our emergency with complain of acute abdomen and vomiting since one day. She was diagnosed on the basis of clinical and ultrasonographic finding. Emergency laparotomy was planned and left salpingooophorectomy was done. Specimen was sent for histopathological examination which showed benign serous cystadenoma with unremarkable tube. Patient was kept under regular antenatal checkup. She delivered alive female baby of birth weight 3.0Kg at term by caesarean section.

Keywords: pregnancy, ovarian torsion, salpingooophorectomy, serous cystadenoma


How to cite this article:
Kumari S, Kiran S, Sinha A, Prasad D, Goel N. Ovarian cyst with torsion during pregnancy. J Indira Gandhi Inst Med Sci 2018;4:52-3

How to cite this URL:
Kumari S, Kiran S, Sinha A, Prasad D, Goel N. Ovarian cyst with torsion during pregnancy. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2022 Jan 20];4:52-3. Available from: http://www.jigims.co.in/text.asp?2018/4/1/52/302987




  Introduction : Top


Torsion of ovary is the partial or total rotation of adenexa around its pedicle. Moderate size, free mobility and long pedicle are the predisposing factors. Because of torsion of the ovary there is venous or lymphatic blockade that result in enlargement of the ovary because of continued arterial flow to the ovary without venous outflow. Eventually, if undiagnosed and untreated, arterial stasis can lead to hemorrhagic infarction and necrosis of the ovarian stroma. Adnexal torsion occurs predominately in the reproductive age group. The incidence of ovarian torsion is 5 per 10000 pregnancies and its risk increases five times during pregnancy.[1] Ovarian torsion carries significant risk to the mother and the fetus. Cystadenoma is the second most common benign ovarian tumor during pregnancy next to benign cystic teratoma. Here we report a case of torsion of ovarian cyst during second trimester of pregnancy.


  Case Report : Top


A 21 yrs old primigravida presented in our emergency at 21 wks gestation with acute pain abdomen and vomiting since one day. Her previous menstrual cycle was regular and conception was spontaneous. She described her pain as sharp and non-radiating in left iliac fossa. She had no history of vaginal bleeding, fever or constipation. Her pulse rate was 90bpm and blood pressure was 100/70 mm of Hg. She was conscious, oriented, average built and with mild pallor. On examination uterus was 20-22 wks irritable. There was generalized tenderness all over abdomen. Her blood and urine examinations were within normal limit. Ultrasonography showed 11*6 cm left sided ovarian cyst with few septations. No evidence of hemorrhage within cyst or pelvic ascitis ? torsion of ovarian cyst. USG also showed single live intrauterine fetus 21 wks 1 day, placenta was upper segment, posterior grade II, liquor was adequate.

With provisional diagnosis of twisted ovarian cyst emergency laparotomy was done under tocolytic coverage. A 10 x 8 cm left ovarian cyst was found to be twisted around its pedicle by two rotation. After untwisting of pedicle as no viable ovarian tissue was found, left salpingooophorectomy was done and specimen was sent for histopathologial examination. Her post operative period was uneventful and she was discharged on 7th post operative day. Histopathology showed unremarkable tube with benign serous cystadenoma of ovary. She was kept under follow-up with regular antenatal check-up. Her pregnancy continued uneventful and she delivered alive female baby with birth weight 3.0 Kg at term by cesarean section.




  Discussion : Top


Adnexal torsion is rare surgical gynaecological emergency in pregnancy. Serous cystadenomas are thin walled, translucent cysts usually unilocular, it may have few daughter cysts, which may vary in size between 20-30 cms. Mostly they are unilateral but can be bilateral. 10-15% of them are borderline malignant while 20- 40% are malignant.

Differential diagnosis of ovarian torsion during pregnancy includes: uterine leiomyomas, non preganant horn of bicornuate uterus, appendiceal abscess, diverticular abscess, pelvic kidney, retroperitoneal tumours, ectopic pregnancy and retroverted gravid uterus.

To make the correct diagnosis of ovarian torsion during pregnancy ultrasonographic confirmation is needed. On color Doppler imaging absence of intraparencymal ovarian blood flow suggest the diagnosis of torsion, a decreased blood flow can be due to incomplete torsion.

The highest incidence of torsion during pregnancy is in the first trimester, but occurrences in the second and third trimester have also been reported.[2],[3] Although conservative treatment has been proposed in patients with adnexal masses during pregnancy,[5],[6] surgical intervention is the treatment of choice once ovarian torsion is highly suspected .[2],[4],[7]

Cyst less than 6 cm and appearing benign are treated conservatively as most of them undergoes resolution. Cyst more than 10 cm are resected because of increased risk of torsion, rupture or malignancy and laparoscopic removal is recommended. However they may require emergency exploratory laparotomy in as many as 50% of cases for rupture, torsion or infarction.[8] In first trimester ovarian torsion can usually be approached laparoscopically. In second and third trimester combined size of pregnant uterus and enlarged ovary usually make laparotomy the approach of choice.

A simple cystectomy can be performed in the absence of overt malignancy. Earliar untwisting of pedicle was avoided to prevent emboli and toxic substances related to hypoxia , from entering pereferal circulation, but recently re-establising ovarian circulation by untwisting has shown to result in viable ovarian tissue with no systemic complications.[1],[9]


  Conclusion : Top


Although adenexal torsion is rare during pregnancy, it should always be considered in differential diagnosis in patients presenting with acute abdomen in pregnancy .Diagnosis can usually be made on the basis of characteristic clinical presentation in conjunction with USG with color Doppler imaging. Early diagnosis is crucial for the preservation of adenexa. Treatment options are limited to surgery either laparoscopy or laparotomy, former becomes difficult in second trimester making laparotomy procedure of choice.



 
  References Top

1.
Ventolini G, Hunter L, Drollinger D, Hurd WW: Ovarian torsion during pregnancy. Resident and Staff Physician 2007; 12(1) : 1-4.  Back to cited text no. 1
    
2.
Hasiakos D, Papakonstantanou K, Kontoravdis A, Gogas L,Aravantinos L, Vitoratos N. Adenexal torsion during pregnancy: report of four cases and review of literature . J Obstet Gynaecol Res 2008 ; 34 :683-7.  Back to cited text no. 2
    
3.
Chang SD, Yen CF, Lo Yen , Lee CL, Liang CC. Surgical intervention for maternal ovarian torsion in pregnancy . Taiwan J Obstet Gynecol 2011; 50 : 458-62.  Back to cited text no. 3
    
4.
Wang PH, Chang WH, Cheng MH, Horng HC. Management of adnexal masses during pregnancy. J Obstet Gynecol Res 2009;35:597e8.  Back to cited text no. 4
    
5.
Schmeler KM, Mayo-Smith WW, Peipert JF, Weitzen S, Manuel MD, Gordinier ME. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol 2005;105:1098e103.  Back to cited text no. 5
    
6.
Katz L, Levy A, Wiznitzer A, Sheiner E. Pregnancy outcome of patients with dermoid and other benign ovarian cysts. Arch Gynecol Obstet 2010;281:811e5.  Back to cited text no. 6
    
7.
Krishnan S, Kaur H, Bali J, Rao K. Ovarian torsion in infertility management- missing the diagnosis means losing the ovary : a high price to pay . J Hum Reprod Sci 2011; 4:39-42.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Hart WR. “Mucinous tumors of ovary. A review.” Int J Gynecol Pathol 2005;24(1):4-25.  Back to cited text no. 8
    
9.
Kolluru V, Gurumurthy R , Vellanki V, Gururaj D. Torsion of ovarian cyst during pregnancy : a case report. Cases Journal 2009;2:9405.  Back to cited text no. 9
    




 

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