Laparoscopically-treated ovarian torsion in a 32-week pregnancy: A case report

Abstract

Ovarian torsion is a gynecologic emergency which, while rare during pregnancy, is associated with increased risk during pregnancy. Most torsions during pregnancy occur during the first and second trimester, with only 10.5% of cases reported during the third trimester.

A 35-year-old woman at 32 weeks and 2 days of gestation presented with right lower quadrant abdominal pain. Transvaginal ultrasound demonstrated a large right ovarian cyst and decreased flow on color Doppler consistent with ovarian torsion. The diagnosis was confirmed via diagnostic laparoscopy with direct visualization of the necrotic, edematous ovarian cyst and pedicle, which had been torsed twice. The pedicle was detorsed and the necrotic cyst was resected while sparing as much of the normal ovary as possible. The patient provided written consent for publication of this case report.

Data supports that laparoscopy is a safe and reasonable treatment for ovarian torsion during pregnancy. It is associated with shorter hospital stays and fewer postoperative complications without increasing the risk of obstetric or neonatal complications. Much of this data, however, is obtained from case reports of torsions during the first and second trimester. The incidence of third trimester ovarian torsion is estimated to be 5–10% of torsion cases that occur in pregnancy. This case demonstrates a successful laparoscopic treatment of a third-trimester torsion in a woman who went on to deliver a healthy baby girl by spontaneous vaginal delivery.

Highlights

• •10–25% of all cases of ovarian torsion occur in pregnant women.
• •The incidence ovarian torsion in the third trimester is likely less than 4 in 10,000.
• •Laparoscopic detorsion is a safe treatment during the third trimester.
• •Laparoscopy did not negatively affect maternal, prenatal, or delivery outcome in the case reported.

1. Introduction

Ovarian torsion occurs when a cyst or mass is present, causing the ovary to rotate around the infundibulopelvic ligament, the utero-ovarian ligament, or both [1]. Rotation of the infundibulopelvic ligament can lead to ovarian artery compression and thus impede blood flow to the ovary. Vascular compression can lead to ovarian ischemia and necrosis. Two to 15 % of patients who have surgical treatment of adnexal masses are found to have torsion [2]. While ovarian torsion can occur at any age, most cases occur in patients of reproductive age, with the mean age being 29–33.5 years [[3], [4], [5]].

Ovarian torsion risk increases by five-fold in pregnancy [6]. Ten to 25 % of ovarian torsion cases occur in pregnant patients [1,7]. Overall, however, ovarian torsion occurs in less than 4 in 10,000 pregnancies [8,9]. This typically occurs between 6 and 14 weeks of gestation. Among pregnant patients, 5–10% ovarian torsions occur in the third trimester [9,10]. The greater incidence of torsion during the first trimester may be related to the presence of a corpus luteum cyst, while torsion during the third trimester is rare, as the gravid uterus produces a compressive effect which reduces mobility of the ovarian pedicles [11,12].

2. Case Presentation

A 35-year-old woman, gravida 2, para 1 at 32 weeks and 2 days of gestation, presented to labor and delivery triage with right lower quadrant abdominal pain. She reported that the pain had begun 8 h prior to presentation, was constant, and had progressively worsened. The pain was associated with nausea and vomiting. She denied fever, chills, dysuria, diarrhea, shortness of breath, chest pain, and vision changes. She reported good fetal movements and denied contractions, leakage of fluid, or vaginal bleeding. Her previous pregnancy resulted in a normal spontaneous vaginal delivery at 39 weeks.

She was afebrile with a heart rate of 73 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 123/56 mmHg, and BMI of 29.8 kg/m². Abdominal exam demonstrated minimal tenderness in the right lower quadrant, with the patient stating that the pain was “deeper.” Bimanual pelvic examination demonstrated right adnexal tenderness without left adnexal or uterine tenderness. CBC was notable for elevated white blood cell count of 11.0 and mild anemia with hemoglobin 10.9 and hematocrit 33.6. BUN, creatinine, ALT, AST, amylase, and lipase were all within normal limits.

Transvaginal ultrasound demonstrated a right ovarian cyst measuring 12.5 × 10.3 × 8.6 cm anterior to the uterus. There was no flow noted to the ovary on color Doppler, and there was a hyperechoic structure surrounded by concentric hypoechoic tubular areas.

In the operating room, a 12 mm skin incision was made approximately 7–8 cm above the uterine fundus. A blunt tip Hassan balloon trocar was passed into the peritoneal cavity. Two additional 5 mm ports were placed to the left and right of the original trocar at the same level of the abdomen. Although visualization was limited by the gravid uterus, the right ovarian cyst and the pedicle on which it had torsed twice could be identified (Fig. 1). The cyst ruptured and presented with clear fluid upon minimal manipulation. The ovarian cyst was necrotic and edematous. It remained purple even with attempts at untwisting the ovary. The cyst and surrounding ovary were grasped and the LigaSure was used to excise it from the remaining normal ovary. A large laparoscopic grasper was used to remove the excised cyst directly through the large camera port. The remaining right ovary was visualized and appeared normal and healthy in both size and appearance. Appropriate hemostasis was observed at the surgical site. Intraabdominal pressure was maintained at 10 to 12 mmHg throughout the procedure. The patient received her first dose of betamethasone intraoperatively.

Fig. 1.

Laparoscopy images depicting the necrotic and edematous appearance of the ovarian cyst and torsed pedicle.

The patient tolerated the procedure well and remained stable when she awoke in the recovery room. Fetal heart rate in the recovery room remained normal, at around 140 beats per minute. Pathology confirmed the resected right cyst from the right ovary was a mucinous cystadenoma with hemorrhage and ischemic changes consistent with torsion. On postoperative day 1, the patient received a second dose of betamethasone and was discharged home in stable condition. She went on to have a normal spontaneous vaginal delivery of a healthy baby girl at 40 weeks 2 days of gestation, with a birth weight of 3550 kg (75th percentile). The Apgar scores were 6 and 9 at one and five minutes, respectively.

3. Discussion

Maternal ovarian torsion incidence is between 1.6 and 4 per 10,000; 55.3% of torsion cases during pregnancy occurred in the first trimester compared with 34.2% in the second trimester and 10.5% in the third trimester [[8], [9], [10]]. Specifically, in pregnant women with known ovarian masses, 60% of torsions occurred between 10 and 17 weeks of gestation, and only 5.9% of cases occurred after 20 weeks, as seen in the patient discussed above [9]. When comparing sonographic characteristics of torsed ovaries in each trimester, multicystic ovaries were more common in adnexal torsion cases in the first trimester, while “normal” ovaries without cystic components were more common in second- and third-trimester torsion cases [10].

The higher incidence of ovarian torsion in early pregnancy is likely due to the presence of a corpus luteum cyst, while, as pregnancy progresses, the enlarged gravid uterus causes decreased mobility of the ovary, which may explain the lower incidence of torsion in late pregnancy [11]. Compared with laparotomy, laparoscopy for second-trimester ovarian torsions is associated with fewer postoperative complications, with no reported adverse effects on pregnancy outcomes, though data regarding third-trimester torsions is limited [13].

There are a few third-trimester ovarian torsion cases reported in the literature, with differing associated ovarian masses and chosen management. One case describes a 33-year-old G2P1 female at 31 weeks of gestation who underwent an exploratory laparotomy which resulted in a salpingo-oophorectomy; the ovary did not contain any tumors [11]. At time of presentation and during surgery there were no signs of fetal distress. There were no post-operative complications, and the patient was discharged after two weeks [11]. Another case report describes a 33-year-old female at 35 weeks and 2 days of gestation who underwent emergency laparotomy with Cesarean section given her obstetric history of two prior C-sections and presentation with vomiting and severe abdominal pain with involuntary guarding and rigidity [12]. During surgery, the right ovary was found to be purple, enlarged, and torsed. A dermoid cyst was discovered and resected. The infant was delivered with Apgar scores of 9 and 10 at five and ten minutes respectively; the infant did not suffer any short-term or long-term consequences of prematurity [12]. Ovarian torsion in the third trimester has also been reported in a case of twin pregnancy. The 34-year-old G2P1 woman at 32 weeks and 6 days of gestation with dizygotic twins underwent laparotomy and oophorectomy. She was found to have a mature cystic teratoma [14]. The patient delivered healthy twins after spontaneous labor four weeks later.

Regardless of treatment chosen, ovarian torsion during pregnancy does not seem to increase the risk of premature delivery, obstetric complications, or neonatal complications; however, these conclusions are based mostly on research of ovarian torsion occurring in the first trimester [14]. Laparoscopic detorsion is recommended to treat ovarian torsion in pregnant women, as it leads to shorter hospital stays as well as favorable surgical and pregnancy outcomes [15]. The patient presented in this report is one of the small number of maternal ovarian torsion cases during the third trimester treated laparoscopically. This case demonstrates that laparoscopic surgical management did not affect maternal, prenatal, or delivery outcomes and may be a safe and reasonable treatment for third-trimester torsions.

Contributors

Anneliese Lapides contributed to concept and design of the study, the literature review, analysis, and interpretation of data, drafting the article, and revision of the article for important intellectual content.

Weida Ma contributed to concept and design of the study, the literature review, drafting the article, analysis and interpretation of data, and revision of the article for important intellectual content.

Cynthia McKinney contributed to patient care, drafting the article, acquisition of data, and revision of the article for important intellectual content.

Linus Chuang contributed to patient care, drafting the article, acquisition of data, and revision of the article for important intellectual content.

All authors approved the final submitted manuscript.

Funding

No funding from an external source supported the publication of this case report.

Patient consent

The patient provided written consent for publication of this case report with the accompanying images.

Provenance and peer review

This article was not commissioned and was peer reviewed.

Conflict of interest statement

The authors have no financial conflict of interest to report..