Adnexal Torsion in the Second Trimester : A Case Report

Aicha Bennani* ^1,2, Hanaa Lazhar ^1&2, Aziz Slaoui ^1&2, Najia Zeraidi ¹, Amina Lakhdar ¹,
Aicha Kharbach ², Aziz Baydada ¹

1. Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.

2. Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.

Corresponding Author: Aicha Bennani, University Hospital Center IBN SINA of Rabat, Gynaecology-Obstetrics and Endoscopy Department & Gynaecology-Obstetrics and Endocrinology Department, Mohammed V of Rabat University, Morocco.

Copy Right: © 2023 Aicha Bennani, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: March 21, 2023

Published Date: April 01, 2023

Abstract

Ovarian torsion is a serious medical condition that occurs when an ovary twists around its supporting ligaments, cutting off its blood supply. While ovarian torsion can happen to any woman, it is particularly concerning for pregnant women, as it can put both the mother and baby at risk. Adnexal torsion is a rare complication in pregnancy and is less common in the second and third trimester. Here, we present the case of ovarian torsion in the second trimester pregnancy. The patient presented to the emergency department with acute onset of abdominal pain associated with vomiting and nausea. The sonographics signs were the presence of a large ovarian cyst, enlarged left ovary and a whirlpool sign. She was admitted immediately to the operating room. A detorsion and cystectomy was performed via laparotomy. The pain was gone, the pregnancy was still evolving and tocolysed. Then, the patient was discharged on postoperative day 3. 

Introduction

Pregnancy is a time of great excitement and joy, but it can also come with its share of challenges. One of these challenges is the risk of ovarian torsion. Adnexal torsion is defined as twisting of the ovary and/or tube around the utero-ovarian ligament and in case of the ovary the infundibulopelvic ligament. Once arterial flow is compromised, the ovary and tube will experience ischemia and possible necrosis. The symptoms of ovarian torsion in pregnant women can be similar to that of other conditions such as preterm miscarriage, preterm labor, appendicitis, retroplacental hematoma, etcetera. We hereby present the case of adnexal torsion in a 26 years old  primigravida woman in her second trimester of pregnancy. This case report has been reported in line with the SCARE Criteria.

Case Presentation

In this case, a 26-years-old primigravida woman at 17 weeks gestation, with no prior medical history, presented to the emergency department with acute left sided abdominal pain that had been increasing in severity over the previous 24 hours. She also reported nausea and vomiting.

On physical examination: sensitivity at the level of the left iliac fossa. The rest of the examination is unremarkable.

On ultrasound, an enlarged ovary measuring 14*7 cm with isoechoic stroma without individualization of peripheral follicles, and containing a large anechoic pure cyst measuring 12*7 cm with the presence of the whirlpool sign. A single viable foetus, head circumference of 130 mm corresponding to 17 weeks of gestation.

45 minutes after her admission, the woman was taken to the operating room for an emergency laparotomy.

We performed spinal anaesthesia. During laparotomy, the diagnosis of ovarian torsion was confirmed. The left ovary was found to be enlarged and twisted. There was no evidence of necrosis, and the ovary appeared to be viable. The ovary was then detorsed and the cyst was removed and sent for histopathological examination.

The surgery was uneventful, and the patient was discharged on postoperative day 3 with a viable intrauterine pregnancy and on progesterone supplement therapy.

A prenatal follow-up at 20 weeks of gestation revealed a viable pregnancy.

Discussion

It's a rare but serious complication of ovarian cysts that can occur in pregnant women.

Incidence of OT in pregnancy is between 1 and 10/10,000 pregnancies. [1]

Ovarian torsion risk increases by five-fold in pregnancy. [2]

Most of the adnexal torsion occurred during the first trimester, while others occurred during the second and third trimesters. [3]

Smorgick and colleagues found that symptoms of the adnexal torsion in pregnant women are similar to nonpregnant women. Such as abdominal pain, nausea, vomiting, tender and enlarged adnexa and increased white blood cell count. However, these symptoms and signs may be misinterpreted in pregnancy [4].

The symptoms of ovarian torsion can be nonspecific which can make diagnosis challenging.

The sonography is usually the first imaging modality used in the evaluation of a patient with pelvic pain. Grey scale ultrasound features of torsion include unilateral ovarian enlargement of more than 4 cm which is the most consistent finding.[5]

In a study, a positive whirlpool sign in the twisted vascular pedicle of the ovary is the most definitive sign of ovarian torsion. [6]

Recommendations for the management of ovarian torsion in pregnancy are limited by the small size of most studies investigating the topic of ovarian torsion, but management is most commonly laparoscopy, with cyst aspiration and laparotomy as alternatives. [7]

Laparoscopic surgical treatment of ovarian torsion during pregnancy does not influence the perinatal and the foetal outcome and it's probably safe procedure during pregnancy with regard to perinatal and neonatal outcome. [8]

Chang and colleagues reported that the patients who underwent laparoscopy had a significantly smaller ovarian mass and a shorter hospital stay than those undergoing laparotomy and there was no significant difference in pregnancy results between laparoscopy and laparotomy. [9]

Conclusion

The ovarian torsion in a pregnant woman is a rare complication but it is at the same time a risk factor especially in the first trimester. The symptoms can be similar to those of other conditions such as appendicitis. Sonographic signs like whirlpool sign, enlarged ovary can help the diagnosis. The surgical approach via laparoscopy is the safest procedure during pregnancy.  With prompt treatment and proper care, women can successfully manage ovarian torsion during pregnancy and have healthy pregnancies.

References

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2. Young R., Cork K. (2017). Intermittent Ovarian Torsion in Pregnancy. Clinical Practice and Cases in Emergency Medicine, 1(2), 108-110.

3. Didar H, Najafiarab H, Keyvanfar A, Hajikhani B, Ghotbi E, Kazemi SN. Adnexal torsion in pregnancy: A systematic review of case repors and case series. Am J Emerg Med. 2023 Mar; 65:43-52.PMID : 36584539

4. Smorgick N, Pansky M, Feingold M, Herman A, Halperin R, Maymon R. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Fertil Steril. 2009 Dec;92(6):1983-7. doi: 10.1016/j.fertnstert.2008.09.028. Epub 2008 Nov 5. PMID: 18990375.

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8. Daykan Y, Bogin R, Sharvit M, Klein Z, Josephy D, Pomeranz M, Arbib N, Biron-Shental T, Schonman R. Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study. J Minim Invasive Gynecol. 2019 Jan;26(1):117-121. doi: 10.1016/j.jmig.2018.04.015. Epub 2018 Apr 24. PMID: 29702270.

9. Chang SD, Yen CF, Lo LM, Lee CL, Liang CC. Surgical intervention for maternal ovarian torsion in pregnancy. Taiwan J Obstet Gynecol. 2011 Dec;50(4):458-62. doi: 10.1016/j.tjog.2011.10.010. PMID: 22212317.