Ovarian autoamputation in a neonate: a case report with literature review

Laparoscopy ıs a defınıtıve dıagnostıc method for auto-amputated ovary ın ınfants

PURPOSE

Antenatal auto-amputation of the ovary is an extremely rare event, and its diagnosis is difficult. We aimed to retrospectively review the cases with antenatal auto-amputation, where the diagnosis was made based on detection of free-floating cyst during surgery.

METHODS

Patients diagnosed with auto-amputated ovary during the surgery between 2012 and 2021 were included in the study. The data were reviewed retrospectively. Clinical, radiological, surgical, and histopathological findings were recorded.

RESULTS

Eight patients underwent surgery for an abdominal cystic mass. The age range of patients who were operated was from 21 days to 9 months. None of the patients had symptoms, except one patient who had a large cyst and was vomiting. Prenatal ultrasound examination indicated an intra-abdominal cyst in all patients, but auto-amputated ovary diagnosis was not made. Differential postnatal diagnoses included an ovarian cyst, ovarian teratoma, tuba-ovarian torsion, mesenteric lymphatic malformation, and intestinal duplication cyst. Only one patient had an auto-amputated ovary suspicion in computed tomography. Laparoscopic exploration (n: 7) or laparotomy (n: 1) was performed. Histopathologic examination was necrosis and calcification (n: 6), necrosis (n: 1), and serous cystadenoma and necrosis (n: 1).

CONCLUSION

We suggest that laparoscopy should be used for diagnosis and treatment of antenatal intra-abdominal cysts that persist postnatally because of diagnostic dilemmas. We recommend in patients diagnosed with auto-amputated ovary that the other ovary should be carefully monitored and followed up in terms of ovarian cyst, due to the possible risk of torsion.

The Role of Surgery in Antenatal Ovarian Torsion: Retrospective Evaluation of 28 Cases and Review of the Literature

STUDY OBJECTIVE

Antenatal ovarian torsion (AOT) is rare and requires differentiating from other congenital cystic masses of the abdomen and pelvis in neonates. In this study, it was aimed to evaluate the prenatal characteristics and postnatal outcomes of AOT. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Hospital records of patients (n = 28) with diagnosis of AOT between 2004 and 2020 were reviewed and their prenatal characteristics, postnatal examination, imaging, operative, and histopathological findings were evaluated.

RESULTS

There were 28 patients during the study period. In most of the patients (25/28; 89.3%) AOTs were detected prenatally. All were term babies with a mean birth weight of 3010 ± 466.6 g. Mean maternal age was 25.75 ± 3.65 years. Prenatal history was event-free in all and none had additional anomalies. Physical examination revealed mobile intra-abdominal cystic lesions in 16 (57.1%) patients. AOTs mimicked other pathologies as intestinal duplication cyst or mesenteric cyst (n = 7), complex ovarian cyst (n = 3), mature cystic teratoma (n = 3), simple renal cyst (n = 1), and ectopic kidney (n = 1) in 15 (53.6%) patients in postnatal ultrasonography. Elective laparoscopic surgery was performed in 26 (92.8%) patients. The other 2 patients required emergency open surgery because of acute symptoms. Ovaries were autoamputated in 17 (60.7%) patients. Histopathological examination revealed necrosis and dystrophic calcification in all specimens. There was neoplastic involvement in 2 patients (serous cystadenoma and gonadoblastoma). No complication occurred in the early follow-up period (mean: 73.9 ± 46.8 months).

CONCLUSION

AOTs can be detected easily during the antenatal period. Neoplastic involvement with AOTs is rare but possible. Although AOTs might mimic other cystic pathologies, it should be one of the first diagnoses to be considered, in the presence of a palpable intra-abdominal mass and complex cystic lesion in infant girls. It can be efficiently and safely managed using minimally invasive techniques.

Autoamputated ovarian mass causing a partial bowel obstruction in an infant with literature review

An autoamputated ovary (AO) is an extremely rare circumstance with a few reports in the literature. We present a case of a 3-month-old girl with a history of vague abdominal symptoms as well as a known ovarian mass, which was initially suspected to be benign and regressing. On laparoscopy for pain and obstructive symptoms, she was found to have an AO. The pathology was consistent with necrotic and torsed ovarian tissue with superimposed infection and possibly a cystic non-malignant teratoma. AOs are thought to originate from a torsion and are typically diagnosed incidentally. This is an interesting case of an AO causing a partial small bowel obstruction.

Asymptomatic Auto Amputation of Normal Ovary

Free-floating intraperitoneal mass is rare and mostly is  related to the ovary. Asymptomatic auto amputation of the ovary is extremely rare that may be due to torsion or inflammation and usually is diagnosed incidentally . We report an interesting case of this rare pathology. A 50-year-old female with postmenopausal bleeding prepared for hysterectomy is presented here. Intraperitoneal free-floating auto-amputated right ovary was encountered. During surgery, we can suspect it from free-floating mass intraperitoneal with failure to detect one of the ovaries attached to the uterus and the related infundibulopelvic ligament.

Case 246: MR Imaging of a Complex Cystic Mass in a Newborn Girl

History A 6-day-old female neonate presented to the outpatient pediatric surgery clinic for evaluation of a possible prenatal abdominal mass. The neonate was delivered at term via cesarean section due to macrosomia, with a reported birth weight of 11 lb 8.7 oz (5.23 kg). The patient's postnatal course was remarkable for resolving neonatal hyperbilirubinemia. A physical examination was remarkable for a palpable mass in the abdomen. Maternal risk factors included class II obesity, type 2 diabetes, and metabolic syndrome. Prenatal images obtained at an outside institution were not available at this time. Ultrasonography (US) of the abdomen and pelvis was performed 6 days after birth. Follow-up US at 29 days of life revealed no substantial change in the appearance of the findings. This patient remained asymptomatic, and gadolinium-enhanced (Magnevist; Bayer Pharma, Berlin, Germany) magnetic resonance (MR) imaging of the abdomen and pelvis was performed at 84 days of life. The mass was excised surgically at 89 days of life, and the patient had an uncomplicated postoperative course.

The Role of Ischemia Modified Albumin and D-dimer as Early or Late Biochemical Markers in Ovarian Torsion

OBJECTIVE

Our aim was to examine the potential roles of ischemia modified albumin(IMA) and D-dimer as reliable early diagnostic markers of ovarian torsion.

MATERIALS AND METHODS

24 Wistar albino rats were included and randomized into three groups. Control (sham) rats underwent laparotomy then bilateral ovaries removed for histopathological examination and concomitant blood sampling for IMA and D-dimer assays after 4 h. In the remaining groups, ovarian ischemia was achieved by rotating bilateral ovaries 1080° clockwise then blood samples were obtained and ovaries were removed after 4 h and 24 h. IMA and D-dimer levels as well as the histopathological injury scores were assessed in all groups.

RESULTS

A statistically higher significant difference in D-dimer levels in the 4-h torsion group (Group 2) than the other groups (P = 0.001, P < 0.01). Despite absence of statistical significance, the difference in IMA levels between the groups was close to statistical significance (P = 0.064; P > 0.05); accordingly IMA levels were higher in the 24-h torsion group (Group 3), than in 4-h torsion (Group 2) or sham (Group 1) group.

CONCLUSION

Our results suggest that D-dimer may represent a valuable acute marker of ovarian torsion. The cut-off value for D-dimer was 402 ng/ml. Although rats in Group3 had higher IMA than in other groups, the difference was only close to statistical significance. Also, increasing duration of torsion was associated with reduced D-dimer levels, while IMA levels exhibited an increase during the 24 h period. In contrast with previous studies, IMA appeared to be a potential marker in the long term rather than the short term.

Diagnosis of neonatal ovarian torsion: Emphasis on prenatal and postnatal sonographic findings

PURPOSE

Our aim was to retrospectively review the imaging findings of patients with neonatal ovarian torsion, emphasizing prenatal and postnatal sonographic findings.

METHODS

Eleven patients who had had neonatal ovarian torsion diagnosed surgically (n = 9) or clinicoradiologically (n = 2) were enrolled. Prenatal and postnatal sonographic features, including sequential postnatal change, were reviewed. Clinical and pathologic features were also investigated.

RESULTS

All patients except one had a fetal ovarian cyst (mean, 5.3 cm) detected on third-trimester sonography, either simple (n = 6) or complex (n = 4). In all 11 patients, initial postnatal sonography had revealed a complex cyst (mean, 4.7 cm) with intracystic clot or debris, the double-wall sign, a fluid-fluid level, and multiple septation. None of the patients had had symptoms or signs related to the ovarian torsion. Follow-up sonography in seven patients had revealed increased echogenicity of the cyst wall with frequent calcification and a decrease in size of the cyst. In two patients, the interval of the change in cyst position was noted, and autoamputation of the torsed ovary had been surgically confirmed. Serous cystadenoma had been identified in one patient.

CONCLUSIONS

Neonatal ovarian torsion most commonly manifests as an asymptomatic complex cyst on sonography due to torsion of a fetal ovarian cyst. Serial monitoring of a fetal ovarian cyst for its resolution or changes in its appearance is mandatory for making an early diagnosis of torsion. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:290-297, 2016.

Imaging Findings of Fetal-Neonatal Ovarian Cysts Complicated With Ovarian Torsion and Autoamputation

OBJECTIVE

Large nonresolving neonatal ovarian cysts may be a risk factor for complications such as torsion, mass effect, rupture, intracystic hemorrhage, and autoamputation. Torsed cysts and autoamputated cysts can cause a diagnostic dilemma. The objective of our study was to correlate the imaging findings of intrauterine ovarian torsion and autoamputated ovaries with their pathologic findings.

MATERIALS AND METHODS

We retrospectively analyzed the pre- and postnatal medical records, sonographic findings, operation notes, and pathologic reports of 15 patients with ovarian torsion. All patients had complex cysts noted on postnatal sonographic examination. A complex heterogeneous ovarian cyst was defined by the presence of a fluid-debris level indicating hemorrhage within the cyst, a retracting clot, septations with or without internal echoes, calcification, and a solid component.

RESULTS

On ultrasound examination, four cysts had solid components, and 11 were heterogeneous and had a fluid-debris level. Calcifications were seen in two patients. The mean patient age at the time of surgery was 3.9 months. Exploratory laparotomy was performed on all patients. Torsed ovaries were identified in five patients. Ten patients had ovaries that were floating free in the peritoneal cavity at the time of surgery. Histopathologic evaluation revealed that 11 of the cysts consisted of extensive hemorrhagic, necrotic autolytic tissue with dystrophic calcification. None of the cysts contained any ovarian tissue.

CONCLUSION

A complex heterogeneous ovarian cyst with a fluid-debris level indicating hemorrhage is a significant sonographic hallmark for the diagnosis of ovarian torsion. A calcified abdominal mass, with or without wandering, can be an autoamputated ovary.

The First Report of an Intraperitoneal Free-Floating Mass (an Autoamputated Ovary) Causing an Acute Abdomen in a Child

A free-floating intraperitoneal mass is extremely rare, and almost all originate from an ovary. Here, we present the first case with an intraperitoneal free-floating autoamputated ovary that caused an acute abdomen in a child and also review the literature. A 4-year-old girl was admitted with signs and symptoms of acute abdomen. At surgery, the patient had no right ovary and the right tube ended in a thin band that pressed on the terminal ileum causing partial small intestine obstruction and acute abdomen. A calcified mass was found floating in the abdomen and was removed. The pathological examination showed necrotic tissue debris with calcifications. An autoamputated ovary is thought to result from ovarian torsion and is usually detected incidentally. However, it can cause an acute abdomen.

Neonatal Ovarian Cysts: Role of Sonography in Diagnosing Torsion

Introduction: The purpose of this case series was to determine the sonographic features of neonatal ovarian torsion. Materials and Methods: Seven surgically proven cases of neonatal ovarian cysts were included in this retrospective study. The patients were divided into 2 groups, torsion and non-torsion. These 7 patients were evaluated for the clinical presentation, sonographic features, surgical and pathological findings. The findings on follow-up sonography after surgery were also noted. Results: The sonographic appearance was variable. Of the 4 cases with torsion, 2 lesions had internal echoes with ‘fish-net appearance’. The other 2 lesions were predominantly cystic on the sonography with internal echoes and echogenic nodule. A calcific focus was present in 1 of these echogenic nodules. One of the cysts had fluid-fluid level. In the non-torsion group, only 1 lesion had mixed echogenic appearance. The other 2 lesions were cystic with low level internal echoes in 1 of the cysts. The surgical procedure performed in the torsion group was salpingo-oophorectomy in 2 patients and oophorectomy in 1 patient. In 1 patient, cystectomy was attempted without success. In the non-torsion group, only cystectomy was performed with preservation of normal ovaries, which was confirmed on follow-up sonography. Conclusion: The sonographic features of cysts with ‘fish-net appearance’, fluid-debris level and cysts with echogenic nodule favour torsion. The former sign has so far not been described as a sonographic predictor for neonatal ovarian torsion. Key words: Ultrasound, Ovary, Doppler, Fish-net appearance, Haemorrhage