Comparison of adnexal torsion between pregnant and nonpregnant women

Adnexal Torsion in the Third Trimester

A 41-year-old woman presented with acute, severe left-sided abdominal pain and vomiting at 37 weeks' gestation. Her symptoms were attributed to renal colic, and she was admitted for supportive treatment. During her admission, she went into spontaneous labour. Due to other obstetric indications, the team proceeded with delivery by emergency caesarean section. Intra-operatively, a necrotic left fallopian tube and ovary were identified, and a diagnosis of adnexal torsion (AT) was recognised. There was no return of tissue perfusion on de-torsion, and a left salpingo-oopherectomy was performed. AT in pregnancy is unusual, with only a minority of cases occurring in the third trimester. This is a challenging diagnosis to establish and requires a high index of suspicion. Ultrasound and magnetic resonance imaging can be helpful in establishing a diagnosis but should not delay definitive treatment. Prompt surgical intervention is paramount to prevent irreversible damage to ovarian tissue.

Ovarian torsion due to ovarian hyperstimulation syndrome diagnosed by sonographic whirlpool sign in the first trimester of pregnancy: A case report

Ovarian torsion during pregnancy is a rare condition that needs prompt diagnosis and detorsion in order to preserve ovarian function. Diagnosing ovarian torsion is a difficult procedure especially in pregnant cases since radiation exposure should be avoided. Detecting the whirlpool sign by ultrasonography is a highly useful technique as it is noninvasive, less time-consuming, and radiation-free. Here is a case of ovarian torsion due to ovarian hyperstimulation syndrome diagnosed solely by sonographic features and in which laparoscopic detorsion was promptly performed. A 26-year-old woman in her sixth week of pregnancy visited a tertiary hospital with sudden onset lower abdomen pain. Transvaginal ultrasound detected an 8 cm left ovary and a whirlpool sign between the uterus and left ovary. Ovarian torsion was suspected and laparoscopic surgery was performed. Intraoperatively, an enlarged left ovary was twisted at 540° involving the left fallopian tube. After detorsion, bilateral ovaries were preserved and the postoperative course was uneventful. Ovarian torsion was suspected solely by ultrasonographic features which led to surgical detorsion quickly, resulting in the preservation of bilateral ovaries. Detecting the whirlpool sign when ovarian torsion is suspected is useful, especially in pregnant women.

Adverse Fetal Outcomes and Maternal Mortality Following Nonobstetric Abdominopelvic Surgery in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

To quantify the absolute risks of adverse fetal outcomes and maternal mortality following nonobstetric abdominopelvic surgery in pregnancy.

SUMMARY BACKGROUND DATA

Surgery is often necessary in pregnancy, but absolute measures of risk required to guide perioperative management are lacking.

METHODS

We systematically searched MEDLINE, EMBASE, and EvidenceBased Medicine Reviews from January 1, 2000, to December 9, 2020, for observational studies and randomized trials of pregnant patients undergoing nonobstetric abdominopelvic surgery. We determined the pooled proportions of fetal loss, preterm birth, and maternal mortality using a generalized linear random/mixed effects model with a logit link.

RESULTS

We identified 114 observational studies (52 [46%] appendectomy, 34 [30%] adnexal, 8 [7%] cholecystectomy, 20 [17%] mixed types) reporting on 67,111 pregnant patients. Overall pooled proportions of fetal loss, preterm birth, and maternal mortality were 2.8% (95% CI 2.2-3.6), 9.7% (95% CI 8.3-11.4), and 0.04% (95% CI 0.02-0.09; 4/10,000), respectively. Rates of fetal loss and preterm birth were higher for pelvic inflammatory conditions (eg, appendectomy, adnexal torsion) than for abdominal or nonurgent conditions (eg, cholecystectomy, adnexal mass). Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%).

CONCLUSIONS

Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.

Pregnancy-Associated Ovarian Torsion - a Single-Center Case-Control Study

The etiology of OT is largely unknown. Any predisposition to rotation of the infundibulopelvic ligament and utero-ovarian ligament should be considered a possible etiology. Information with respect to ovarian torsion (OT) among pregnant is underreported and based on small studies. We aim to compare characteristics of confirmed OT to laparoscopies performed for the indication of suspected OT, in which no OT was found among pregnant women. This is a retrospective case-control study. We included pregnant women who underwent laparoscopy for a suspected OT between March 2011 and August 2020. Pregnant women with confirmed OT (torsion group) were compared to those without (no torsion group). There were 169 women with suspected OT. OT was confirmed in 140 (82.8%) women. There was higher proportion of assisted reproductive technology (ART) gestation in the torsion group [76 (54.3%) vs. 5 (17.2%), p < 0.001]. The rate of pregnant approaching evaluation within 8 h of symptoms onset was higher in the torsion group [57 (40.7%) vs. 2 (6.9%), p < 0.001]. The mean visual analogue score (VAS) was higher in the torsion group (8.5 vs. 7.1, p = 0.002). The mean pulse was lower in the torsion group (79 vs. 88 bpm, p < 0.001). From sonographic characteristics examined, the following was higher in the torsion group; mean maximal size of the ovary (70 mm in the torsion group vs. 54 mm in the no torsion group, p = 0.011). In a multivariable logistic regression analysis, number of hours of symptoms was negatively associated with AT [aOR, 95% CI 0.95 (0.91-0.98)] and pulse was negatively associated with OT [aOR, 95% CI 0.78 (0.63-0.95)]. Among the 29 cases in which no OT was found during laparoscopy, the following findings were noted: 16 (55.2%) no abnormality at all, 5 (17.2%) functional ovarian cyst, 2 (6.9%) mature teratoma and 6 cases of peritoneal adhesions (20.7%). The time from pain onset to approaching evaluation and women's pulse should be considered and acknowledged in the evaluation of OT during pregnancy.

Successful pregnancy-preserving laparoscopic adnexectomy for complicated ovarian torsion during late pregnancy: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

A rare disorder called ovarian torsion (OT) during pregnancy can harm both the mother and the fetus. Predisposing variables for the condition include enlarged ovaries, free mobility, and a long pedicle, despite the fact that its genesis is not entirely understood. When ovarian stimulation is used to treat infertility, the disease's incidence rises. Magnetic resonance imaging and ultrasound are examples of diagnostic imaging modalities (MRI).

CASE PRESENTATION

A 26-year-old woman with a 33-week pregnancy presented to our emergency department with acute, severe left groin pain. Laboratory evaluation was unremarkable except for leukocytosis (18.800/μL) with neutrophil shift. A radiologist used ultrasound to examine the abdomen and pelvis, and the results revealed a bulk enlargement of the left adnexa. The patient underwent a non-enhanced MRI in order to obtain a conclusive diagnosis, which revealed a massive enlargement and torsion of the left ovary with large areas of necrosis. The patient underwent a successful laparoscopic adnexectomy with preservation of the pregnancy. She delivered a healthy baby and had an uneventful follow up period.

DISCUSSION

The etiology of OT is largely unknown. Any tendency to rotate the infundibulopelvic and utero-ovarian ligaments should be considered as a possible etiology. The prevalence of OT among pregnant women is underreported and determined by small limited studies.

CONCLUSION

Ovarian torsion should be included in the differential diagnosis of patients with suspected acute abdomen in advanced stages of pregnancy. In addition, MRI should be used as an alternative diagnostic modality in patients with normal sonographic findings.

Retrospective analysis of patients with surgically proven ovarian torsion, our experience

Aim

To study the patients who were admitted to our hospital with surgically proven ovarian torsion and were operated for the same and to study for whom detorsion was done.

Materials and Methods

A retrospective analysis of the medical records and surgical notes of 150 patients with surgically proven ovarian torsion over a 10-year period between January 2011 and January 2021 was carried out. Surgical notes included details like mode of the surgery (laparotomy or laparoscopy), type of surgery (oophorectomy, detorsion, detorsion with cystectomy), whether fixation was done or not, size of mass/ovary, laterality, appearance of the torted ovary, color of the ovary, and number of twists. Histopathologic reports of the patients who underwent oophorectomy or detorsion with cystectomy were also recorded.

Results

During the 10-year study period, 88 (58.7%) patients had undergone laparotomy and 62 (41.2%) patients had undergone laparoscopy. Detorsion with cystectomy was done in 96 (64%) cases, detorsion alone in 14 (9.3%) cases, and oophorectomy was done in 40 (26.6%) cases. There was no significant difference in terms of increase in postoperative complications.

Conclusion

Laparoscopic detorsion with cystectomy is the most common surgical procedure used for ovarian torsion at King Hussein Medical Center.

Adnexal Torsion Associated With Recurrent Ovarian Hyperstimulation Syndrome: A Case Report

Adnexal torsion due to hyperstimulation is one of the well-recognized serious complications of assisted reproductive techniques like in vitro fertilization (IVF). We report a case of a 35-year-old primigravida who presented to the emergency department with complaints of acute severe left iliac fossa pain and nausea. Further history revealed that the patient had previously undergone one cycle of ovulation induction and was diagnosed with ovarian hyperstimulation syndrome (OHSS). After prompt management, she reportedly underwent a cycle of IVF successfully. Her gestational age was five weeks and one day on presentation. A transabdominal ultrasound revealed bilateral enlarged ovaries with adequate blood supply and a single intrauterine gestational sac with a yolk sac. The patient was admitted as a case of recurrent OHSS for conservative management. Despite the initial improvement of symptoms with parenteral analgesia, an emergency laparoscopic surgery was done later due to worsening symptoms. Intraoperative findings were consistent with the suspected diagnosis of adnexal torsion which was managed accordingly. Postoperatively, the patient recovered without complications and was discharged two days later with a plan for outpatient follow-up.

A Case of Twisted Ovarian Dermoid Cyst During Pregnancy

Ovarian cysts are common during pregnancy as an outcome of routine prenatal ultrasounds. Although most cases are benign, complications, such as torsion, rupture, and malignant changes, can occur. Torsion risk increases fivefold during pregnancy. It is extremely hazardous to expectant mothers and unborn children. In a rural health tertiary center, we report the case of a 23-year-old primigravida with 14 weeks of pregnancy presented with acute abdomen and nausea, vomiting for four hours. On ultrasonography, she was diagnosed with a 14 cm × 11 cm left dermoid cyst. She underwent a laprotomy, and a twisted dermoid cyst was found; therefore, a left oophorectomy was performed with consent. Histopathological examination revealed the presence of a dermoid cyst. She is regularly followed up at our center with a healthy intrauterine fetus growing within. Although antepartum surgical intervention has been proven safe, there are some risks associated with abdominal surgery for both pregnant women and their unborn children. As a result, the management strategy must be chosen based on a risk-benefit analysis of adnexal mass characterization and gestational age.

Adnexal masses during pregnancy: diagnosis, treatment, and prognosis

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.

Healthy adnexal torsion in pregnancy: A case report

•Adnexal torsion during pregnancy is a rare surgical emergency. •The diagnosis of certainty of adnexal torsion can only be made intraoperatively. •In the absence of any contraindication, laparoscopy should be the preferred approach. •Ovariopexy is proposed by certain authors in order to prevent recurrence.

Perioperative Outcomes in Pregnant Women Who Underwent Surgery for Adnexal Torsion

OBJECTIVE

 To evaluate clinical characteristics, maternal and fetal outcomes in pregnant women who underwent surgery for adnexal torsion (AT).

METHODS

 All patients, who underwent surgical operation due to AT during pregnancy at the Department of Obstetrics and Gynecology, School of Medicine, Ege University between 2005 and 2020 were retrospectively investigated. Main clinical and perioperative outcomes were evaluated.

RESULTS

 A total of 21 patients who underwent surgery due to AT during pregnancy were included. Of all patients, 61.9% underwent laparoscopy and the remaining 38.1% underwent laparotomy. The most common surgical procedure was adnexal detorsion in both groups (48%). Mean gestational age at the time of diagnosis, duration of surgery and hospitalization were significantly lower in the laparoscopy group, when compared with the laparotomy group (p = 0.006, p = 0.001, and p = 0.001, respectively.) One of the patients had an infection during the postoperative period. Spontaneous abortion was only observed in one case.

CONCLUSION

 It can be concluded that the surgical intervention implemented for the exact diagnosis and treatment of AT (laparotomy or laparoscopy) did not have an unfavorable effect on pregnancy outcomes such as abortion, preterm delivery, and fetal anomaly. However, laparoscopy may be superior to laparotomy in terms of advantages.

Computed Tomography Features of Adnexal Torsion: A Meta-Analysis

OBJECTIVES

We performed a meta-analysis of studies examining the computed tomography (CT) features of adnexal torsion (AT).

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies involving the proportion of CT features in patients with AT and that used surgery as the reference test. Study quality was assessed using the Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality tool.

RESULTS

Twelve articles involving 483 patients were included. The pooled proportion of right-sided adnexal lesion was 54% (95% confidence interval [CI]: 49%-56%). The pooled proportions of the ovarian lesion histopathological types were: benign germ cell tumors, 33% (95% CI: 28%-37%); benign cystic lesions, 26% (95% CI: 21%-30%); benign epithelial neoplasms, 24% (95% CI: 20%-29%); sex cord-stromal tumors, 4% (95% CI: 2%-6%); borderline neoplasms, 3% (95% CI: 1%-6%); and hemorrhagic cysts, 2% (95% CI: 0%-3%). The pooled proportions of CT features were: Adnexal enlargement, 99% (95% CI: 98%-99%); adnexal with mass, 98% (95% CI: 97%-100%); twisted pedicle, 81% (95% CI: 78%-83%); mass with thickened wall, 77% (95% CI: 73%-81%); tubal thickening, 73% (95% CI: 68%-77%); abnormal location of adnexa, 69% (95% CI: 63%-75%), pelvic ascites, 43% (95% CI: 38%-49%); pelvic fat infiltration, 41% (95% CI: 34%-48%); uterine deviation, 37% (95% CI: 31%-42%); and lack of enhancement, 20% (95% CI: 14%-25%).

CONCLUSION

Adnexal enlargement, adnexal mass, and twisted pedicle may be the most important CT features for diagnosing AT.

Pediatric and adolescent females are at higher risk of adnexal torsion recurrence—A large‐scale retrospective study

Aim

Methods

Results

Conclusions

Adnexal Torsion: A Retrospective Analysis From a Tertiary Care Teaching Hospital in Northern India

Background Adnexal torsion is an acute gynecological emergency presenting with acute abdomen which can be missed owing to non-specific symptoms. Among reproductive-age women, conservative surgery is preferred. The present study was a retrospective analysis of adnexal torsion cases reported to a tertiary care teaching hospital in Northern India. The purpose of the study was to describe the demography, clinical features, diagnostic and treatment modalities, and prognosis of adnexal torsion cases. Methods Surgically proven adnexal torsion case records were retrieved and data were entered in an excel sheet from a period of two and half years from January 2018 to June 2020. Results There were 28 cases with an age range of 7-85 years (median age 24 years) with lower abdominal pain and nausea/vomiting symptoms. The majority were in the reproductive age group (71.4%). A Colour Doppler was done which detected 75% (12/16) of the ovarian torsion cases. The size of the adnexal torsion was 5-10 cm in 60.7% with right-sided torsion seen in 57.14%. Detorsion and salpingo-oophorectomy was done in 14 (50%) and 11 (39.2%) cases, respectively. Histopathological examination revealed hemorrhagic/necrotic infarcts (54.2%) and dermoid cysts (33.3%). Conclusions Owing to non-specific symptoms, adnexal torsion is diagnosed with strong clinical suspicion as routine ultrasonography diagnosed only 7.1% in the present study. Conservative surgery is preferred in the reproductive age group.

Surgically confirmed adnexal torsion during pregnancy: Does the trimester make a difference?

AIM

To investigate the clinical and the sonographic characteristics of adnexal torsion (AT) during pregnancy and to underline differences in AT manifestation between pregnancy trimesters.

METHODS

This is a retrospective cohort study in a tertiary medical center. The study included all pregnant women with surgically confirmed AT between March 2011 and April 2020. The patients were divided into three groups according to pregnancy trimesters, and the clinical and sonographic characteristics were compared between the groups.

RESULTS

The study cohort included 140 cases of AT. Ninety-nine (70.7%) of the cases occurred during the 1st trimester, and 31 (22.1%) and 10 (7.1%) occurred during the 2nd and the 3rd trimesters, respectively. Conception by assisted-reproductive technologies (ART), nausea, and finding of enlarged ovary on ultrasound scan were all more common among patients in the 1st trimester group as compared to the 3rd trimester group (p = 0.001, 0.015, and 0.024, respectively). The mean time from admission to surgery was significantly shorter in the 1st trimester group as compared to late pregnancy (p = 0.001). The majority of cases were right-sided. There was a significant difference in the organs involved in every trimester of pregnancy-ovary only, ovary and fallopian tube, and fallopian tube only (p = 0.023).

CONCLUSIONS

Most AT cases during pregnancy occurred during the 1st trimester. Conception by ART and enlarged ovary on ultrasound scan were also more common in AT cases during early pregnancy. Time from admission to surgery was longer as pregnancy progressed and organs involved differed between trimesters. Understanding the difference in manifestation of AT in every trimester might improve the preoperative evaluation of AT in pregnancy.

Ovarian Cystic Teratoma in Pregnant Women: Conservative Management or Prophylactic Oophorectomy?

Acute abdominal pain in pregnancy is common and the differential diagnosis is vast. Mature cystic teratomas are rarely the cause of adnexal torsion during pregnancy and can be difficult to diagnose. Timely surgical intervention is required to avoid ovarian infarction. We report a 22-year-old patient presenting with sudden right lower abdominal pain. Imaging including bedside Doppler ultrasonography and MRI were negative for signs of acute ovarian torsion. Despite no definitive imaging findings, due to severe pain, we made the decision for diagnostic multi-port laparoscopic examination with possible oophorectomy. The right cystic ovary was noted to be torsed three times around the utero-ovarian ligament. A right oophorectomy was performed. Grossly, cystic teratoma was confirmed with a large amount of hair and sebum, and pathological analysis also confirmed a benign mature teratoma. The patient recovered well and delivered without any complications. Bedside ultrasonography is a highly accessible tool; however, imaging can be uncertain. Despite the rarity of ovarian torsion due to mature teratomas in second- and third-trimester pregnancies, physicians should be aware of the possibility of acute ovarian torsion in a pregnant patient even with uncertain imaging results, especially those with a documented ovarian mass. Early prophylactic surgical intervention preferably with laparoscopy should be pursued for ovarian masses between 5 cm and 10 cm.

Incidence of Adnexal Torsion in the Republic of Korea: A Nationwide Serial Cross-Sectional Study (2009-2018)

Background: This study aimed to evaluate the incidence and risk factors of adnexal torsion (AT) in the Korean population from 2009 to 2018 (10 years). Methods: We analyzed the 2009−2018 data obtained from the Health Insurance Review and Assessment Service National Inpatient Sample (HIRA-NIS) database. AT was identified by both diagnosis codes and surgery codes of adnexal surgery. Results: A total of 6,262,910 women were recorded in the database. The incidence of AT was 6 per 100,000 women (95% confidence interval (CI), 6−6). The incidence of AT tended to decrease with age after peaking in the late 20s to early 30s. In the weighted logistic regression analysis, women of childbearing age, especially in their 20s and 30s, had the highest AT incidence. Corpus luteal cyst (p < 0.001) and benign neoplasm (p < 0.001) increased the incidence of AT. Low socioeconomic status (SES), Charlson comorbidity index (CCI), and pregnancy were unrelated to AT. Conclusion: The incidence of AT is 6 per 100,000 women and peaks in the 20s to early 30s.

Pregnancy outcomes following laparoscopy for suspected adnexal torsion during pregnancy

OBJECTIVE

To evaluate pregnancy outcomes of women with surgically confirmed adnexal torsion (AT) as compared to those in whom AT was ruled out.

METHODS

A retrospective cohort study in a tertiary medical center. All pregnant women who underwent diagnostic laparoscopy due to suspected AT between 3/2011 and 4/2020 were included. We compared maternal, delivery and neonatal outcomes of both groups. We further compared women with confirmed AT to a control group of women who did not undergo laparoscopy during pregnancy.

RESULTS

During the study period, 112 women met the inclusion criteria. AT was confirmed in 93 cases (83.0%). Baseline characteristics did not differ between groups, excluding the rate of previous AT [5.4% in the torsion vs. 26.3% in the no-torsion group, odds ratio (OR) 0.15, 95% confidence interval (CI) 0.04-0.62, p = .004], and nulliparity rate (57.0% in the torsion vs. 31.6% in the no-torsion group, OR 2.41, 95%CI 1.004-8.21, p = .043). Pregnancies conceived by assisted reproductive technology were more common in the AT group compared to the no-AT group (46.2% vs. 10.5%, OR 7.21, 95%CI 1.59-33.45, p = .002). Miscarriage and stillbirth rates, gestational age at delivery, delivery characteristics and neonatal outcomes were favorable and did not differ between groups. Outcomes of pregnancies with confirmed AT did not differ from a control group of women who did not undergo laparoscopy during pregnancy.

CONCLUSION

Pregnancy outcomes among women who underwent laparoscopy for a suspected AT during pregnancy were reassuring, irrespective of the surgical findings and gestational week. Outcomes did not differ when compared to pregnant women who did not undergo laparoscopy.

SYNOPSIS

Maternal, fetal and neonatal outcomes among women who underwent laparoscopy for suspected adnexal torsion during pregnancy are reassuring, irrespective of the surgical findings and gestational week.

Adnexal torsion recurrence-is the adnexal twist degree a risk factor? A retrospective cohort study

OBJECTIVE

To evaluate whether the adnexal twist degree is related to torsion recurrence and whether there is a dose-dependent correlation.

DESIGN

A retrospective cohort study.

SETTING

Single tertiary medical centre.

POPULATION

The study includes non-pregnant patients operated, for the first time, for adnexal torsion, between 2011 and 2018.

METHODS

Information regarding the degree of adnexal twist was collected from surgical reports. Recurrence was identified using a computerised database and ascertained via telephone with a response rate of 87.2% (253/290).

MAIN OUTCOME MEASURES

Adnexal torsion recurrence rate.

RESULTS

A total of 182 women who had undergone laparoscopic detorsion met the inclusion criteria. Twenty-two had torsion recurrence (12.1%). Adnexal twist degree in the primary event was associated with a higher recurrence risk: 4.3% of women with twist degree ≤360 (n = 3/70), 14.5% of women with twist degree of 361-720 (n = 9/62) and 20% of women with twist degree >720 (n = 10/50) (P = 0.03). The median twist degree was 540 (interquartile range [IQR] 360-855) and 720 (IQR 675-1080) degrees in the control and study groups, respectively (P = 0.005). Additional possibly associated factors for recurrence were evaluated. Age emerged as a possible risk factor, with a median age of 19 years in the recurrence group (IQR 14-27 years) versus 28.5 (IQR 19-36 years) in the non-recurrence group (P < 0.01). Logistic regression analysis revealed that together with age, adnexal twist degree remained significantly associated with torsion recurrence (odds ratio [OR] 1.98, 95% CI 1.09-3.61; P = 0.02).

CONCLUSION

Adnexal twist degree was found to be positively associated with the risk of torsion recurrence.

TWEETABLE ABSTRACT

Adnexal twist degree was found to be positively associated with the risk of torsion recurrence.

Diagnostic value of the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in adnexal torsion cases

AIM

To evaluate if the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) could be used to diagnose adnexal torsion.

METHODS

A retrospective study reviewed medical records of women who underwent surgery due to an adnexal mass between January 2012 and December 2017 at a tertiary referral center in Turkey. According to the surgical findings, the women were divided into a torsion group and a control group. NLR and PLR were compared between women who had adnexal torsion and those who did not.

RESULTS

A total of 201 women were included in the study: 67 in the torsion group and 134 in the control group. Mean WBC count (9584.0 ± 3080.8 vs. 6678.2 ± 1886.1 h/mm³ ), mean NLR (5.9 ± 4.3 vs. 2.1 ± 0.8), and mean PLR (210.5 ± 132.7 vs. 147.9 ± 48.7) were higher in the torsion group than in the control group (p < 0.001). According to the ROC curve analyses, the optimal cut-off value for NLR and PLR were 2.51 (sensitivity, 72%; specificity, 78%) and 154.4 (sensitivity, 61%; specificity, 64%) in the diagnosis of adnexal torsion, respectively.

CONCLUSION

NLR and PLR have been found useful hematological markers for the diagnosis of adnexal torsion. NLR and PLR could be helpful in cases, which is difficult to make a definitive diagnosis with patients' symptom and the ultrasonographic examination.

Distinctive pattern of left-right asymmetry of ovarian benign teratomas in Chinese population: a 12-year-long cross-sectional study

Purpose

Given the lack of research on the left–right asymmetry of ovarian teratoma among Chinese patients, this study aimed to determine the lateral distribution and related clinical characteristics of Chinese ovarian teratoma patients treated at a single center.

Methods

We conducted a cross-sectional study of surgical patients pathologically diagnosed with ovarian teratomas in the gynecology inpatient department of the International Peace Maternity and Child Health Hospital in Shanghai between July 2006 and July 2018.

Results

Of the 4417 patients with ovarian teratoma, 3835 were finally analyzed. There were 2030 (53.24%) cases of right-sided benign ovarian teratoma versus 1783 (46.76%) cases of left-sided benign teratoma (P < 0.001). The recurrence rate of benign ovarian teratoma was 4.2%; recurrence occurred more often on the left side (left vs. right = 55 vs. 45%, P = 0.033). Compared with the right-sided ovarian teratoma patients, left-sided ones had significantly high recurrence risk (OR 1.430; 95% CI 1.03–1.99). The rate of ovarian torsion in patients with ovarian mature cystic teratomas (MCTs) during intrauterine pregnancy was 3.17 versus 1.72% in non-pregnant MCT patients (P = 0.049). For those MCT patients with intrauterine pregnancy, ovarian torsion occurs more often on the right side (left vs. right = 16.67 vs. 83.33%, P = 0.028).

Conclusion

This study confirms a distinctive right-side dominance of benign ovarian teratomas. Compared with the right side, recurrent ovarian teratomas occur more often on the left side, requiring close follow-up. Intrauterine pregnancy may increase the risk of ovarian torsion, particularly on the right side, in MCT patients.

A new type of abdominal incision for emergencies in pregnancy: a case report

Adnexal torsion in pregnancy is a rare gynecologic emergency that causes severe abdominal pain. The current paper reports a case of a woman with 18 weeks pregnancy who was referred to our tertiary clinic with sudden lower abdominal pain. Ultrasound scan showed a very large multicystic adnexal torsion mass on the right side displacing the gravid uterus to the anterior left. An oblique paramedian incision was made for right salpingo-oophorectomy. To our knowledge the incision presented in this case has not been described in the literature previously. We suggest an alternative incision to be used during pregnancy especially for emergencies due to an adnexal mass.

Obstetrical outcomes following laparoscopy during pregnancy: a retrospective case-control study

PURPOSE

To evaluate pregnancy outcome of patients who undergo laparoscopy during pregnancy.

METHODS

A retrospective case-control study, conducted in a single university-affiliated tertiary care medical center, comparing pregnancy outcomes of women who underwent laparoscopy during pregnancy to women without operations during pregnancy. The study group (n = 232) included all pregnant women who underwent a single laparoscopic surgery during pregnancy (4-28 weeks of gestation) which culminated in delivery between 2006 and 2017; this study group was matched to a control group (n = 463) without surgical intervention during pregnancy, in a 2:1 ratio by maternal age, parity, and multiple gestation.

RESULTS

The main pregnancy outcomes included preterm birth, cesarean section, small for gestational age (≤ 10 percentile), and Apgar score of less than 7 in 5 min. Laparoscopy during pregnancy was associated with an increased risk for cesarean section (32.3% vs. 24.6%, adjusted OR = 1.9, CI 1.2-3.1, p = 0.011). We found no difference between the groups with regard to other outcomes, including rates of preterm birth (12.1% vs. 10.4%, adjusted OR = 1.3, CI 0.64-2.72, p = 0.451). In a subgroup analysis of the study group, various perioperative parameters such as operation duration, hospitalization length, and others, did not correlate with adverse pregnancy outcome.

CONCLUSIONS

Laparoscopy during pregnancy may be associated with an increased rate of cesarean section. We did not find an increase in any other pregnancy or neonatal complication. Different perioperative parameters did not appear to predict adverse pregnancy outcome.

Maternal and perinatal outcomes following laparoscopy for suspected adnexal torsion during pregnancy: a multicenter cohort study

PURPOSE

To investigate the association of maternal and perinatal outcomes with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy.

STUDY DESIGN

This is a multicenter retrospective study and telephone questionnaire of urgent laparoscopies that occurred during pregnancy for suspected torsion between 2004 and 2019 in three tertiary medical centers. Pregnancy outcomes of women with the surgical diagnosis were compared with those whose laparoscopy was negative for adnexal torsion. Multivariable regression modeling was applied to control for possible confounders ((adjusted odds ratios (aOR) ± 95% confidence intervals (CI)].

RESULTS

The study cohort included 186 women. Adnexal torsion was surgically found in 129/186 (69.4%) cases. The torsion group was characterized by higher rate of nulliparity, fertility treatments and multiple gestations as well as lower rates of previous cesarean delivery. Live birth was reported for 171 (91.9%) pregnancies, and the miscarriage rate was significantly higher in the non-torsion group. Women with torsion were more likely to be hospitalizes due to preterm labor; however, rates of preterm delivery were comparable between the groups (10.8% vs. 10.9%, p = 0.99). Logistic regression analysis had demonstrated that the performance of laparoscopy prior to 8 weeks of gestation was the only independent factor associated with miscarriage (8.23, 2.01-33.67).

CONCLUSION

Pregnancy outcomes following the diagnosis of adnexal torsion throughout gestation were overall favorable. Laparoscopic procedure during early stages of pregnancy was associated with higher rates of miscarriage, regardless of the surgical diagnosis of adnexal torsion.

Clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women: a retrospective study

Background

Adnexal torsion during pregnancy is a gynecological emergency. Delayed diagnosis and treatment can cause ovarian necrosis and fetal loss. This study assessed the clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women.

Methods

A retrospective study was conducted at a tertiary center between January 2008 and January 2018. Eighty-two pregnant women with surgically confirmed adnexal torsion were included. The clinical characteristics, ultrasound data, surgical interventions and pregnancy outcomes were analyzed.

Results

The median age of the patients was 28 (range, 18–38) years. The median gestational age was 11 (range, 6–31) weeks: 53 (64.6%) were in the first trimester, 21 (25.6%) were in the second trimester, and 8 (9.8%) were in the third trimester. The most common symptoms and signs were sudden pelvic pain (100%) and adnexal or pelvic masses (97.6%), followed by nausea and vomiting (61%). The Doppler blood flow signal disappeared in 62.5% of the patients. Sixty-three (76.8%) patients underwent laparoscopy, and 29 (24.2%) underwent laparotomy. The median gestational age in patients undergoing laparotomy was higher than that in those undergoing laparoscopy (26 weeks vs 10 weeks, p < 0.001). Fifty-three (64.6%) patients underwent conservative surgery, with 48 detorsions and cystectomies, 2 detorsions and cyst fenestrations, 1 detorsion only and 2 salpingectomies only. Twenty-nine (25.4%) patients underwent unilateral salpingo-oophorectomy. There were no cases of postoperative thrombosis, spontaneous abortion or recurrence during the same pregnancy. Seven patients underwent simultaneous artificial abortion. One patient experienced intrauterine fetal death, and 74 patients had live births.

Conclusion

Surgical intervention was required as soon as possible. Laparoscopic conservative surgery is safe and may be appropriate to preserve ovarian function.

The Diagnostic Accuracy of Magnetic Resonance Imaging for Maternal Acute Adnexal Torsion during Pregnancy: Single-Institution Clinical Performance Review

Background: For acute adnexal torsion of pregnant women, appropriate treatment based on an accurate diagnosis is especially important for fertility preservation and timely treatment. The 2017 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 723 announced its practice-changing guidelines to ensure that diagnostic magnetic resonance imaging (MRI) conducted during the first trimester and gadolinium exposure at any time during pregnancy are safe for fetal stability. Unfortunately, few studies have been performed to evaluate the usefulness of the diagnostic accuracy of MRI for acute adnexal torsion during pregnancy. Objective: We sought to determine the efficacy of diagnostic MRI modality using multiparameter for maternal adnexal torsion during pregnancy. Methods: From 1 January 2007 to 31 January 2019, 131 pregnant with MRI tests were reviewed. In this retrospective cohort study, 94 women were excluded due to conditions other than an adnexal mass, and 37 were identified through MRI analyses conducted before surgery for suspected adnexal torsion. The primary outcome was the diagnostic accuracy of sonography and MRI, and the secondary outcome was the usefulness of Apparent diffusion coefficient (ADC) values for predicting the severity of hemorrhagic infarction between the medulla and cortex of the torsed ovarian parenchyma. Results: Our study demonstrates that in the diagnosis of adnexal torsion during pregnancy, the sensitivity, specificity, positive predictive value, and negative predictive value are 62.5%, 83.3%, 90.9%, and 45.5% for sonography and 100%, 77.8%, 90.5%, and 100% for MRI. MRI results in surgical-proven adnexal torsion patients revealed unilocular ovarian cysts (36.8% (7/19)), multilocular ovarian cysts (31.6% (6/19)), and near normal-appearing ovaries (31.6% (6/19)). Pathology in adnexal torsion revealed a corpus luteal ovarian cyst (63.2% (12/19)) and underlying adnexal pathology (46.8% (7/19)). Maternal adnexal torsion during pregnancy was more likely to occur in corpus luteal ovarian cysts than in underlying adnexal masses (odds ratio, 2.14; 95% confidence interval (CI), 0.428–10.738). MRI features for adnexal torsion were as follows: tubal wall thickness, 100% (19/19); ovarian stromal (medullary) edema, 100% (19/19); symmetrical or asymmetrical ovarian cystic wall, 100%(19/19); prominent follicles in the ovarian parenchyma periphery, 57.9% (11/19); periadenxal fat stranding, 84.2% (16/19); uterine deviation to the twisted side, 21.1% (4/19); and peritoneal fluid, 42.1% (8/19). The signal intensity of the ADC values of the ovarian medulla and cortex were compared between the cystectomy and detorsion (CD) and salpingo-oophorectomy (SO) groups. The ADC values of the CD and SO groups were 1.81 ± 0.09 × 10⁻³ mm²/s and 1.91 ± 0.18 × 10⁻³ mm²/s, respectively (P = 0.209), in the ovarian medulla and 1.37 ± 0.32 × 10⁻³ mm²/s and 0.96 ± 0.36 × 10⁻³ mm²/s, respectively (P = 0.022), in the ovarian cortex. The optimal cut-off value of ADC values for predictable total necrosis in the torsed ovarian cortex was ≤ 1.31 × 10⁻³ mm²/s (area under the curve (AUC) = 0.81; 95% CI 0.611–1.0; P = 0.028). Conclusion: Our data showed that maternal adnexal torsion during pregnancy occurred in most corpus luteal cystic ovary cases and some normal-appearing ovary during the 1st and 2nd trimesters of gestation. Therefore, this study is the first study to elaborate on the existence or usefulness of the diagnostic MRI for acute maternal adnexal torsion during pregnancy and to provide a predictive diagnosis of the severity of hemorrhagic infarction for deciding surgical radicality.

Characteristics and surgical invervention of ovarian torsion in pregnant compared with nonpregnant women

The aim of our study was to compare the clinical and surgical characteristics of pregnant and nonpregnant women with surgically verified ovarian torsion, as well as the differences among 3 trimesters during pregnancy.We conducted a retrospective study of patients diagnosed with surgically proven ovarian torsion in our hospital from January 2012 to June 2018. The clinical characteristics, surgical procedure, pathologic outcomes, and trimesters of pregnancy were analyzed.Thirty-three pregnant and 72 nonpregnant patients diagnosed with surgically proven ovarian torsion were assessed during the study period. The most common presenting symptom in both groups was abdominal pain (90.2% and 99.0%, respectively). The median time from admission to surgery was shorter in pregnant patients than nonpregnant patients (5.3 compared with 47.7 hours, P < .001). Pregnant patients had a higher number of twists than nonpregnant patients (median of 2 compared with 1, P < .01). Benign cyst was the most common cyst causing ovarian torsion in both groups, and luteum cyst was more common in the pregnant group. The mean size of ovarian cyst in pregnant patients was much smaller in the third trimester than the first and the second trimesters (6.6 ± 2.0, 8.4 ± 2.1and 8.1 ± 1.5 cm, respectively; P = .097). Cystectomy performed in the third trimester was more frequent compared with the other 2 trimesters (77.8%, 26.7%, and 22.2%, respectively; P = .021).Abdominal pain is the most common feature of ovarian torsion. Clinical presentation of ovarian torsion is relatively similar between pregnant and nonpregnant women, and among different trimesters. The tumor size was smaller in the third trimester of pregnancy than the other 2 trimesters of pregnancy. Cystectomy performed in pregnant patients is more during the third trimester compared with the other 2 trimesters.

Ovarian cysts in pregnancy: a narrative review

Most adnexal masses are benign, incidental findings of pregnancy which resolve spontaneously. They may present clinically due to haemorrhage, rupture, torsion and mass effect. Aetiological classification includes ovarian benign, ovarian malignant, non-ovarian, gynaecological, non-ovarian non-gynaecological and an additional subset of pathologies unique to pregnancy. Ultrasound is the first-line imaging modality for the evaluation of adnexal masses. This may be supplemented with magnetic resonance imaging. Tumour markers support evaluation of malignant potential, but interpretation of results in pregnancy is challenging. Surgical intervention requires consideration of gestation, lesion characteristics and presence of complications. Laparoscopy is preferred owing to shorter operative time, quicker recovery and resultant lower thrombotic risk. Post-viability, fetal wellbeing and assessment must be considered. Management of the pregnancy may include cardiotocography, steroids, non-teratogenic antibiotics and tocolytics. In rare cases, particularly related to malignancy, termination of pregnancy may be required to enable immediate management where there are concerns for maternal wellbeing.

Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings

Background

Differences in the ultrasonographic features and histological diagnosis of ovarian torsion in pregnant and non-pregnant women have not been defined. A better characterization of these features may help improve the accuracy of preoperative diagnosis. The present study aimed to compare the clinical characteristics, sonographic findings, operative procedures, and histological spectrum of ovarian torsion in pregnant and non-pregnant women.

Methods

This was a retrospective investigation of female patients at reproductive age with ovarian torsion between January 2010 and May 2017. Each patient received a detailed preoperative ultrasound, and the diagnosis was confirmed by surgery. The clinical characteristics, ultrasonic features, operative procedures, and histological diagnosis of ovarian torsion were retrieved from medical records and were compared in non-pregnant and pregnant patients according to the method of conception.

Results

The overall preoperative ultrasonic detection rate of ovarian torsion was 0.84, which was significantly different between pregnant and non-pregnant women. The presence of ovarian edema and abnormal adnexal positions also differed between pregnant and non-pregnant women. The ultrasonic features were not significantly different between the two pregnant sub-groups. The most common histologic diagnoses in the pregnant group and the non-pregnant group were a normal ovary and teratoma, respectively. The incidence of ovarian neoplasm was significantly lower in pregnant women. There were significant differences in the surgical procedures between the groups based on neoplastic or non-neoplastic lesions.

Conclusions

Ovarian edema, absence/decreased blood flow in the ovary, and the whirlpool sign were reliable ultrasonic markers for ovarian torsion at reproductive ages. The preoperative ultrasonic detection rate of ovarian torsion was higher in pregnant women, and ovarian edema was more common. The clinical features of ovarian torsion in pregnant women were similar, independent of the method of conception. In women with ovarian torsion, the incidence of non-neoplastic lesions was more frequent in pregnant women, whereas neoplastic lesions were more common in non-pregnant women. Ultrasonography provides useful parameters for the preclinical diagnosis of ovarian torsion to improve patient management.

Nonfetal Imaging During Pregnancy: Acute Abdomen/Pelvis

Abdominal pain is a common occurrence in pregnant women and may have a variety of causes, including those that are specific to pregnancy (eg, round ligament pain in the first trimester) and the wide range of causes of abdominal pain that affect men and women who are not pregnant (eg, appendicitis, acute cholecystitis). Noncontrast magnetic resonance (MR) imaging is increasingly performed to evaluate pregnant women with abdominal pain, either as the first-line test or as a second test following ultrasonography. The imaging appearance of causes of abdominal pain in pregnant women are reviewed with an emphasis on noncontrast MR imaging.

Laparoscopic Adnexal Detorsion in a 20-Week Pregnant Patient: A Case Report and Literature Review

Adnexal torsion is a cause of severe pelvic pain in reproductive aged women and during pregnancy. Adnexal torsion occurs when there is a complete turn of the ovary, tube, or both resulting in impaired blood flow to the ovary. The diagnosis of adnexal torsion is sometimes challenging due to the enlarged effect of the uterus, the displacement of abdominal and pelvic structures and the nonspecific symptoms in pregnancy. Therefore, prompt diagnosis is essential for better maternal and neonatal outcomes. The gold standard for confirmation and treatment of ovarian torsion is surgery. Laparoscopy and Laparotomy are surgical options with defined risks and benefits. Therefore, choosing the best surgical technique and surgical procedure are of utmost importance to decrease the chances of adverse events intra and postoperatively. Little literature exists regarding the laparoscopic approach of an ovarian torsion during the second trimester. Our case is a 20-week pregnant patient who had a 1080 degree rotation of the left adnexa. She required laparoscopy for adnexal detorsion and had good intraoperative, postoperative, maternal, and neonatal outcomes following management.

Palliative Care and the Pregnant Surgical Patient: Epidemiology, Ethics, and Clinical Guidance

Obstetricians and general surgeons frequently navigate the challenges of providing surgical care that is mindful of the unique circumstances of pregnancy. Ensuring pregnant patients have high-quality surgical care is an ethical imperative. Providers should maintain a high index of suspicion for surgical disease to ensure that surgical diagnoses are not missed or inadequately treated. A variety of imaging modalities are used in pregnancy. Surgical management includes laparoscopic and open approaches. Perioperative fetal monitoring should be the subject of multidisciplinary discussion. Symptomatic control in pregnancy should have the same goals as for nonpregnant patients. Enhanced recovery after surgery pathways frequently are appropriate.

Torsion of ovarian endometrioma in pregnancy: a case report and review of the literature

Adnexal torsion induced by an endometrioma has seldom been reported. Because of its rarity and its complexity in respect of fetal health during pregnancy, the diagnosis and treatment is challenging. We report a 25-year-old primigravida in the eighth week of gestation presenting with acute onset lower abdominal pain. A pelvic ultrasonography showed an intrauterine single viable embryo with a right ovarian cyst measuring 6 × 6 cm in diameter. Exploratory laparotomy revealed torsion of the right adnexa by 360°. After a right adnexectomy was performed, the patient proceeded to full-term pregnancy. Adnexal torsion is defined as rotation of > 45° in the long axis of the adnexae. Its occurrence during gestation is reported as 2%, accounting for 2.7% of surgical emergencies in pregnant women. Most cases are caused by dermoid and functional ovarian cysts. Because of the rarity of torsion induced by an endometrioma, the diagnosis and treatment are challenging. In poor-resource conditions, a diagnostic laparoscopy (or laparotomy) remains a logical method of diagnosis, offering simultaneous therapeutic options.

Ovarian hyperstimulation syndrome: A review for emergency clinicians

INTRODUCTION

A great deal of literature has recently evaluated the prevention and management of ovarian hyperstimulation syndrome (OHSS) in the outpatient setting, but there remains a dearth of research evaluating OHSS in the emergency department (ED) and its management.

OBJECTIVE

This narrative review evaluates the underlying pathophysiology and clinical manifestations of OHSS and discusses approaches to patient care in the ED based on current literature.

DISCUSSION

OHSS is an iatrogenic complication caused by an excessive response to controlled ovarian stimulation during assisted reproductive cycles (ART). OHSS complicates up to 30% of ART cycles, and many of these patients seek initial care in the ED. Risk factors for the development of OHSS include age < 35, history of polycystic ovarian syndrome or previous OHSS, and pregnancy. Emergency physicians will be faced with several complications including ascites, abdominal compartment syndrome, renal dysfunction, acute respiratory distress syndrome, thromboembolic disease, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary obstetrics/gynecology team is needed, which improves patient outcomes. This review provides several guiding principles for management of OHSS and associated complications.

CONCLUSIONS

OHSS occurs in up to 30% of IVF cycles and carries a high morbidity. Effective care of the OHSS patient begins with early diagnosis while evaluating for other diseases and complications. Understanding these complications and an approach to the management of OHSS is essential to optimizing patient care.

Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study

STUDY OBJECTIVE

To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy.

DESIGN

A retrospective case-control study (Canadian Task Force classification II-2).

SETTING

A tertiary care academic medical center.

MEASUREMENTS AND MAIN RESULTS

The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012).

CONCLUSION

Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.

Laparoscopic Adnexectomy for Ovarian Torsion during Late Pregnancy: Case Report of a Non-Conservative Treatment and Literature Analysis

Diagnosis of adnexial torsion is difficult during pregancy (1). The time of decision and laparoscopy is that of the risk of necrosis of the adnexa and, therefore, of the ovarian prognosis. The loss of an ovary can compromise the following fertility. Even if concerns related to laparoscopy in pregnant patients include a limited surgical field, with a risk of uterine injury and negative fetal effects of CO₂ insufflation. Evidence base suggests that minimally invasive surgery can be safe and better than laparotomy for management of adnexal masses during late pregnancy with good postoperative and obstetric outcomes. If for most authors laparoscopy appears to become the best approach for ovarian torsion during pregnancy (2), nonetheless, the ideal surgical laparoscopic approach of adnexa in late pregnancy remains controversial. Since there is no technical gold standard to overcome surgical difficulties which could make laparoscopic procedures as real challenge in patients in second and third trimester (3); at least, in case of radical and non-conservative treatment, the risk for a first trimester of pregnancy is to remove the corpus luteum (1).

First-trimester emergencies: a radiologist's perspective

The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.

Association between peak estradiol levels and ovarian torsion among symptomatic patients receiving gonadotropin treatment

PURPOSE

Ovarian torsion is a surgical emergency that can be clinically challenging to diagnose. Patients who have received assisted reproductive technologies (ART) are a subset of women with an increased risk for torsion. As the ART population continues to increase, there is a need to delineate risk factors for the development of ovarian torsion in this unique population. A pilot study was performed to determine the proportion of patients with suspected ovarian torsion who have received ART and to identify possible diagnostic biomarkers for ovarian torsion among these patients.

METHODS

A single institution retrospective cohort study of patients taken to surgery for suspected ovarian torsion over a 5-year period.

RESULTS

During the study period, 171 patients were taken to surgery for suspected ovarian torsion. Patients receiving ART constituted 19 (11%) of these patients. Among the 19 fertility treatment patients, 16 had received treatment with gonadotropins, 10 of which had surgically confirmed ovarian torsion. These ten patients had higher preoperative peak estradiol levels (3122 versus 1875 pg/mL, p = 0.05) and a larger ovarian diameter (9.7 versus 7.6 cm, p = 0.05) than the six patients receiving gonadotropins found to not have ovarian torsion.

CONCLUSIONS

These results suggest infertility treatment using gonadotropins for ovarian hyperstimulation may be an independent risk factor for ovarian torsion as suggested by the disproportionate number of such individuals represented in the study population (9% of all patients, 84% of fertility patients). Additionally, among women taking gonadotropins, an association exists between peak estradiol levels, ovarian diameter, and risk for ovarian torsion.

[Epidemiological, clinical and therapeutic aspects of supposed benign ovarian tumors at the Central Hospital of Yaoundé]

Introduction

Les tumeurs ovariennes présumées bénignes (TOPB) constituent l'un des motifs les plus fréquents de consultation gynécologique, et l'une des indications les plus fréquentes en chirurgie gynécologique.

Méthodes

Nous avons mené une étude descriptive rétrospective dans le service de gynécologie-obstétrique de l'hôpital central de Yaoundé. La durée de l'étude était de 6 mois sur une période 5ans du 1er janvier 2010 au 31 décembre 2014. La population de l'étude était constituée de toutes les patientes opérées pour une tumeur ovarienne présumée bénigne pendant la période de l'étude.

Résultats

L'âge moyen était de 29,33± 6,83 avec un âge minimum de 20 ans et un âge maximum de 48ans. La tranche d'âge la plus représentée est celle de 21à 25 ans. Le motif de consultation était les douleurs pelviennes 93,90% des cas. Onze patientes avaient une grossesse soit 33,3% de notre population d'étude et 72,70% étaient au premier trimestre de la grossesse. Les TOPB répertoriés dans notre série étaient : la rupture de kyste (36,40%), la torsion d'annexe (27,30%), le volumineux kyste ovarien (21,20%), l'hémorragie intrakystique (15,20%). Le traitement était conservateur chez 26 (78,78%) patientes. Cependant, l'annexectomie a été réalisée chez 5 patientes sur 9 qui ont eu une torsion d'annexe.

Conclusion

Les TOPB compliquées sont présentes dans notre milieu surtout chez des patientes en âge de procréer. Le diagnostic tardif particulièrement en cas de torsion d'annexe oblige un traitement radical qui est délétère pour le patient. Le traitement chirurgical par laparoscopie est le plus recommandé si le plateau technique le permet car il diminue les risques de complications.