Transvaginal ovarian cystectomy for adnexal torsion during pregnancy

Adnexal torsion in pregnancy: A systematic review of case reports and case series

OBJECTIVES

This study aimed to investigate clinical presentations, surgical procedures and findings, complications, and predisposing factors of adnexal torsion in pregnant women.

METHODS

We searched PubMed/Medline, Embase, and Web of Science from January 2000 to March 2022. All case reports and case series with full-text English language reporting adnexal torsion in pregnant women were included. Medical history, clinical presentations, surgical procedures and findings, complications related to adnexal torsion, and predisposing factors were independently extracted by two investigators.

RESULTS

A total of 182 articles reporting 662 pregnant women with adnexal torsion were included. Most of the adnexal torsions occurred during the first trimester (54.63%), while others occurred during the second (26.36%) and third (19.00%) trimesters. The most common symptom of adnexal torsion was sudden-onset pain (80.60%). Enlargement of the adnexa was the most prevalent ultrasound finding in a twisted adnexa (95.20%). Additionally, about half of the patients had decreased blood flow in Doppler ultrasound (53.80%). Laparoscopic surgery was the favorite option (56.88%), while cystectomy and detorsion were the most commonly performed procedure (29.06%). Expectant management was reported in only 2.99% of the patients. In addition, the most common complications were preterm labor (27.58%) and emergent cesarean sections (25.28%).

CONCLUSIONS

Clinicians should think of adnexal torsion when pregnant women complain of sudden-onset pain. Then, using ultrasound, adnexal enlargement or masses should be explored seriously. They should take invasive and urgent therapy to preserve ovaries and prevent complications.

Is Ultrasound a Reliable and Reproducible Method for Assessing Adnexal Masses in Pregnancy? A Systematic Review

In this study, we aimed to systematicallyreview the current evidence regarding the diagnostic accuracy of ultrasound in assessing adnexal masses in pregnancy. The Cochrane Register of Controlled Trials, PubMed, and EMBASE databases were searched for all types of clinical studies that utilised ultrasound for the diagnosis of adnexal masses in pregnancy. Only studies that used outcome measures of either histological diagnosis or significant regression of the adnexal mass on imaging follow-up were included. The quality of each study was assessed for risk of bias. The diagnostic performance of ultrasound in each study type was calculated, along with the pooled diagnostic performance of ultrasound in differentiating benign from malignant masses. The initial search yielded 4,915 articles, of which 2,547 qualified for abstract screening. A total of 83 articles were included in this review, including one prospective cohort study, six retrospective observational studies, seven case series, and 69 case reports. In the included studies, the total number of adnexal masses was 559. The mean patient age was 29.2 years (95% confidence interval [CI]: 28.7-29.7), with a mean gestational age at diagnosis of 13.8 weeks (95% CI: 13.2-14.4). The mean quality assessment score was 75%. The International Ovarian Tumour Analysis Simple Rules were used in two articles, whereas subjective impression was used in the remaining 81 articles. The most frequently diagnosed mass was a simple or physiological cyst (35%). The prevalence of malignancy in the entire sample was 46/559 (8%; 95% CI: 34-61%). The overall pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of ultrasound in detecting ovarian malignancy were 64% (95% CI: 30-88%), 88% (95% CI: 64-97%), 5.6 (95% CI: 1.2-25.4), and 0.4 (95% CI: 0.15-1), respectively. In conclusion, currently, there is a lack of high-quality prospective studies to guide the management of adnexal masses in pregnancy. Ultrasound appears to have an adequate accuracy in differentiating benign from malignant masses; however, more research is required to assess the role of ultrasound models, rules, and subjective assessment in pregnancy compared to non-pregnant women.

Adnexal torsion in pregnancy after in vitro fertilization: Case report and literature review

RATIONALE

Torsion is the most common gynecologic emergency of the adnexal mass occurring during pregnancy. We report the clinical data of a case of twin pregnancy with adnexal torsion after in vitro fertilization (IVF) and embryo transfer, in which the patient underwent surgery for adnexal detorsion and experienced preterm delivery. One child died as a neonate, and the other child was diagnosed with hematological disease, which, to our knowledge, has not been reported previously. We also performed a systematic literature review to increase knowledge of the need for prompt surgical intervention.

PATIENT CONCERNS

The patient was a 32-year-old pregnant woman, who presented to our center with acute onset of stabbing and non-radiating continuous lower left abdominal pain after urination, of 6 hours duration.

DIAGNOSIS

Physical examination revealed that the lower abdominal tenderness was worse on the left side, and there were no signs of peritonitis. Transvaginal ultrasonographic examination indicated a multiloculated left ovary measuring 12.1 × 7.1 cm with sparse blood flow. The size of the largest cyst was 7.2 × 6.6 cm, the right ovary appeared normal, and two live fetuses were seen.

INTERVENTIONS

laparoscopy was performed 1.5 hours later, which revealed a cystic and multilocular left ovary with a black purplish surface and thin wall. The left ovary and left fallopian tube had undergone 720° torsion (3 rotations), and detorsion was performed laparoscopy.

OUTCOMES

The left adnexa recovered to near normal appearance 20 minutes postoperatively. The patient was discharged from hospital 5 days postsurgery, without complications. Unfortunately, the patient delivered two preterm babies at 30 weeks of gestation.

CONCLUSIONS

We should be alert to the possible risk of adnexal torsion in pregnant women after IVF. Adnexal torsion necessitates prompt surgical intervention, detorsion and preserving ovarian function are the main treatment methods. Furthermore, the possibility of recurrence, and pregnancy outcomes for the patient, as well as newborn health, should be considered.