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Delgado-Miguel C, Arredondo-Montero J, Moreno-Alfonso JC, San Basilio M, Peña Pérez R, Carrera N, Aguado P, Fuentes E, Díez R, Hernández-Oliveros F. The Role of Neutrophyl-to-Lymphocyte Ratio as a Predictor of Ovarian Torsion in Children: Results of a Multicentric Study. Life (Basel) 2024; 14:889. [PMID: 39063642 PMCID: PMC11277755 DOI: 10.3390/life14070889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/03/2024] [Accepted: 07/13/2024] [Indexed: 07/28/2024] Open
Abstract
INTRODUCTION Pediatric ovarian torsion (OT) is an emergency condition that remains challenging to diagnose because of its overall unspecific clinical presentation. The aim of this study was to determine the diagnostic value of clinical, ultrasound, and inflammatory laboratory markers in pediatric OT. METHODS We performed a retrospective multicentric case-control study in patients with clinical and ultrasound suspicion of OT, in whom surgical examination was performed between 2016-2022 in seven pediatric hospitals. Patients were divided into two groups according to intraoperative findings: OT group (ovarian torsion), defined as torsion of the ovarian axis at least 360°, and non-OT group (no torsion). Demographics, clinical, ultrasound, and laboratory features at admission were analyzed. The diagnostic yield analysis was performed using logistic regression models, and the results were represented by ROC curves. RESULTS We included a total of 110 patients (75 in OT group; 35 in non-OT group), with no demographic or clinical differences between them. OT-group patients had shorter time from symptom onset (8 vs. 12 h; p = 0.023), higher ultrasound median ovarian volume (63 vs. 51 mL; p = 0.013), and a significant increase in inflammatory markers (leukocytes, neutrophils, neutrophil-to-lymphocyte ratio, C-reactive protein) when compared to the non-OT group. In the ROC curve analysis, the neutrophil-to-lymphocyte ratio (NLR) presented the highest AUC (0.918), with maximum sensitivity (92.4%) and specificity (90.1%) at the cut-off point NLR = 2.57. CONCLUSIONS NLR can be considered as a useful predictor of pediatric OT in cases with clinical and ultrasound suspicion. Values above 2.57 may help to anticipate urgent surgical treatment in these patients.
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Affiliation(s)
- Carlos Delgado-Miguel
- Pediatric Surgery Department, Fundación Jiménez Díaz University Hospital, Avenida de los Reyes Católicos, 2, 28040 Madrid, Spain
- Institute for Health Research IdiPAZ, La Paz University Hospital, 28046 Madrid, Spain
| | - Javier Arredondo-Montero
- Pediatric Surgery Department, Complejo Asistencial Universitario de León, 24071 Castilla y León, Spain
| | | | - María San Basilio
- Pediatric Surgery Department, La Paz University Hospital, 28046 Madrid, Spain
| | - Raquel Peña Pérez
- Pediatric Surgery Department, Rey Juan Carlos University Hospital, 28933 Móstoles, Spain
| | - Noela Carrera
- Pediatric Surgery Department, Toledo University Hospital, 45005 Toledo, Spain
| | - Pablo Aguado
- Pediatric Surgery Department, Fundación Jiménez Díaz University Hospital, Avenida de los Reyes Católicos, 2, 28040 Madrid, Spain
| | - Ennio Fuentes
- Pediatric Surgery Department, Fundación Jiménez Díaz University Hospital, Avenida de los Reyes Católicos, 2, 28040 Madrid, Spain
- Pediatric Surgery Department, Rey Juan Carlos University Hospital, 28933 Móstoles, Spain
- Pediatric Surgery Department, Villalba University Hospital, 28400 Villalba, Spain
| | - Ricardo Díez
- Pediatric Surgery Department, Fundación Jiménez Díaz University Hospital, Avenida de los Reyes Católicos, 2, 28040 Madrid, Spain
- Pediatric Surgery Department, Rey Juan Carlos University Hospital, 28933 Móstoles, Spain
- Pediatric Surgery Department, Villalba University Hospital, 28400 Villalba, Spain
| | - Francisco Hernández-Oliveros
- Institute for Health Research IdiPAZ, La Paz University Hospital, 28046 Madrid, Spain
- Pediatric Surgery Department, La Paz University Hospital, 28046 Madrid, Spain
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Güvenç M, Yüksel M, Kutlu T, Etyemez M, Gökçek İ, Cellat M. Protective effects of esculetin against ovary ischemia-reperfusion injury model in rats. J Biochem Mol Toxicol 2024; 38:e23528. [PMID: 37661762 DOI: 10.1002/jbt.23528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/15/2023] [Accepted: 08/25/2023] [Indexed: 09/05/2023]
Abstract
AIMS Ovarian ischemia-reperfusion (I/R) injury is a phenomenon that necessitates urgent intervention, which occurs as a result of ovarian torsion, and it is frequently seen in young women. A large amount of free radical and oxidative damage as a result of I/R plays a role in the cause of the incident. Antioxidant agents are thought to be beneficial in preventing this damage, and the potential protective effects of esculetin, which had not been tested previously, were investigated in this study. STUDY DESIGN The rats in the study were divided into five groups at random: control, sham, esculetin, I/R, and treatment. Oxidative stress parameters, proinflammatory cytokines, nuclear factor erythroid 2-related factor 2 (Nrf-2)/nuclear factor-kβ (NF-κβ) pathway, and histopathological analyses were evaluated at the end of the study. KEY FINDINGS After I/R, malondialdehyde levels, proinflammatory cytokines, tumor necrosis factor-α and interleukin-1β levels and NF-κβ expressions were increased, Nrf-2 expression and glutathione level decreased and the histopathologic picture deteriorated. However, as a result of the esculetin treatment, ameliorative effects in the aforementioned parameters were determined, and it was ensured that they returned to normal levels. CONCLUSION According to these findings, esculetin has protective effects on I/R damage by lowering lipid peroxidation and having antioxidant and anti-inflammatory properties. SIGNIFICANCE Our results proved the protective effect of esculetin against ovarian IR injury in rats and this may be attributed to Nrf-2/NF-κβ axis which showed antioxidant and anti-inflammatory effects. Therefore, esculetin can be used in the future for preventive effects to ovarian IR injury.
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Affiliation(s)
- Mehmet Güvenç
- Department of Physiology, Faculty of Veterinary Medicine, University of Hatay Mustafa Kemal, Antakya, Hatay, Turkey
| | - Murat Yüksel
- Department of Obstetrics and Gynecology, Faculty of Veterinary Medicine, University of Hatay Mustafa Kemal, Antakya, Hatay, Turkey
| | - Tuncer Kutlu
- Department of Pathology, Faculty of Veterinary Medicine, University of Hatay Mustafa Kemal, Antakya, Hatay, Turkey
| | - Muhammed Etyemez
- Department of Physiology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - İshak Gökçek
- Department of Physiology, Faculty of Veterinary Medicine, University of Hatay Mustafa Kemal, Antakya, Hatay, Turkey
| | - Mustafa Cellat
- Department of Physiology, Faculty of Veterinary Medicine, University of Hatay Mustafa Kemal, Antakya, Hatay, Turkey
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Zhao JC, Huang H, Gong HL, Zhao QK, Wu H. Ovarian cyst torsion in Prader-Willi Syndrome. BMC Pediatr 2023; 23:391. [PMID: 37553631 PMCID: PMC10408171 DOI: 10.1186/s12887-023-04223-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/02/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Prader-Willi syndrome (PWS) is a genetic disorder involving multiple systems, with an incidence of about 1/10000-25000. Ovarian torsion (OT) is not commonly found in children. Ovarian cyst acts as one of the primary factors resulting in OT. While ovarian cyst torsion with Prader-Willi Syndrome has not been reported before. CASE PRESENTATION A 12-years old female was admitted to Emergency Department of our hospital with the chief complaint of abdominal pain. The outcomes of physical examination revealed the height of 150 cm, weight of 103 kg, BMI of 45.77 kg/m2. The patient manifested the special facial features, an obese body, with the abdomen distended into a spherical shape. The fat accumulation in the abdomen significantly embarrassed the palpation. The abdominal CT scan indicated a huge cystic mass in the abdominal cavity, sized about 138 mm × 118 mm. According to medical history, the patient was born with low crying and hypotonia, who has developed the uncontrollable eating behavior since 3-years old. These abnormalities led to a speculation of PWS syndrome, so a genetic test was performed and finally confirmed it, concluding a torsion of ovarian cyst with PWS. With the multidisciplinary consultation, a careful treatment strategy containing the control of blood pressure and blood sugar, coenzyme Q10 was administrated to nourish the myocardium and the application of Growth Hormone was developed. All the above preoperative treatments have brought great benefits to patients. Thus promising the successful completion of operation. The postoperative follow-up till now indicated that the abdominal incision was well healed, without operative complications. CONCLUSIONS This may be the first case report. In the treatment of ovarian cyst torsion, PWS syndrome requires fully consideration, as the latter can lead to multisystem abnormalities, especially the relation to perioperative management, and even fatalities. Genetic testing should be conducted early when PWS was suspected, accompanied with adequate preparation for the perioperative period, the follow-ups of patients should be maintained for a long time after surgery.
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Affiliation(s)
- Ji-Cun Zhao
- Department of General Surgery, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Heng Huang
- Department of Hand and Foot Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hong-Lei Gong
- Department of General Surgery, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Qing-Kai Zhao
- Department of General Surgery, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - He Wu
- Department of General Surgery, Women and Children's Hospital, Qingdao University, Qingdao, China.
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Ashmore AA, Blackstock S, Kenny C, Ismail A. Recognition and initial management of ovarian torsion. BMJ 2023; 381:e074514. [PMID: 37116904 DOI: 10.1136/bmj-2022-074514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Ayisha A Ashmore
- Gynaecology Department, University Hospitals Leicester NHS Trust, Leicester, UK
| | | | - Conor Kenny
- The Old Church GP Surgery, Chingford, London, UK
| | - Aemn Ismail
- Gynaecology Department, University Hospitals Leicester NHS Trust, Leicester, UK
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George JS, Rosen MW, Curci N, Torres ML, Wasnik AP, Smith YR, Quint EH. Sonographic Predictors of Ovarian Torsion in Premenarchal Girls. J Pediatr Adolesc Gynecol 2023:S1083-3188(23)00310-8. [PMID: 36944392 DOI: 10.1016/j.jpag.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/07/2023] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
STUDY OBJECTIVE To identify preoperative transabdominal sonographic predictors of surgically-confirmed ovarian torsion (OT) in premenarchal girls. METHODS Retrospective case-control study of 32 premenarchal girls aged 0-12 undergoing surgery for OT (cases) or a non-torsed ovarian mass (controls) from 2006-2017 at a single academic center. Cases had ICD-9/10 codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube and surgically-confirmed OT; controls had codes for ovarian mass or cyst and surgically-confirmed absence of OT. Preoperative transabdominal ultrasounds were analyzed by three radiologists blinded to final diagnosis. Chi-square, Fisher's exact, and Student's t-test were used for statistical comparisons. RESULTS From 2016-2017, 32 patients presented with acute abdominal pain or symptoms concerning for ovarian mass requiring ultrasound imaging and subsequent diagnostic laparoscopy-24 (75.0%) had confirmed OT by laparoscopy; eight (25.0%) did not. Mean age in both groups was similar (7.3±2.9 years). Preoperative sonographic variables significantly associated with OT included presence of a simple cyst (20.8% vs 12.5%), ovarian heterogeneity (100% vs 12.5%), presence of peripheralized follicles (70.8% vs 0%), and asymmetry of color Doppler (75.0% vs 37.5%)-all p<0.05. Presence of free fluid, arterial color Doppler, and a whirlpool sign were not predictive of OT. CONCLUSION In premenarchal patients, while certain variables on transabdominal sonography predicted surgically-confirmed OT, only the presence of peripheralized follicles was unique to girls with OT. The decision to proceed with diagnostic laparoscopy for suspected OT can be aided by these specific sonographic findings but should ultimately be based on high clinical suspicion.
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Affiliation(s)
- Jenny S George
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI
| | - Monica W Rosen
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI.
| | - Nicole Curci
- Department of Radiology, Michigan Medicine, Ann Arbor, MI
| | | | | | - Yolanda R Smith
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI
| | - Elisabeth H Quint
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI
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Scheier E. Diagnosis and Management of Pediatric Ovarian Torsion in the Emergency Department: Current Insights. Open Access Emerg Med 2022; 14:283-291. [PMID: 35770141 PMCID: PMC9236466 DOI: 10.2147/oaem.s342725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/17/2022] [Indexed: 11/23/2022] Open
Abstract
Ovarian torsion is defined as twisting of the ovary around an axis consisting of its vascular pedicle, the infundibulopelvic ligament and the tubo-ovarian ligament, and can occur in females of any age. Torsion can be a result of ovarian mass causing asymmetry and subsequent torsion, or can be spontaneous. While ovarian torsion is a surgical emergency, early diagnosis and treatment can preserve ovarian viability even if necrosis is seen operatively. Presentation classically involves sudden onset severe abdominal pain and vomiting but diagnostic delay can follow subtler presentations. Diagnosis is most commonly based on sonographic findings, but advanced imaging such as CT or MRI may be required if sonography is not diagnostic. Treatment is surgical, with ovarian preservation preferred in almost all cases. In this review, I present the most recent evidence on epidemiology, diagnosis, and management of pediatric ovarian torsion, with a focus on point-of-care ultrasound for the emergency care provider.
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Affiliation(s)
- Eric Scheier
- Pediatric Emergency Department, Kaplan Medical Center, Rehovot, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Tielli A, Scala A, Alison M, Vo Chieu VD, Farkas N, Titomanlio L, Lenglart L. Ovarian torsion: diagnosis, surgery, and fertility preservation in the pediatric population. Eur J Pediatr 2022; 181:1405-1411. [PMID: 35094159 DOI: 10.1007/s00431-021-04352-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/04/2021] [Accepted: 12/01/2021] [Indexed: 11/03/2022]
Abstract
Ovarian torsion is rare in the pediatric population. Delayed diagnosis can significantly impact fertility. The aim of this review is to highlight current knowledge regarding clinical presentation, diagnosis, surgical management, and follow-up in the pediatric population. Whilst the presentation is often very unspecific, most children will present with sudden severe unilateral pelvic pain associated with vomiting. A key diagnostic test is pelvic ultrasonography, which may help demonstrate an asymmetric enlarged ovary with peripherally displaced follicles. In the pediatric population, ovarian torsion may occur in a normal ovary. However, underlying lesions can be found in half of cases. Benign neoplasms (teratomas or cystic lesions) represent the commonest etiology, with the risk of malignancy being less than 2%. Surgical management should be focused on fertility preservation. This is achievable through ovarian detorsion ± ovarian cystectomy ± oophoropexy to avoid recurrence. Follow-up studies demonstrate excellent recovery rates of detorsed ovaries including those with ischemic appearances. What is Known: • Ovarian torsion is a rare diagnosis in the pediatric population. • Aspecific symptoms and differential diagnoses lead to missed or delayed diagnosis increasing the risk of oophoprectomy and further infertility. What is New: • Reviewing the latest knowledge about clinical presentation, diagnostic, surgical management, and follow-up of ovarian torsion in the pediatric population. • Adiponectin was negatively associated with diastolic blood pressure and HOMA-IR, and chemerin was negatively associated with glucose.
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Affiliation(s)
- Alexandra Tielli
- Department of Pediatric Emergency Care, APHP - Hôpital Robert Debré, 48 Boulevard Serurier, 75019, Paris, France
| | - Andrea Scala
- Department of Abdominal Surgery, NHS, Guildford, UK
| | - Marianne Alison
- Department of Pediatric Radiology, APHP - Hôpital Robert Debré, Paris, France.,NeuroDiderot, Inserm U1141, Equipe 5 inDev - Imaging Neurodevelopmental Phenotypes, HU I2D2, 75019, Paris, France
| | - Van Dai Vo Chieu
- Department of Pediatric Radiology, APHP - Hôpital Robert Debré, Paris, France
| | | | - Luigi Titomanlio
- Department of Pediatric Emergency Care, APHP - Hôpital Robert Debré, 48 Boulevard Serurier, 75019, Paris, France.,Paris University, INSERM U1141, DHU Protect, Paris, France
| | - Léa Lenglart
- Department of Pediatric Emergency Care, APHP - Hôpital Robert Debré, 48 Boulevard Serurier, 75019, Paris, France.
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Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Ovarian torsion. Am J Emerg Med 2022; 56:145-150. [PMID: 35397355 DOI: 10.1016/j.ajem.2022.03.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity. OBJECTIVE This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence. DISCUSSION Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED. CONCLUSIONS An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Ovarian Torsion: Presentation and Management in a Pediatric Patient. Case Rep Obstet Gynecol 2022; 2022:9419963. [PMID: 35402055 PMCID: PMC8984062 DOI: 10.1155/2022/9419963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background. Adnexal torsion is the fifth most common gynecologic emergency accounting for approximately 20 to 30% of ovarian surgeries in pediatric patients. Case. The patient is a ten-year-old female who presented to the emergency room for severe left lower quadrant abdominal pain. On presentation, she was hemodynamically stable with an acute abdomen. A transabdominal ultrasound showed a predominantly anechoic structure measuring up to 5.6 cm without definitive Doppler flow, concerning for a large cyst causing ovarian torsion. Gynecology was consulted, and the patient underwent a diagnostic laparoscopy, aspiration of the left ovarian cyst, and left ovarian detorsion. Pathology results were consistent with benign cystic contents. Conclusion. Appropriate diagnosis and timely surgical gynecological intervention allowed this pediatric patient to salvage and preserve ovarian function.
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Characteristics and Risk Factors for Ischemic Ovary Torsion in Children. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020206. [PMID: 35204926 PMCID: PMC8869959 DOI: 10.3390/children9020206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/04/2022] [Indexed: 01/02/2023]
Abstract
Identifying ischemic ovary as a complication of ovary torsion (OT) is a significant challenge in children. This study identified risk factors for ischemic OT among pediatric OT patients to prevent delayed treatment. This retrospective study included pediatric inpatients who underwent operation for OT over 20 years. We employed multivariable logistic regression to find the risk factors associated with ischemic OT. Among the 118 patients included in this study, 78 (66.1%) had ischemic OT. Patients with ischemic OT tended to be younger; had more frequent vomiting; and had elevated White blood cell (WBC), C-Reactive protein (CRP), and segments in comparison with non-ischemic OT patients. Multivariable regression showed increased odds of ischemic ovary torsion, associated with higher WBC (12.3 × 103/mm3 vs. 8.7 × 103/mm3, p < 0.001), CRP (50.4 mg/L vs. 8.4 mg/L, p < 0.001), and vomiting (55.1% vs. 25%, p = 0.002) than in non-ischemic patients. A receiver-operating characteristic (ROC) analysis indicated that patients with vomiting, leukocytosis, or CRP ≧ 40 mg/L were more likely to have ischemic OT (sensitivity, 92%; specificity, 54%; PPV, 79.6; NPV, 78.9%). Ischemic OT is common among pediatric OT patients. The presence of potential risk factors of vomiting, leukocytosis, and CRP more significant than 40 mg/L may assist clinicians in ensuring an expedited surgical treatment.
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Kaplan S, Türk A. Effects of vitamin B12 on rat ovary with ischemia-reperfusion injury. Biotech Histochem 2021; 97:284-289. [PMID: 34353191 DOI: 10.1080/10520295.2021.1961863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
We investigated the histopathological and biochemical effects of vitamin B12 on ischemia-reperfusion (I-R) injury using a rat ovarian torsion-detorsion model. We used four groups of female Wistar albino rats. Group 1 (sham group): both ovaries were removed. Group 2 (torsion group): ovarian torsion was established. Group 3 (torsion-detorsion group) perfusion was retored after ischemia for 2 h. Group 4 (torsion-detorsion-vitamin B12 group): after 2 h ovarian torsion, perfusion was re-established and 4 mg/kg vitamin B12 was administered for 2 h. Follicular degeneration, vascular congestion, hemorrhage, edema and infiltration were evaluated histologically. Tissue damage was decreased in group 4 compared to groups 2 and 3. Total antioxidant status TAS), total oxidant status (TOS) and malondialdehyde (MDA) level were measured. The values for TOS and MDA for groups 1 and 4 were similar. We found a significant increase in MDA and TOS levels in group 3 compared to group 2. MDA and TAS levels decreased and TOS levels were increased in group 4 compared to groups 2 and 3. MDA, TAS and TOS values were increased in groups 2 and 3 compared to group 1. We found that vitamin B12 reduced I-R damage in the rat ovary.
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Affiliation(s)
- Selçuk Kaplan
- Department of Gynecology and Obstetrics, Adıyaman Univercity School of Medicine, Adıyaman, Turkey
| | - Ahmet Türk
- Department of Histology and Embryology, Adıyaman Univercity School of Medicine, Adıyaman, Turkey
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Corre A, Dandekar S, Lau C, Ranasinghe L. A Case Report of Pediatric Ovarian Torsion: The Importance of Diagnostic Laparoscopy. Clin Pract Cases Emerg Med 2021; 5:109-112. [PMID: 33560966 PMCID: PMC7872599 DOI: 10.5811/cpcem.2020.12.50319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/31/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Pediatric ovarian torsion is a relatively rare occurrence with chances of significant morbidity and possible mortality if not treated emergently. Case Report In this report, we review a case of pediatric ovarian torsion in a nine-year-old that was difficult to diagnose on initial presentation to the hospital due to various factors, which inevitably led to delayed resolution. Conclusion We discuss the diagnosis of pediatric ovarian torsion including risk factors, symptoms, imaging modalities, and surgical diagnostics. To improve diagnosis and shorten time to treatment, this case supports the use of laparoscopy for diagnosis of ovarian torsion if indicated by clinical suspicion and supplemental imaging studies.
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Affiliation(s)
- Alana Corre
- California Northstate University College of Medicine, Elk Grove, California
| | - Shebani Dandekar
- California Northstate University College of Medicine, Elk Grove, California
| | - Christopher Lau
- Kaiser Permanente, Department of Emergency Medicine, Modesto, California
| | - Leonard Ranasinghe
- California Northstate University College of Medicine, Elk Grove, California
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Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without an adnexal mass. J Pediatr Surg 2021; 56:180-182. [PMID: 33121739 DOI: 10.1016/j.jpedsurg.2020.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE The aims of this study were to identify ultrasound-based predictors of ovarian torsion in girls without an adnexal mass and establish a set of normal values for ovarian volume ratio (OVR). METHODS A retrospective review was performed of all premenarchal patients ≥3 years of age with a normal pelvic ultrasound between January 2016 and January 2019. A comparison group of premenarchal girls presenting between 2011 and 2019 with torsion in the absence of an adnexal mass was utilized. RESULTS Five-hundred and four premenarchal girls underwent pelvic ultrasound evaluation with a normal examination. The mean OVR was 1.6 ± 0.7 (range 1.0-6.5). OVR did not vary with age (r = -0.06) as compared to ovarian width which increased steadily with age (r = 0.53, p < 0.001). OVR was increased in girls with torsion (7.6 vs 1.4, p < 0.0001), and by receiver operating characteristic (ROC) analysis a cutoff value of >2.5 demonstrated the best diagnostic accuracy of any predictive variable (sensitivity 100%, specificity 94%, AUC 0.991, p < 0.001). CONCLUSIONS OVR is an excellent predictor of ovarian torsion in premenarchal girls without an adnexal mass. Unlike ovarian width, OVR does not increase with age, and a cutoff OVR > 2.5 demonstrates high sensitivity and specificity for identifying ovarian torsion in this population. TYPE OF STUDY Study of diagnostic test. LEVEL OF EVIDENCE Level III.
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Bardin R, Perl N, Mashiach R, Ram E, Orbach-Zinger S, Shmueli A, Wiznitzer A, Hadar E. Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2020; 41:688-694. [PMID: 31703238 DOI: 10.1055/a-1014-2593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion. MATERIALS AND METHODS Retrospective cohort analysis of 322 women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion. RESULTS The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026). CONCLUSION Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.
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Affiliation(s)
- Ron Bardin
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Noga Perl
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Reuven Mashiach
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Eitan Ram
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | | | - Anat Shmueli
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Arnon Wiznitzer
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Eran Hadar
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
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15
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Moro F, Bolomini G, Sibal M, Vijayaraghavan SB, Venkatesh P, Nardelli F, Pasciuto T, Mascilini F, Pozzati F, Leone FPG, Josefsson H, Epstein E, Guerriero S, Scambia G, Valentin L, Testa AC. Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:934-943. [PMID: 31975482 DOI: 10.1002/uog.21981] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 12/31/2019] [Accepted: 01/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To describe the clinical and ultrasound characteristics of adnexal torsion. METHODS This was a retrospective study. From the operative records of the eight participating gynecological ultrasound centers, we identified patients with a surgically confirmed diagnosis of adnexal torsion, defined as surgical evidence of ovarian pedicle, paraovarian cyst and/or Fallopian tube twisted on its own axis, who had undergone preoperative ultrasound examination by an experienced examiner, between 2008 and 2018. Only cases with at least two available ultrasound images and/or videoclips (one grayscale and one with Doppler evaluation) were included. Clinical, ultrasound, surgical and histological information was retrieved from each patient's medical record and entered into an Excel file by the principal investigator at each center. In addition, two authors reviewed all available ultrasound images and videoclips of the twisted adnexa, with regard to the presence of four predefined ultrasound features reported to be characteristic of adnexal torsion: (1) ovarian stromal edema with or without peripherally displaced antral follicles, (2) the follicular ring sign, (3) the whirlpool sign and (4) absence of vascularization in the twisted organ. RESULTS A total of 315 cases of adnexal torsion were identified. The median age of the patients was 30 (range, 1-88) years. Most patients were premenopausal (284/314; 90.4%) and presented with acute or subacute pelvic pain (305/315; 96.8%). The surgical approach was laparoscopic in 239/312 (76.6%) patients and conservative surgery (untwisting with or without excision of a lesion) was performed in 149/315 (47.3%) cases. According to the original ultrasound reports, the median largest diameter of the twisted organ was 83 (range, 30-349) mm. Free fluid in the pouch of Douglas was detected in 196/275 (71.3%) patients. Ovarian stromal edema with or without peripherally displaced antral follicles was reported in the original ultrasound report in 167/241 (69.3%) patients, the whirlpool sign in 178/226 (78.8%) patients, absent color Doppler signals in the twisted organ in 119/269 (44.2%) patients and the follicular ring sign in 51/134 (38.1%) patients. On retrospective review of images and videoclips, ovarian stromal edema with or without peripherally displaced antral follicles (201/254; 79.1%) and the whirlpool sign (139/153; 90.8%) were the most commonly detected features of adnexal torsion. CONCLUSION Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Common ultrasound signs are an enlarged adnexa, the whirlpool sign, ovarian stromal edema with or without peripherally displaced antral follicles and free fluid in the pelvis. The follicular ring sign and absence of Doppler signals in the twisted organ are slightly less common signs. Recognizing ultrasound signs of adnexal torsion is important so that the correct treatment, i.e. surgery without delay, can be offered. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Moro
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - G Bolomini
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - M Sibal
- Department of Fetal Medicine and Obstetric and Gynecologic Ultrasound, Manipal Hospital, Bangalore, India
| | | | - P Venkatesh
- Department of Fetal Medicine and OBGYN Ultrasound, Manipal Hospital, Bangalore, India
| | - F Nardelli
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Institute for Women's Health, University College Hospital, London, UK
| | - T Pasciuto
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - F Mascilini
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - F Pozzati
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - F P G Leone
- Department of Obstetrics and Gynecology, Biomedical and Clinical Sciences Institute L. Sacco, University of Milan, Milan, Italy
| | - H Josefsson
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden
| | - E Epstein
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - G Scambia
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - A C Testa
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
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Smorgick N, Nir O, Pekar-Zlotin M, Maymon S, Pansky M, Maymon R. Long-Term Ultrasound Follow-Up After Pediatric Adnexal Torsion. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2020; 41:404-409. [PMID: 31238383 DOI: 10.1055/a-0858-2240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE Conservative surgical management of adnexal torsion in pre- and post-menarchal girls by de-torsion and adnexal conservation is the current standard of care. The aim of this study is to investigate the long-term outcome of adnexal torsion in this population in terms of ultrasound appearance and ovarian volume. METHODS Patients who were surgically treated for adnexal torsion and were < 18 years old at time of surgery were prospectively invited for ultrasound follow-up. The ultrasound exam included measurements of ovarian volume and grayscale appearance including identification of ovarian follicular activity. RESULTS 84 cases of torsion in this population were identified, and 37 of them were included in the study. Of those, the affected ovary could not be demonstrated on follow-up scan in six (16.2 %) cases. A difference of ≥ 2 cm3 in ovarian volume between the affected and non-affected ovaries was diagnosed in 12 (32.4 %) cases, but follicular activity was observed in 10 of those. Thus, possible ovarian injury (including cases of non-demonstrated ovary and volume difference of ≥ 2 cm3 between the affected and non-affected ovaries) was found in 18 (48.6 %) cases. Of the clinical and surgical parameters (including age at time of torsion, duration of pain prior to admission, cystectomy procedure and intraoperative "bluish" appearance of the ovary), only the presence of fever on admission was significantly associated with possible ovarian injury (p = 0.01). CONCLUSION Long-term ultrasound follow-up of pre- and post-menarchal girls with a history of adnexal torsion may identify patients with adversely affected ovarian volume. The significance of this finding in terms of fertility is unknown.
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Affiliation(s)
- Noam Smorgick
- Obstetrics & Gynecology department affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Asaf Harofe medical center, Zerifin, Israel
| | - Omer Nir
- Obstetrics & Gynecology department affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Asaf Harofe medical center, Zerifin, Israel
| | - Marina Pekar-Zlotin
- Obstetrics & Gynecology department affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Asaf Harofe medical center, Zerifin, Israel
| | - Shlomit Maymon
- Obstetrics & Gynecology department affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Asaf Harofe medical center, Zerifin, Israel
| | - Moty Pansky
- Obstetrics & Gynecology department affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Asaf Harofe medical center, Zerifin, Israel
| | - Ron Maymon
- Obstetrics & Gynecology department affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Asaf Harofe medical center, Zerifin, Israel
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17
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Pade KH, Waterhouse MR. Case 4: 1 Month of Constipation and Abdominal Pain in a 2-year-old Girl. Pediatr Rev 2020; 41:369-372. [PMID: 32611803 DOI: 10.1542/pir.2017-0228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Kathryn H Pade
- Department of Emergency Medicine, Rady Children's Hospital, San Diego, CA
| | - Marie R Waterhouse
- Department of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA
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18
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Abstract
An adolescent female patient presented to the emergency department with diffuse, severe lower abdominal pain and vomiting. The initial suspected diagnosis was appendicitis. Point-of-care ultrasound did not visualize the appendix but demonstrated a suspected left ovarian torsion, which was confirmed by radiology-performed ultrasound. The clinical presentation, in combination with images obtained via point-of-care ultrasound, helped to expedite gynecology consultation and immediate surgery.
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19
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Northridge JL. Adnexal Masses in Adolescents. Pediatr Ann 2020; 49:e183-e187. [PMID: 32275763 DOI: 10.3928/19382359-20200227-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Adnexal masses in adolescents, such as functional cysts, are often benign and can usually be managed expectantly since they typically regress on their own. The most common ovarian neoplasm in adolescents is a benign cystic teratoma. Both functional cysts and benign cystic teratomas are associated with ovarian torsion. Of concern, ovarian torsion requires a high level of suspicion when adolescents present with acute abdominal pain, as almost one-half of cases have no associated adnexal masses. The most common malignant adnexal masses in this age group include germ cell tumors, followed by epithelial cell tumors. Finally, ectopic pregnancy and tubo-ovarian abscesses must be considered in the differential diagnosis of adnexal mass, as delays in treatment may seriously affect an adolescent's health and future fertility. Obtaining an accurate history, including a sexual history, requires reviewing this history with the adolescent privately. Management of adnexal mases should prioritize fertility preservation. [Pediatr Ann. 2020;49(4):e183-e187.].
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20
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Adnexal Torsion in Pediatric Age: Does Bolli's Score Work? Report of Two Cases. Case Rep Obstet Gynecol 2019; 2019:9701874. [PMID: 31885967 PMCID: PMC6925918 DOI: 10.1155/2019/9701874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/27/2019] [Accepted: 10/16/2019] [Indexed: 11/26/2022] Open
Abstract
Adnexal torsion is a surgical emergency requiring early diagnosis in order to avoid demolitive surgery. Adnexal torsion's diagnosis could be very difficult in pediatric patients because children cannot explain symptoms accurately. Furthermore reproductive organs lie high in abdomen, causing unclear examinations findings. For reducing diagnostic mistakes or delay clinical and hematological criteria could be useful. No radiological criteria (CT or MRI) should be taken in count because of the costs and the required time. By combining clinical presentation in patients with OT three useful diagnostic variables have been identified: age, duration of pain, vomiting. Presence of vomiting, short duration of abdominal pain and high CRP levels have great predictive value for the diagnosis of adnexal torsion. In those patients an exploratory laparoscopy should be performed without any doubt and/or delay. These data may aid physicians in the evaluation of abdominal pain in premenarchal girls.
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21
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Prieto JM, Kling KM, Ignacio RC, Bickler SW, Fairbanks TJ, Saenz NC, Nicholson SI, Lazar DA. Premenarchal patients present differently: A twist on the typical patient presenting with ovarian torsion. J Pediatr Surg 2019; 54:2614-2616. [PMID: 31500875 DOI: 10.1016/j.jpedsurg.2019.08.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 08/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to characterize differences between pre- and postmenarchal females with ovarian torsion. METHODS A single-center review was conducted of all nonneonatal pediatric patients with ovarian torsion from 2011 to 2018. Clinical data were compared between pre- and postmenarchal patients. RESULTS One hundred and twenty-seven patients were identified, and 25% were premenarchal. Premenarchal patients were more likely to have a delay in diagnosis (38% vs 20%, p = 0.042), develop ovarian necrosis (34% vs 17%, p = 0.036), and present without an associated adnexal mass (44% vs 0%, p < 0.001). All patients without a mass (n = 14) were premenarchal and presented with ovarian asymmetry. Patients without an associated mass underwent oophoropexy in the majority of cases. There were no differences in postoperative complication or recurrence rates between groups. CONCLUSION Premenarchal females with ovarian torsion can present differently than females postmenarche and often have a delay in diagnosis. Premenarchal females are more likely to undergo torsion without an associated adnexal mass and are at higher risk for ovarian necrosis. Oophoropexy is an appropriate treatment in the absence of an adnexal mass. A high-index of suspicion for ovarian torsion should be maintained for premenarchal females presenting with abdominal pain and an otherwise negative workup. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- James M Prieto
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego; Department of Surgery, Naval Medical Center San Diego
| | - Karen M Kling
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego
| | - Romeo C Ignacio
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego
| | - Stephen W Bickler
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego
| | - Timothy J Fairbanks
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego
| | - Nicholas C Saenz
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego
| | - Sneha I Nicholson
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego
| | - David A Lazar
- Division of Pediatric Surgery, Department of Surgery, University of California San Diego.
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Abstract
The emergency medicine provider sees a broad range of pathology involving the female genitourinary system on a daily basis. Must-not-miss diagnoses include pelvic inflammatory disease and ovarian torsion, because these diagnoses can have severe complications and affect future fertility. Although most patients with abnormal uterine bleeding are hemodynamically stable, it can present as a life-threatening emergency and providers should be adept managing severe hemorrhage. Bartholin gland cysts are common complaints that often require procedural intervention. This article discusses these diagnoses and appropriate evaluation and management in the emergency department.
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Affiliation(s)
- Sarah Mahonski
- Heritage Valley Health System, 1000 Dutch Ridge Road, Beaver, PA 15009, USA
| | - Kami M Hu
- Emergency/Internal/Critical Care Medicine, University of Maryland, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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23
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24
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Warwar RE, Schmidt GE. Bilateral ovarian torsion with ovarian fusion in the setting of polycystic ovarian syndrome: A case report. Case Rep Womens Health 2019; 23:e00129. [PMID: 31431889 PMCID: PMC6580322 DOI: 10.1016/j.crwh.2019.e00129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 11/24/2022] Open
Abstract
Background Case Conclusion Polycystic ovarian syndrome is a risk factor for ovarian torsion because the ovaries are enlarged and heavy. De-torsion with adnexal conservation is favored over removal of the adnexa because of its high rate of functional preservation. Oophoropexy should be considered for the prevention of recurrence of torsion when there is no removable ovarian pathology.
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25
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Sze A, Fogel J, Grotell L, Tetrokalashvili M. Predictors of Ovarian Torsion: Clinical and Sonographic Characteristics. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2018.0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Angelica Sze
- Department of Obstetrics and Gynecology, Nassau University Medical Center, East Meadow, NY
| | - Joshua Fogel
- Department of Business Management, Brooklyn College, Brooklyn, NY
| | - Lauren Grotell
- Department of Obstetrics and Gynecology, Nassau University Medical Center, East Meadow, NY
| | - Maggie Tetrokalashvili
- Department of Obstetrics and Gynecology, Nassau University Medical Center, East Meadow, NY
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Ovarian Torsion in Premenarchal Girls. J Pediatr Adolesc Gynecol 2019; 32:254-258. [PMID: 30367984 DOI: 10.1016/j.jpag.2018.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To investigate characteristics that differentiate premenarchal girls with ovarian torsion (OT) from those without OT at the time of surgery. DESIGN Retrospective chart review of 36 premenarchal girls who underwent 42 surgeries for either OT (n = 33) or a nontorsed ovarian mass (n = 9) from 2006 to 2017. SETTING Large, tertiary care academic institution. PARTICIPANTS We included patients aged 0-12 years with International Classification of Diseases, Ninth Revision codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube. Controls had International Classification of Diseases, Ninth Revision codes for ovarian mass or cyst, who also underwent surgery and did not have OT. INTERVENTIONS Records were reviewed for patient characteristics including laboratory and imaging studies, surgical intervention, and pathologic diagnosis. Fischer exact test and the nonparametric Mann-Whitney U test were used for statistical analysis. MAIN OUTCOME MEASURES Characteristics predictive of OT in premenarchal girls. RESULTS Twenty-nine premenarchal patients were diagnosed with 33 episodes of OT. Nine patients underwent surgery for ovarian masses but did not have OT. All patients with OT reported abdominal pain (compared with 55.6% without OT; P < .001) and most had nausea and/or emesis (81.8% vs 33.3%; P < .009). Ultrasound findings of ovarian enlargement and decreased Doppler flow were significant in the OT group (P < .083, P < .009). There were 2 cases of malignancy in each group. CONCLUSION Patients with OT had significantly more nausea, emesis, and abdominal pain compared with those without OT. Additionally, 2 of 4 malignancies were found in patients with OT, indicating that malignancy should still be considered with large, complex masses.
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27
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Isolated Tubal Torsion after Tubal Ligation. J Minim Invasive Gynecol 2019; 26:595-596. [DOI: 10.1016/j.jmig.2018.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 11/23/2022]
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28
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Huang C, Hong MK, Chu TY, Ding DC. A retrospective study of surgical treatment and outcome among women with adnexal torsion in eastern Taiwan from 2010 to 2015. PeerJ 2018; 6:e5995. [PMID: 30533300 PMCID: PMC6284449 DOI: 10.7717/peerj.5995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background Adnexal torsion is a gynecologic emergency that requires surgical treatment. In this study, we reviewed the surgical outcomes of women with adnexal torsion in eastern Taiwan (Hualien county, area 4,629 km2, 330,000 residents). Methods This retrospective study included 42 women diagnosed with surgically-proven adnexal torsion from January 1, 2010, to September 31, 2015. We compared the symptoms, objective findings, and surgical outcomes of patients who underwent laparotomy or laparoscopy. Results The laparoscopy and laparotomy groups included 27 and 15 patients, respectively. The most common symptom and sign was abdominal pain, followed by nausea and vomiting. In all patients, an adnexal tumor was detected through ultrasound. The median and range of time from admission to surgery was 1.5 (1–11.5) and 1.0 (1–11) hours in the laparotomy and laparoscopy groups, respectively. Compared with those undergoing laparotomy, the smaller tumor size [7 (4.2–10) vs. 10 (7–17) cm] and shorter hospital stay [4 (2–8) vs. 6 (3–9) days] in patients undergoing laparoscopy were significantly noted, respectively (P < 0.01). No differences were observed in age, operative time, and blood loss between both groups. The surgeries performed were mostly detorsion with cystectomy and adnexectomy. The most common pathology was a simple ovarian cyst, followed by teratoma. Regarding the surgical types, older age is the only risk factor for radical surgery. Discussion Acute onset of abdominal pain with a presenting ovarian tumor is the most common feature of adnexal torsion. Laparoscopic surgical group showed a small tumor size and a short ER hospital stay than laparotomy. Older age is the risk factor for radical surgery.
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Affiliation(s)
- Ci Huang
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan, Taiwan
| | - Mun-Kun Hong
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan, Taiwan
| | - Tang-Yuan Chu
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Tawian, Taiwan
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Schwartz BI, Huppert JS, Chen C, Huang B, Reed JL. Creation of a Composite Score to Predict Adnexal Torsion in Children and Adolescents. J Pediatr Adolesc Gynecol 2018; 31:132-137. [PMID: 28847757 DOI: 10.1016/j.jpag.2017.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/13/2017] [Accepted: 08/18/2017] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To create a composite score to predict adnexal torsion in children and adolescents. DESIGN A prospective cross-sectional study. SETTING Emergency department of a tertiary care children's hospital. PARTICIPANTS Three hundred twenty-four female participants aged 6-21 years who presented to the emergency department with lower abdominal pain and underwent ultrasound or computed tomography imaging. INTERVENTIONS Collection of possible clinical and radiologic predictors of torsion. MAIN OUTCOME MEASURES The primary outcome was a composite score to predict adnexal torsion. We used χ2 analyses to identify possible risk factors. The classification and regression tree decision method was used to identify risk factor cutoff points. Independent risk factors were combined into a composite score. Receiver operating characteristic curve analyses were used to assessed score performance. RESULTS Of 324 participants with abdominal pain, 241 underwent imaging, and 6.6% (16 of 241) had torsion. Duration of pain, intermittent pain, nausea, and absence of arterial or venous flow were not associated with torsion. Vomiting (P = .05 in premenarchal subjects; P < .001 in menarchal subjects), adnexal volume (P = .008 in premenarchal subjects; P < .001 in menarchal subjects), and adnexal volume ratio (P = .04 in premenarchal subjects; P < .001 in menarchal subjects) were independent predictors of torsion. These predictors were incorporated into a composite score. No torsions were identified with a score of less than 2. There was an increasing risk of torsion for each 1-point score increase. CONCLUSION Independent predictors of torsion can reliably be combined into a composite score to identify children and adolescents at risk for adnexal torsion. This score might aid in improving triage and management of these challenging patients.
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Affiliation(s)
- Beth I Schwartz
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Jill S Huppert
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer L Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Taylor JE, Spinale R. Asynchronous Bilateral Ovarian Torsion. J Osteopath Med 2017; 117:403. [PMID: 28556864 DOI: 10.7556/jaoa.2017.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gonzalez DO, Cooper JN, Aldrink JH, Hewitt GD, Fallat ME, Minneci PC, Deans KJ. Variability in surgical management of benign ovarian neoplasms in children. J Pediatr Surg 2017; 52:944-950. [PMID: 28343661 DOI: 10.1016/j.jpedsurg.2017.03.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/09/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND/PURPOSE Although most pediatric ovarian neoplasms are benign and may be treated with ovary-sparing surgery (OSS), consensus is lacking on the optimal surgical approach. We aimed to determine the proportion of pediatric benign ovarian neoplasms managed with OSS and to assess variability in management across hospitals and specialties. METHODS Using the Pediatric Health Information System, we studied patients aged 6-21 years treated in 2006-2014 for a benign ovarian neoplasm with oophorectomy or OSS. Inter-hospital variability and predictors of the type of surgery were determined using logistic mixed effects models with random hospital effects. RESULTS Of 1164 patients with benign ovarian neoplasms, 646 underwent oophorectomy, and 518 underwent OSS. Across hospitals, there was significant variability in the proportion of OSS (range: 21.7-76.6%). In multivariable analysis, patients managed by pediatric surgeons (vs. pediatric and adolescent gynecologists) (OR: 0.27, 95%CI: 0.17-0.43, p<0.001), younger patients (OR: 0.94 per year, 95%CI: 0.90-0.98, p=0.007), and those admitted through the emergency department (OR: 0.76, 95%CI: 0.58-0.99, p=0.04) were less likely to undergo OSS. Inter-hospital variability remained significant after adjusting for relevant patient and hospital characteristics (p<0.001). CONCLUSIONS Significant variability exists in management of benign ovarian neoplasms across hospitals and specialties. Collaborative efforts between treating specialists may improve implementation of evidence-based guidelines for OSS. TYPE OF STUDY retrospective study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Dani O Gonzalez
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Geri D Hewitt
- Department of Surgery, Division of Obstetrics and Gynecology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Mary E Fallat
- Department of Surgery, Division of Pediatric Surgery, University of Louisville, Kosair Children's Hospital, Louisville, KY
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH.
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Robertson JJ, Long B, Koyfman A. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med 2017; 52:449-456. [PMID: 27988260 DOI: 10.1016/j.jemermed.2016.11.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/15/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
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Trotman GE, Cheung H, Tefera EA, Darolia R, Gomez-Lobo V. Rate of Oophorectomy for Benign Indications in a Children's Hospital: Influence of a Gynecologist. J Pediatr Adolesc Gynecol 2017; 30:234-238. [PMID: 27769688 DOI: 10.1016/j.jpag.2016.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To compare the rates of oophorectomy performed by pediatric surgeons for benign indications before and after the addition of a gynecologist to the surgical staff of a children's hospital. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We used a retrospective chart review of patients ages 5-21 years who underwent surgical management by pediatric surgeons for benign adnexal indications at a tertiary care children's hospital. Patient characteristics and clinical outcomes were recorded. Rates of oophorectomy for patients managed before the addition of a gynecologist (1998-2004) were compared with those managed after a gynecologist joined the surgical staff (2005-2013). Logistic regression analysis was conducted to compare the likelihood of oophorectomy before and after the addition of a gynecologist to the surgical staff. RESULTS One hundred sixty-five cases were included in the final analysis. Pediatric surgeons were 8 times more likely to perform an oophorectomy for benign indications before the addition of a gynecologist to the surgical staff (odds ratio, 8.3; 95% confidence interval, 3.76-18.16). Oophorectomy was performed in 45% (25/56) of cases from 1998 to 2004 compared with 11% (12/109) of cases from 2005 to 2013. Younger age (P = .009), ischemic-appearing adnexa (P < .0001), presence of torsion (P = .017), and mature teratoma (P = .041) were associated with higher likelihood of oophorectomy. CONCLUSION There was a higher rate of ovarian preservation for benign indications performed by pediatric surgeons after the addition of a gynecologist to the surgical staff. Younger patients, those with a mature teratoma, and ovarian torsion continue to be at higher risk for oophorectomy.
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Affiliation(s)
- Gylynthia E Trotman
- Children's National Health Services, Washington, District of Columbia; MedStar Washington Hospital Center, Washington, District of Columbia.
| | - Helen Cheung
- Georgetown University School of Medicine, Washington, District of Columbia
| | | | - Renuka Darolia
- MedStar Washington Hospital Center, Washington, District of Columbia
| | - Veronica Gomez-Lobo
- Children's National Health Services, Washington, District of Columbia; MedStar Washington Hospital Center, Washington, District of Columbia; Georgetown University School of Medicine, Washington, District of Columbia
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Recurrent ovarian torsion in an adolescent after oophoropexy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2016.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%-15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.
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Affiliation(s)
- Ci Huang
- Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Mun-Kun Hong
- Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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CA-125: What does that lab really mean? Diagnosis (Berl) 2016. [DOI: 10.1515/dx-2016-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Ovarian torsion is often a diagnosis of exclusion, and while less common in pre-pubertal females, it is on the differential for a pelvic mass. Tumor markers can be used to characterize a pelvic mass, with varying sensitivity and specificity. This is a case of a 10-year-old pre-pubertal female presenting with abdominal pain and found to have an ovarian mass. Her tumor markers demonstrated an elevated CA-125, increasing concern for neoplasm. This led to a delayed operative course and she was ultimately found to have an ovarian torsion. There is unclear utility of CA-125 in pediatrics and reliance on tumor markers during the work-up of an ovarian mass should be limited to avoid diagnostic error.
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