Association between pregnancy and adnexal torsion: A population-based, matched case-control study

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.

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.

Maternal disease factors associated with neonatal jaundice: a case-control study

Background

Neonatal jaundice is common, and despite the considerable medical costs associated with it, there are still few studies on the maternal factors associated with it. Identification of maternal factors associated with neonatal jaundice is very important in terms of prevention, screening and management of neonatal jaundice. The current study aimed to identify maternal disease factors associated with neonatal jaundice.

Methods

We compared the maternal disease diagnostic codes during pregnancy (study A) and 1 year before conception (study B) in mothers whose insurance claims data included newborns treated for neonatal jaundice before birth registration via the National Health Insurance Service–National Sample Cohort (control group). To decrease the effect of confounding variables, the neonatal jaundice and control groups were matched at a ratio of 1:10 via propensity score matching using covariates including age and income.

Results

The matched samples for studies A and B included 4,026 and 3,278 (jaundice group: 366 and 298) delivery cases, respectively. In both studies, the jaundice group had a higher proportion of patients who underwent cesarean section than the control group. In study A, other diseases of the digestive system had the highest odds ratio (OR) (K92; adjusted OR: 14.12, 95% confidence interval [CI]: 2.70–82.26). Meanwhile, gastritis and duodenitis had the lowest OR (K29; adjusted OR: 0.39, 95% CI: 0.22–0.69). In study B, salpingitis and oophoritis had the highest OR (N70; adjusted OR: 3.33, 95% CI: 1.59–6.94). Heartburn had the lowest OR (R12; adjusted OR: 0.29, 95% CI:0.12–0.71).

Conclusions

This study identified maternal disease factors correlated with neonatal jaundice during pregnancy and 1 year before conception. Maternal risk factors for neonatal jaundice included syphilis and leiomyoma during pregnancy, and salpingo-oophoritis before pregnancy. The protective factors included infection, inflammatory diseases, and dyspepsia.

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.

Adnexal Torsion: Review of Radiologic Appearances

Adnexal torsion is the twisting of the ovary, and often of the fallopian tube, on its ligamental supports, resulting in vascular compromise and ovarian infarction. The definitive management is surgical detorsion, and prompt diagnosis facilitates preservation of the ovary, which is particularly important because this condition predominantly affects premenopausal women. The majority of patients present with severe acute pain, vomiting, and a surgical abdomen, and the diagnosis is often made clinically with corroborative US. However, the symptoms of adnexal torsion can be variable and nonspecific, making an early diagnosis challenging unless this condition is clinically suspected. When adnexal torsion is not clinically suspected, CT or MRI may be performed. Imaging has an important role in identifying adnexal torsion and accelerating definitive treatment, particularly in cases in which the diagnosis is not an early consideration. Several imaging features are characteristic of adnexal torsion and can be seen to varying degrees across different modalities: a massive, edematous ovary migrated to the midline; peripherally displaced ovarian follicles resembling a string of pearls; a benign ovarian lesion acting as a lead mass; surrounding inflammatory change or free fluid; and the uterus pulled toward the side of the affected ovary. Hemorrhage and absence of internal flow or enhancement are suggestive of ovarian infarction. Pertinent conditions to consider in the differential diagnosis are a ruptured hemorrhagic ovarian cyst, massive ovarian edema, ovarian hyperstimulation, and a degenerating leiomyoma. Online supplemental material is available for this article. ^©RSNA, 2021.

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.

Laparoscopic detorsion of the ovary in ovarian hyperstimulation syndrome during the sixth week of gestation: A case report and review

INTRODUCTION

Ovarian torsion in ovarian hyperstimulation syndrome (OHSS) is a relatively rare but serious complication in pregnant women. A delay in treatment increases the risk for functional loss of the ovary and early termination of pregnancy. In this report, we present the case of a 40-year-old female with OHSS who experienced ovarian torsion that was successfully treated with laparoscopic detorsion.

PRESENTATION OF CASE

A 40-year-old pregnant woman in the 6th week of gestation who had conceived following in vitro fertilization presented to us with severe and persistent lower abdominal pain. Ultrasound examination revealed a viable singleton intrauterine pregnancy and bilateral enlarged ovaries with scanty ascites. Approximately 14 h after symptom onset, exploratory laparoscopy was performed. The right ovary was found to be twisted once around over the pedicle, and laparoscopic detorsion was completed. Postoperative follow-up was uneventful, and she successfully delivered a healthy infant at 38 weeks of gestation.

DISCUSSION

Although the reports on successful laparoscopic surgery for pregnant women with ovarian torsion are becoming more frequent, there are few reports on laparoscopic surgery for ovarian torsion in OHSS during the early first trimester. Optimal management of ovarian torsion during pregnancy needs to be explored for these patients.

CONCLUSION

Immediate explorative laparoscopic surgery is a potentially safe and useful strategy for treating ovarian torsion during the early first trimester of pregnancy.

Erratum: Medicine, Volume 95, Issue 24: Erratum

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