Preoperative sonographic and clinical characteristics as predictors of ovarian torsion

The Role of Neutrophyl-to-Lymphocyte Ratio as a Predictor of Ovarian Torsion in Children: Results of a Multicentric Study

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.

Key clinical predictors in the diagnosis of ovarian torsion in children

OBJECTIVE

Ovarian torsion (OT) represents a severe gynecological emergency in female pediatric patients, necessitating immediate surgical intervention to prevent ovarian ischemia and preserve fertility. Prompt diagnosis is, therefore, paramount. This retrospective study set out to assess the utility of combined clinical, ultrasound, and laboratory features in diagnosing OT.

METHODS

The authors included 326 female pediatric patients aged under 14 years who underwent surgical confirmation of OT over a five-year period. Logistic regression analysis was employed to pinpoint factors linked with OT, and the authors compared clinical presentation, laboratory results, and ultrasound characteristics between patients with OT (OT group) and without OT (N-OT group). The authors conducted receiver operating characteristic (ROC) curve analysis to gauge the predictive capacity of the combined features.

RESULTS

Among 326, OT was confirmed in 24.23 % (79 cases) of the patients. The OT group had a higher incidence of prenatal ovarian masses than the N-OT (22 cases versus 7 cases) (p < 0.0001). Similarly, the authors observed significant differences in the presence of lower abdominal pain, suspected torsion on transabdominal ultrasound, and a high neutrophil-lymphocyte ratio (NLR > 3) between the OT and non-OT groups (p ˂ 0.05). Furthermore, when these parameters were combined, the resulting area under the curve (AUC) was 0.868, demonstrating their potential utility in OT diagnosis.

CONCLUSION

This study demonstrates a prediction model integrating clinical, laboratory, and ultrasound findings that can support the preoperative diagnosis of ovarian torsion, thereby enhancing diagnostic precision and improving patient management. Future prospective studies should concentrate on developing clinical predictive models for OT in pediatric patients.

Ovarian Salvage With Prompt Surgical Intervention for Adnexal Torsion: Does Timing Matter?

BACKGROUND

Adnexal torsion requires treatment to limit ischemic injury and tissue loss. Optimal time to surgical intervention has not been established. We compared outcomes of ovarian loss amongst pediatric patients.

METHODS

We conducted a retrospective review of 88 patients with adnexal torsion from March 2014 through April 2021. Rates of ovarian loss were compared for patients who underwent surgery within and beyond 60 minutes from diagnosis.

RESULTS

Most patients underwent surgery more than 60 minutes from the time of diagnosis (83%; median time 116 minutes). Comparing patients with and without ovarian loss, there was no statistically significant difference in time to surgery from time of diagnosis (P = .618). Patients with ovarian loss had a longer duration of symptoms (24 vs 96 hours; P = .017).

CONCLUSIONS

While surgical repair of adnexal torsion may be urgent, this study suggests that duration of symptoms should be considered when assessing a patient's likelihood of ovarian loss.

Can Natural Language Processing Improve Adnexal Torsion Predictions?

STUDY OBJECTIVE

To create a decision support tool based on machine learning algorithms and natural language processing (NLP) technology, to augment clinicians' ability to predict cases of suspected adnexal torsion.

DESIGN

Retrospective cohort study SETTING: Gynecology department, university-affiliated teaching medical center, 2014-2022.

PATIENTS

This study assessed risk-factors for adnexal torsion among women managed surgically for suspected adnexal torsion based on clinical and sonographic data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The dataset included demographic, clinical, sonographic, and surgical information obtained from electronic medical records. NLP was used to extract insights from unstructured free text and unlock them for automated reasoning. The machine learning model was a CatBoost classifier that utilizes gradient boosting on decision trees. The study cohort included 433 women who met inclusion criteria and underwent laparoscopy. Among them, 320 (74%) had adnexal torsion diagnosed during laparoscopy, and 113 (26%) did not. The model developed improved prediction of adnexal torsion to 84%, with a recall of 95%. The model ranked several parameters as important for prediction. Age, difference in size between ovaries, and the size of each ovary were the most significant. The precision for the "no torsion" class was 77%, with a recall of 45%.

CONCLUSIONS

Using machine learning algorithms and NLP technology as a decision-support tool for the diagnosis of adnexal torsion is feasible. It improved true prediction of adnexal torsion to 84% and decreased cases of unnecessary laparoscopy.

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

Aim

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

Materials and Methods

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

Results

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

Conclusion

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

The value of clinical symptoms, the neutrophil-to-lymphocyte ratio, and ultrasonographic features in predicting adnexal torsion: A case-control study

AIM

Adnexal torsion remains a diagnostic challenge due to the nonspecific symptoms, sonographic features, and laboratory findings. The value of combining clinical, sonographic, and laboratory features is not well established, and controversy continues regarding their value in diagnosis. This study aimed to review sonographic, clinical, and laboratory features and to analyze their value separately and in combination, in managing and diagnosing adnexal torsions.

METHODS

The study included 278 women who underwent urgent laparoscopic surgery due to suspected adnexal torsion, according to clinical suspicion, with or without sonographic concordance. Laparoscopy findings confirmed the definitive diagnosis of torsion. Clinical laboratory and sonographic features were compared between those with and without adnexal torsion.

RESULTS

Adnexal torsion was confirmed in 110/278 (39.6%) women. In the torsion compared to nontorsion group, proportions were higher of women with acute abdominal pain in the preceding 24 h ([50] 45.5% vs. [35] 20.8%, p < 0.001), with vomiting ([45] 40.9% vs. [24] 14.3%, p < 0.001) and with suspected torsion by transvaginal sonography ([49] 44.5% vs. [23] 13.7%, p < 0.001). A high neutrophil-to-lymphocyte ratio (>3) was identified in 65 (59.1%) of the study group and 60 (35.7%) of the control group (p < 0.001). Combining the latter three findings, the predicted probability of torsion was 58%-85%, depending on the combinations.

CONCLUSIONS

A simple predictive model based on combinations of clinical, laboratory, and sonographic findings can contribute to preoperative diagnosis of adnexal torsion, with predicted probability of 85%. Our model may assist clinicians in evaluating women with suspected adnexal torsion, and improve preoperative diagnostic accuracy.

Right Iliac Fossa Pain other than Appendicitis: A Pictorial Review

Right iliac fossa pain is a common presentation. Although appendicitis is the most common surgical emergency, many other pathologies can have similar presentations and should be considered. This review describes the findings and shows examples of conditions other than appendicitis that should be examined for in a patient who presents with right iliac fossa pain, particularly if the appendix is not seen or seen to be normal.

Ultrasonographic diagnosis of adhesions, quantification of uterine wall and managerial perspectives of uterine torsion in buffaloes

The present study aimed to diagnose uterine adhesion using ultrasonography to decide the treatment approach for better survival of buffaloes suffering from uterine torsion. The peculiar visceral slide against the other abdominal organs induced by breathing was considered an absence of uterine adhesion, while the total absence of visceral slide was considered the presence of uterine adhesions on ultrasonographic examination. The 59 Mehsana buffaloes suffering from uterine torsion were divided into two groups based on the presence (Group I; n=27) or absence (group II; n=32) of adhesions. The mean pixel values (MPV) and thickness of uterine wall were also quantified in both the groups. In group I, sever type adhesions (n=16/27) were directly subjected to cesarean section (CS), while fibrinous adhesions (n=11/27) were subject to rolling by Sharma's modified Schaffer's method, and if rolling failed were further, subjected to CS and adhesions were confirm during CS. In Group II, 28 buffaloes were subjected to rolling by Sharma's modified Schaffer's method and 4 buffaloes were directly subjected to CS because of longer duration of illness (≥3 days), higher degree (≥180°), and previous field handling. The incidence of adhesions was 45.76 per cent (27/59) in buffaloes with uterine torsion. The degenerative changes such as oedematous (hyperedema - hypoechoic with anechoic trabeculae) or thin (homogenous hypoechoic), sloughing of serosa, and wall separation were observed in the uterine wall. The significantly thinner uterine wall (P=0.017) and higher MPV (P=0.001) were evident in group I than group II. The weak negative non-significant correlation between uterine wall thickness and MPV was observed in group I (r = -0.250, P = 0.147) and group II (r = -0.235, P = 0.089). The dam survival rate was 48.15 per cent (13/27) in group I and 81.25 % (26/32) in group II. There was a significant (P=0.04) association between the treatment approach and dam survival. Ultrasonography has synergistic diagnostic value for uterine adhesions by evaluating uterine surfaces beyond the reach of obstetricians during a manual clinical examination. Thereby avoiding futile efforts to relieve uterine torsion by rolling might help to improve dam survival by planning a better obstetrical maneuver to salvage buffaloes suffering from uterine torsion.

Adnexal torsion: a review of diagnosis and management strategies

PURPOSE OF REVIEW

Adnexal torsion remains a diagnostic challenge heavily reliant on high clinical suspicion, with patient presentation and imaging used as adjuncts to aid in its diagnosis. This review summarizes diagnostic and management techniques of adnexal torsion to assist providers when encountering this surgical emergency.

RECENT FINDINGS

Common findings of adnexal torsion include abdominal pain, nausea, vomiting, and adnexal mass or ovarian enlargement. An elevated neutrophil to lymphocyte ratio may be useful for diagnosis. A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion. Intraoperative visual diagnosis of ovarian death is highly inaccurate, with only 18-20% of ovaries necrotic on pathological examination. Necrotic appearing ovaries have been shown to have follicular activity on ultrasound one year postoperatively.

SUMMARY

Pelvic ultrasound remains the first-line imaging modality. In patients of reproductive age, we recommend performing detorsion with ovarian conservation, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death. Retention of ovarian function is also reliant on a timely diagnosis and intervention. We emphasize that the risk of ovarian damage/loss outweigh the risk of a diagnostic laparoscopy in patients of reproductive age.

Oophorectomy for ovarian torsion - should this be abandoned?

BACKGROUND

Management of ovarian torsion ranges from de-torsion to oophorectomy and is dependent on various factors. Oophorectomy can have significant implications for fertility and general health, thus requiring careful consideration.

AIMS

We evaluate the management of ovarian torsion at a tertiary hospital over a ten-year period and identify the predictors of oophorectomy in ovarian torsion cases.

MATERIALS AND METHODS

Inpatient notes of patients who underwent surgical management for acute ovarian torsion at a tertiary hospital in Victoria, Australia, were reviewed, from January 2008 to June 2018. We reported the incidence and predictors of oophorectomy and ovarian ischaemia and current practices in oophoropexy.

RESULTS

Our analysis included 159 patients. The incidence of oophorectomy was 47%. After confounders were adjusted, increasing age was the only significant predictor for oophorectomy. The adjusted odds ratio of having an oophorectomy based on age alone was 1.10 for each year increase in age between the ages of 15 and 68 (P = 0.001, 95% confidence interval 1.04-1.16). Of those with oophorectomy, 57% had ischaemia confirmed histologically. There were no significant predictors for ischaemia.

CONCLUSION

The incidence of oophorectomy in this audit is comparable to reported incidences in current literature. However, with increasing evidence to support ongoing ovarian function even in cases where ischaemia is histologically confirmed, this incidence could be lowered. Age was the only variable that was found to have a significant effect on the incidence of oophorectomy.

Accurate Diagnosis of Adnexal Torsion-Not Only for Expert Sonographers: A Retrospective Cohort Analysis

OBJECTIVES

The aim of the study was to evaluate the clinical and sonographic parameters associated with a correct or incorrect diagnosis of adnexal torsion made by resident/attending physicians who are not expert sonographers.

METHODS

A retrospective study design included women who presented to the Emergency Department (ED) of a tertiary medical center between 2010 and 2019 with acute lower abdominal pain, who were subsequently diagnosed laparoscopically with adnexal torsion. Women who were correctly diagnosed in the ED by an obstetrician-gynecologist who was not an expert sonographer were compared for clinical and sonographic parameters with women who were initially incorrectly diagnosed and underwent a second ultrasound examination by an expert sonographer following admission.

RESULTS

Of 118 women with surgically proven adnexal torsion, 76 were correctly diagnosed in the ED and 42 were initially incorrectly diagnosed. The correctly diagnosed group was characterized by a significantly shorter mean time from admission to surgery, higher rate of vomiting, shorter duration of abdominal pain, and higher rate of prior torsion (P < .05). Physicians who made the correct diagnosis utilized more sonographic parameters than those who did not, namely ovarian size, ovarian edema, and Doppler flow. The correctly diagnosed group had a higher rate of bluish-black (ischemic) adnexa at laparoscopy, but a higher rate of recovery following detorsion.

CONCLUSIONS

Physicians in the ED should be alerted to the need to address some basic sonographic features when adnexal torsion is suspected. The diagnostic accuracy of adnexal torsion can be improved by utilizing simple sonographic markers, even in the ED setting.

Acute Adnexal Torsion: Is Immediate Surgical Intervention Associated with a Better Outcome?

OBJECTIVES

We aimed to investigate whether surgery for adnexal detorsion within 6 hours from admission to the hospital is associated with less adnexal ischemia.

DESIGN

Retrospective cohort study Participants/Materials, Setting, Methods: This retrospective study was conducted at two university-affiliated medical centers, assessed women aged 18 to 45 years with adnexal torsion who hospitalized within 12 hours from pain onset and underwent surgery for detorsion within 24 hours. The study group was divided into 2 groups: early, surgical intervention within less than 6 hours and late, surgical intervention between 6 to 24 hours. The primary outcome was the rate of macroscopic appearance of ischemic adnexa.

RESULTS

Two-hundred and twenty women fulfilled the inclusion criteria. In 101 women, the adnexa with the torsion appeared macroscopically ischemic. There was no difference in ischemic adnexa between the early and late intervention groups. (48% vs. 40%; P=0.269). No significant association was found between the physical examination or ultrasonographic findings and the rate of ischemic adnexa within each group.

LIMITATIONS

The main limitations of our study are its retrospective nature. Much of the clinical and ultrasonographic data are subjective and operator dependent. The decision to operate may vary from one surgeon to another.

CONCLUSION

Immediate surgical intervention in patients with adnexal torsion is not associated with a lower rate of adnexal ischemia. These findings suggest that in acute adnexal torsion there wider time window to for a thorough evaluation before surgery.

Ovarian Torsion in Adolescents with and without ovarian mass: A Cross-sectional Study

STUDY OBJECTIVE

The aim of this study was to compare the characteristics of adolescents with and without adnexal mass who were diagnosed with ovarian torsion (OT).

DESIGN

Retrospective cross-sectional study.

SETTING

Gynecology Department at Tepecik Education and Reseach Hospital, Izmir, Turkey.

PARTICIPANTS

Adolescent girls who received surgery for OT between March 2012 and October 2020 in our institution.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The patients were divided into 2 groups according to the presence or absence of an ovarian mass and compared. Demographic and clinical characteristics, imaging findings, surgery, and pathology reports of the patients were obtained. Differences in initial symptoms, ultrasound findings, the diagnostic process, and the degree of torsion in patients with and without ovarian mass.

RESULTS

Seventy-six patients were diagnosed with OT. Of the 76 patients, 41/76 (53.9%) had an ovarian mass (OTwM), and 35/76 (46.1%) had no pathology (OTnP). The admission to surgery interval was longer in the OTnP group (P = .03). Ultrasound findings of ovarian edema and the appearance of free fluid were significant in the OTnP group (P = .001). The largest dimension of the nontorsion ovary in the OTnP group was greater than in the OTwM group (P = .03). In addition, it was found that torsion more than 360° was more common in the OTnP group than in the OTwM group (24/35, 68.5% vs 41/18, 43.9%; P = .03).

CONCLUSION

In symptomatic adolescents without an ovarian mass, the presence of follicle peripheralization suggesting ovarian edema on ultrasound and the presence of free fluid in the abdomen are important in terms of suspicion of torsion for clinicians. In addition, the degree of torsion was increased in these patients.

Can various complete blood count parameters helpful in preoperative diagnosis of adnexal torsion?

OBJECTIVE

Adnexal torsion is an important gynecological emergency due to nonfrequent but possible adverse reproductive outcomes. There is no specific laboratory marker to support the preoperative diagnosis or that can be used clinically. The aim of this study was to investigate the diagnostic values of platelet, neutrophil, lymphocyte, and red cell markers as an early indicator of ovarian torsion.

METHODS

This retrospective study included 28 female patients who were treated surgically for adnexal torsion between August 2010 and July 2020, and 29 control group women. The demographic data and routine hematological values of patients were compared for adnexal torsion prediction.

RESULTS

There were no differences between the groups in terms of the platelet count, platelet distribution width, red cell distribution width, and mean platelet volume values, and there were no differences in the demographic data. Statistical differences were found among white blood cell, hemoglobin, hematocrit, neutrophil and lymphocyte counts, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio, and 81.5% sensitivity and 82.1% specificity were identified for neutrophil/lymphocyte ratio 2.45 (area under the curve AUC 0.892; 95%CI 0.808-0.975; p<0.001). Odds ratio for neutrophil/lymphocyte ratio was 2.62 (95%CI 0.861-7.940, p=0.029).

CONCLUSION

According to the regression analysis, neutrophil/lymphocyte ratio was found to be the most beneficial among all blood count parameters for the pre-diagnosis of AT.

Predictive Value of Single or Combined Ultrasound Signs in the Diagnosis of Ovarian Torsion

OBJECTIVES

To determine predictive values of isolated and combined ultrasound signs in the diagnosis of adnexal torsion.

METHODS

This work was a retrospective study of 129 adult female patients who underwent an ultrasound examination followed by a definitive surgical procedure within a 24-hour period to determine whether adnexal torsion was present.

RESULTS

The positive predictive value (PPV) of the ultrasound diagnosis of adnexal torsion was 82.2%. The statistically significant ultrasound signs in multivariate logistic regression with single-predictor analyses were relative enlargement of the ovary, an abnormal adnexal position, a twisted vascular pedicle, and the follicular edema "ring sign." Possible combinations of these ultrasound criteria showed high specificities (74%-100%), high PPVs (93%-100%), and lower sensitivities (29%-71%) and negative predictive values (24%-35%). Any combination that included a twisted vascular pedicle or the follicular ring sign as one of the signs had high odds ratios and positive likelihood ratios.

CONCLUSIONS

Ultrasound has a high PPV as a first-choice imaging modality in the diagnosis of adnexal torsion. The combinations of the following 4 statistically significant ultrasound signs, consisting of an abnormal position, relative enlargement of the index ovary, a twisted vascular pedicle, and the follicular edema ring sign, substantially narrow the imaging differential diagnosis in such cases. The presence of vascular pedicle twisting and the follicular ring sign was highly associated with a positive ovarian torsion diagnosis, with 100% specificity.

The Flipped Ovary Sign in Ovarian Torsion

The diagnosis of ovarian torsion is challenging and relies mostly on morphologic findings. Occasionally, women or children with acute pelvic pain who have undergone an initial ultrasound (US) evaluation with results interpreted as negative for ovarian torsion will return with recurrent or increasing pain, prompting an US reevaluation. The flipped ovary sign refers to a demonstrable change in the orientation of the ovary on follow-up US examinations, recognized by changing positions of ovarian landmarks established by follicles, cysts, or masses. This sign is valuable for identifying ovarian torsion in these patients, even in the absence of classic morphologic or Doppler features of ovarian torsion.

Ovarian torsion in a twin pregnancy at 32 weeks and 6 days: A case-report

BACKGROUND

Ovarian torsion during pregnancy is a rare event and occurs mostly during the first trimester. This is the first case describing the diagnosis and management of an ovarian torsion at 33 weeks in a twin pregnancy with a normal term delivery.

CASE SUMMARY

The patient presented with irregular uterine contraction due to an acute abdominal pain in the right iliac fossa. A cyst was discovered during the ultrasound scan on the right ovary and a torsion was highly suspected. A small laparotomy facing the ovarian mass after an ultrasound guidance was chosen. The patient finally delivered at 37 weeks.

CONCLUSION

The clinic holds a preponderant place in the diagnosis of ovarian torsion. Our surgical approach by laparotomy under ultrasound guidance was less risky than by laparoscopy.

Original Articles Preoperative Hematological Parameters for Predicting Ovarian Torsion in Patients with Mature Cystic Teratoma

Objective

The objective of this study is to evaluate the preoperative hematological parameters to predict ovarian torsion in patients with ovarian mature cystic teratoma. We also analyzed the diagnostic value of these makers to predict ovarian necrosis in cases of torsion as well as the effect of torsion on ovarian reserve.

Patients and Methods

This is a retrospective study of 132 patients who received either laparoscopic or laparotomy surgery for OMCT at a single university hospital. Clinical characteristics and preoperative hematological parameters were compared between patients with or without torsion. Patients with torsion were further classified as infarction and non-infarction group. Preoperative parameters were compared between the two groups as well.

Results

White blood cell (WBC) count, neutrophil percent, neutrophil count, and neutrophil to lymphocyte ratio (NLR) were higher in the torsion group (n=37) than the non-torsion group (n=95) (p<0.05 for all). Although statistically insignificant, the preoperative anti-Mullerian hormone (AMH) was lower in the torsion group than the non-torsion group (4.07 ± 3.38 vs 6.1 ± 3.6, p=0.122). In cases of torsion, the infarction group showed higher WBC count and lymphocyte count but lower hemoglobin level and platelet to lymphocyte ratio (PLR) than the non-infarction group (p<0.05 for all).

Conclusion

The WBC count, neutrophil percent, neutrophil count, and NLR were higher in the cases of OMCT with torsion, and these parameters may be useful to diagnose OMCT with torsion. Also, adnexal torsion may deteriorate ovarian reserved as indicated by decreased AMH in torsion group.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pearls and Pitfalls in Imaging of Pelvic Adnexal Torsion: Seven Tips to Tell It's Twisted

Pelvic adnexal torsion is a collective term referring to twisting of an ovary, fallopian tube, or paraovarian cyst on its axis with varying degrees of vascular compromise. Although it is the fifth most common gynecologic emergency, the diagnosis is challenging and often missed due to symptoms, physical examination findings, and imaging features that are nonspecific. Delay in salvage surgery may lead to ovarian or tubal loss, dysfunction, and infertility. The tips shared herein are based on the authors' observations of key clinical and imaging features of torsion, with the intent of heightening radiologists' index of suspicion and diagnostic accuracy in a clear and memorable fashion. Clinically, severe acute pain with a known adnexal mass or of severity to elicit nausea or vomiting should raise concern. At imaging, features of ovarian edema are key to the diagnosis, including asymmetric ovarian enlargement, peripheralized follicles, adjacent free fluid, and foci of stromal hemorrhage. The converse finding of symmetric nonenlarged ovaries in a normal location with any imaging modality has a high negative predictive value for torsion, obviating the need for additional imaging. The whirlpool sign (twisted vascular pedicle), abnormal ovarian location, and uterine tilting are additional key imaging manifestations. The presence of color Doppler flow or contrast enhancement only suggests that an ovary is still viable and should not be used to exclude the diagnosis of torsion. In cases of isolated tubal or paraovarian cyst torsion, the ovaries may appear normal; therefore, recognition of this entity along with appreciation of several key imaging findings may assist with this difficult diagnosis. An invited commentary by Dighe is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis

INTRODUCTION

Color Doppler ultrasonography (CDU) is widely used to diagnose adnexal torsion (AT). However, its validity remains questionable due to its low sensitivity. Our study aimed to evaluate the accuracy of CDU for the preoperative diagnosis of AT.

MATERIAL AND METHODS

The electronic medical records of patients who were taken to the operating room with the diagnosis of suspected AT were reviewed. Patients having surgically/pathologically-proven AT were compared with patients who were found to have a different pathology at the time of surgery. CDU validity was assessed using a 2 × 2 table and compared with a diagnostic model that consists of the Doppler findings, patient's age, and previous surgical history.

RESULTS

AT was diagnosed correctly in 74.6% of cases. Absent Doppler flow was seen in only 18.6% of cases. Although its specificity and positive predictive value were high, CDU had very low sensitivity and negative predictive value. The combined diagnostic model exceeded CDU alone in terms of diagnostic accuracy.

CONCLUSIONS

The use of CDU alone is not a reliable modality to exclude AT. Absent Doppler flow is a sign of ovarian necrosis. Clinical correlation between CDU findings and the patient's symptoms makes the diagnosis of AT more timely and accurate.

Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain

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.

Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion

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.

Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis

BACKGROUND

Adnexal torsion (AT), a serious gynaecological emergency, often presents with non-specific symptoms leading to delayed diagnosis.

OBJECTIVE

To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT.

SEARCH STRATEGY

We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019.

SELECTION CRITERIA

Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow-up period until resolution of symptoms (Reference Standard).

DATA COLLECTION AND ANALYSIS

We assessed study quality using QUADAS-2. We conducted test accuracy meta-analysis using a univariate model or a hierarchical model.

MAIN RESULTS

We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90.

CONCLUSIONS

Ultrasound has good performance as a first-line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed.

TWEETABLE ABSTRACT

To investigate adnexal torsion, ultrasound is a good first-line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76.

[Ovarian torsion during the postpartum period: about a case]

La torsion d'ovaire est une étiologie rare de douleurs pelviennes en postpartum. L'absence de signes cliniques et radiologiques spécifiques rend la suspicion et le diagnostic préopératoire difficiles. Le retard de prise en charge peut mettre en jeu la viabilité de l'ovaire. Nous présentons le cas d'une patiente de 24 ans à J5 du postpartum qui s'est présentée aux urgences pour des douleurs pelviennes aiguës, chez qui le diagnostic de torsion ovarienne sur masse kystique a été fait sur la base des signes échographiques, permettant à la patiente de bénéficier d'une kystectomie et d'un traitement conservateur.

Gynecologic Ultrasound Evaluation of the Nongravid Woman with Pelvic Pain

Pelvic pain is a common condition. Many underlying gynecologic and nongynecologic conditions can contribute to this symptom. Pelvic ultrasound using comprehensive 2-dimensional interactive imaging techniques as well as color Doppler and 3-dimensional imaging optimizes the detection of inciting etiologies.

Surgically Managed Ovarian Masses at the Royal Children's Hospital, Melbourne -19 Year Experience

BACKGROUND/PURPOSE

To describe the clinicopathological characteristics and management of surgically removed ovarian masses at the Royal Children's Hospital, Melbourne from 1993 to 2012.

METHODS

Medical records were reviewed retrospectively. Data regarding clinical findings, imaging and surgical management were evaluated.

RESULTS

There were 266 ovarian masses found in 258 surgeries (eight had bilateral masses). Most were benign (246/266, 92.5%), 2.3% (6/266) were borderline, and 5.3% (14/266) were malignant. The most common presenting symptom was abdominal pain for benign masses (169/246, 68.7%), and a palpable mass for borderline and malignant masses (12/20, 60.0%). Sensitivity and specificity of ultrasound for detection of malignancy was 64.7% and 52.9% respectively. Ovarian torsion occurred in 22.1% (n=57), none with malignancy, with seven cases diagnosed under one year of age. Sensitivity and specificity of ultrasound for ovarian torsion was 22.0% and 91.9%, respectively. The proportion undergoing ovarian cystectomy rather than oophorectomy has increased from 56.3% during 1993-1997 to 93.8% during 2008-2012 (p<0.005). Ovarian torsion was managed with ovarian conservation in 82.6% of cases between 2008-2012.

CONCLUSION

The majority of pediatric and adolescent ovarian masses were benign. Sensitivity of ultrasound was fair for detection of malignancy, and poor for ovarian torsion. Conservative surgeries are increasingly common.

LEVEL OF EVIDENCE

Level IV - case series with no comparison group TYPE OF STUDY: Retrospective Study.

Ultrasonographic and multimodal imaging of pediatric genital female diseases

Ultrasonography is the first-line imaging modality in the evaluation of the female pelvis in childhood and adolescence, because it is easy to perform, non-invasive and it does not require sedation. The transabdominal approach is preferred in children and adolescents, after filling the bladder to move away the bowel loops from the pelvis. The probe frequency must be adapted to age, thickness of tissues and depth of the structures under examination. High-frequency (4-12 MHz) linear or convex probes are used in newborns; high-frequency linear probes (4-12 MHz) in toddler, convex 5-7.5 MHz probes in girls and convex 3.5-5 MHz probes in teenagers. In this article, the main pathological conditions of the genital female tract in pediatric age are examined, such as congenital anomalies, disorders of sex development, ovarian cysts, ovarian tumors, adnexal torsion, primary amenorrhea, precocious puberty and pelvic inflammatory disease.

Drivers to adopting B-flow ultrasonography:contextualizing the integrated technology acceptance model

Background

Ovarian torsion is an unprecedented gynecological crisis that regularly influences ladies of regenerative age. Its signs and indications are like those of other abdominal conditions, which make its differential determination testing. B-flow ultrasonography (B-flow USG), which is utilized for the differential determination of ovarian torsion, is the highest quality level non-intrusive indicative instrument in the early period of an ovarian torsion. The aim of this paper is to investigate and incorporate variety of factors affecting physicians’ actual use of B-flow USG.

Methods

Drawing from technology acceptance model (TAM), five variables – actual use, behavioral intention to use, attitude toward use, perceived ease of use and perceived usefulness – are integrated with social influence and knowledge to propose a theoretical model. The data was collected from the medical doctors including radiologists, urologists, gynecologists, pediatric surgeons between June and October 2018. The sample size is N = 512 hence, structural equation modeling (SEM) methodology has been implemented to study the relationship between explanatory factors and actual use of B-flow USG. SmartPLS 3.2.7 software was used for the data analysis and testing of the validity of the eight hypotheses.

Results

The results indicate that actual use of B-flow USG is positively affected by knowledge, social influence, perceived ease of use, perceived usefulness, attitude toward use and behavioral intention to use.

Conclusions

It is discovered that perceived usefulness mediates the relationship between perceived ease of use and attitude toward use, and attitude toward use mediates the relationship between perceived usefulness and behavioral intention to use B-flow USG. The implications of the outcomes are discussed, and suggestions for future research are made.

No. 341-Diagnosis and Management of Adnexal Torsion in Children, Adolescents, and Adults

OBJECTIVE

To review the evidence and provide recommendations on the diagnosis and management of adnexal torsion in children, adolescents, and women.

OUTCOMES

Elements evaluated include the risk factors, diagnostic accuracy, management options, and outcomes of adnexal torsion.

EVIDENCE

Published literature was retrieved through searches of MEDLINE, Embase, CINAHL, and the Cochrane Library using appropriate controlled vocabulary and key words ("adnexal torsion," "ovarian torsion"). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and new material incorporated in the guideline to December 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence obtained was reviewed and evaluated by the Canadian Paediatric and Adolescent Gynaecology and Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors. Recommendations were made according to guidelines developed by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS AND COSTS

Guideline implementation should assist the practitioner in developing an optimal approach to the diagnosis and management of adnexal torsion while minimizing harm and improving patient outcomes.

VALIDATION

These guidelines have been reviewed and approved by the Gynaecology Committee of the SOGC and approved by the council of the SOGC.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada SUMMARY STATEMENTS: RECOMMENDATIONS.

Accuracy of Pelvic Ultrasound in Diagnosing Adnexal Torsion

Ovarian/adnexal torsion is a rather frequent occurrence in women of reproductive age group worldwide. Etiologies are quite diverse with ovarian lesions and corpus luteal cysts being the most two common. Pelvic or intravaginal ultrasound remains the first-line imaging modality used for diagnosis and evaluation of suspected ovarian/adnexal torsion. In this study, we have adopted a case-based statistical analysis to identify important sonographic markers and further evaluated their contribution in identifying ovarian torsion. Our study successfully determined the important sonographic markers. Our observation and analysis suggest that ovarian enlargement is the most sensitive marker. Ovarian edema was found to be the most specific marker to identify the ovarian torsion with higher level of accuracy and confidence. This pioneer study will provide valuable information and direction to the medical practitioners and radiologists for better diagnosis. Further studies with large sample size will help in establishing our findings universally.

Analysis of the risk of ovarian torsion in 49 consecutive pediatric patients treated at a single institution

Purpose

An early diagnosis of ovarian torsion is sometimes difficult due to variable clinical symptoms and non-specific imaging findings. We retrospectively reviewed patients with pediatric ovarian masses manifesting torsion.

Methods

Fifty-eight ovarian masses (55 episodes) in 49 non-neonatal patients treated from April 1984 to March 2017 were retrospectively analyzed. The Mann-Whitney U test and Fisher’s exact test were used for the statistical analysis.

Results

The median age of these 55 episodes was 10.5 years old (range 1.0–23.0). Thirty-three patients presented with abdominal pain. Forty-five tumors and 13 cystic masses were resected and diagnosed pathologically (50 benign and 8 malignant). Torsion was identified in 15 cases (25.9%) at operation. The torsion masses were all benign, and 8 ovaries (53.3%) were successfully preserved. Comparing the torsion cases with the non-torsion cases, only the white cell count was significantly higher in the torsion cases (p=0.0133) and in the patients presented with abdominal pain (p=0.0068). The duration of abdominal pain was significantly shorter in ovary preserved cases than in oophorectomy cases.

Conclusion

The white blood cell may be a helpful indicator of the presence of torsion as well as the need for surgery.

Doppler indices of middle uterine artery as a tool for predicting the fetal status in cattle with uterine torsion and the recovery of uterine blood flow subsequent to detorsion

The aim was assessment of blood flow to uterus in cattle suffering from uterine torsion as a tool for predicting the fetal survivability after detorsion. Dairy cattle (14) with uterine torsion were detorted and fetal delivery was completed within 30 min after detorsion. Doppler sonography of middle uterine artery ipsilateral (IpsiUA) and contralateral (ContUA) to the side of torsion was carried out before uterine detorsion and 30 min after fetal delivery for Doppler indices, viz. blood flow volume (BFV), time-averaged peak velocity (TAP), resistance index (RI) and pulsatility index (PI). Before uterine detorsion, RI-IpsiUA and PI-IpsiUA were high in comparison to their values in ContUA. Although RI-IpsiUA and PI-IpsiUA had difference between their values before uterine detorsion and 30 min after fetal delivery, but in contrast, at the same time point, there was no difference in RI-ContUA and PIContUA. In comparison to RI-IpsiUA and PI-IpsiUA before detorsion, their respective values decreased after fetal delivery subsequent to successful detorsion, and were almost similar to their respective post-fetal delivery RIContUA and PI-ContUA. In cases where fetus after detorsion of uterus was delivered dead, in the middle uterine artery ipsilateral to the side of uterine torsion, BFV-IpsiUA and TAP-IpsiUA were low, whereas PI-IpsiUA were high. In conclusion, depicting the blood flow within middle uterine artery using Doppler sonography could be helpful in predicting the viability of fetus in uterine torsion affected cattle and may confirm the resumption of blood flow to uterus subsequent to detorsion.

Corpus luteum with ovarian stromal edema is associated with pelvic pain and confusion for ovarian torsion

PURPOSE

To distinguish the corpus luteum with adjacent ovarian stromal edema as an entity associated with pelvic pain, with confounding ultrasound features that may lead to false-positive diagnosis of ovarian torsion.

METHODS

This is a blinded, retrospective study of 243 corpora lutea on transvaginal ultrasound. Imaging parameters included ovarian and corpus luteum volumes, central cystic space within the corpus luteum, vascularity around the corpus luteum, peripherally displaced follicles, and complex free fluid. Residual volume (ovarian volume minus corpus luteum volume) was used as a surrogate for ovarian stromal edema. Clinical parameters included age, pregnancy, and location/acuity of pain if present. Concern for ovarian torsion in radiology reports was documented.

RESULTS

51.0% (124/243) of patients presented with pain. Multivariate regression analysis of factors significantly associated with pain (including age, p = 0.001; larger corpus luteum volume, p = 0.002; larger residual volume, p < 0.001; complex free fluid, p = 0.002; and peripherally displaced follicles, p < 0.001) left only increased residual volume as significantly associated with pain [OR 1.02-1.16; p = 0.01]. False-positive concern for ovarian torsion on ultrasound was present in 12.9% (16/124) of patients with pain, associated with enlarged ovaries (p < 0.001) and peripherally displaced follicles (p < 0.001). High correlation between location of pain and side of the corpus luteum was demonstrated in patients with pain < 14 days duration (p < 0.001).

CONCLUSION

Corpus luteum with ovarian stromal edema is associated with pelvic pain and can mimic ovarian torsion on ultrasound. Further research should explore diagnostically useful differences between cases of ovarian torsion and cases of ovarian edema related to corpora lutea.

Management of pediatric ovarian torsion: evidence of follicular development after ovarian preservation

PURPOSE

This study reviews contemporary management and follow-up of pediatric ovarian torsion.

METHODS

This is a retrospective series of patients from birth to 19 years undergoing operative management of ovarian torsion from 2012 to 2016.

RESULTS

We studied 43 girls who underwent 51 operations for ovarian torsion. The median age was 8.3 years. Ultrasound was utilized for diagnosis in 24/29 patients (83%) evaluated in a children's hospital. In contrast, computed tomography was used initially in 7 cases (50%) in children imaged at non-children's hospitals before transfer. Initial operation for ovarian torsion was completed laparoscopically in 38 (88%). Overall, ovarian preservation was performed in 37 (86%) patients, while 6 (13%) underwent oophorectomy. Indications for oophorectomy included 5 infants with in utero torsion and an 18-year-old with a suspected malignancy. In girls with acute ovarian torsion, the oophorectomy rate was reduced to 2%. Postoperatively, 1 patient developed a small bowel obstruction requiring operation after laparoscopic ovarian detorsion. Recurrent torsion occurred in 3 patients (7%). In total, 34 patients underwent postoperative ovarian imaging. A total of 25 (74%) had follicles visualized in the previously torsed ovary.

CONCLUSION

Ovarian-sparing operations for acute torsion are safe and result in ovarian salvage and preservation of follicular development in more than 70% of children and adolescents.

Conservative laparoscopic management of adnexal torsion based on a 17-year follow-up experience

Laparoscopic unwinding of adnexal torsion has been proposed for decades. However, this technique is still controversial regarding the concern of thromboembolic events. We present two cases of conservative laparoscopic management of adnexal torsion. In the first case, a 16-year-old adolescent with serous cystadenoma was successfully managed by untwisting and cystectomy. We followed up this patient for 17 years with regular re-examinations in our hospital. To the best of our knowledge, this is the longest follow-up reported of this condition. In the second case, a 32-year-old infertile woman who received oocyte retrieval 3 days before being admitted to hospital was referred to hospital with right ovarian torsion. We treated her successfully based on our long-term follow-up experience, and she is now asymptomatic and in her 7th month of pregnancy.

First-trimester emergencies: a radiologist's perspective

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

Pediatric Ovarian Torsion and its Recurrence: A Multicenter Study

STUDY OBJECTIVE

To report results of a retrospective multicentric Italian survey concerning the management of pediatric ovarian torsion (OT) and its recurrence.

DESIGN

Multicenter retrospective cohort study.

SETTING

Italian Units of Pediatric Surgery.

PARTICIPANTS

Participants were female aged 1-14 years of age with surgically diagnosed OT between 2004 and 2014.

INTERVENTIONS

Adnexal detorsion, adnexectomy, mass excision using laparoscopy or laparotomy. Different kinds of oophoropexy (OPY) for OT or recurrence, respectively.

MAIN OUTCOME MEASURES

A total of 124 questionnaires were returned and analyzed to understand the current management of pediatric OT and its recurrence. The questionnaires concerned patient age, presence of menarche, OT site, presence and type of mass, performed procedure, OPY technique adopted, intra- and postoperative complications, recurrence and site, procedure performed for recurrence, OPY technique for recurrence, and 1 year follow-up of detorsed ovaries.

RESULTS

Mean age at surgery was 9.79 ± 3.54 years. Performed procedures were open adnexectomy (52 of 125; 41.6%), laparoscopic adnexectomy (25 of 125; 20%), open detorsion (10 of 125; 8%), and laparoscopic detorsion (38 of 125; 30.4%). Recurrence occurred in 15 of 125 cases (12%) and resulted as significant (P = .012) if associated with a normal ovary at the first episode of torsion. Recurrence occurred only in 1 of 19 cases after OPY (5.2%). Ultrasonographic results of detorsed ovaries were not significant whether an OPY was performed or not (P = 1.00).

CONCLUSION

Unfortunately, oophorectomy and open technique are still widely adopted even if not advised. Recurrence is not rare and the risk is greater in patients without ovarian masses. OPY does not adversely affect ultrasonographic results at 1 year. When possible OPY should be performed at the first episode of OT.