Pregnancy outcome after unwinding of twisted ischaemic-haemorrhagic adnexa

Acute Abdomen in the 17th Week of Twin Pregnancy due to Ovarian Torsion - A Late Complication of IVF

Background: A 32-year-old woman with tubal factor infertility due to bilateral laparoscopic salpingectomy conceived twins with in vitro fertilization (IVF). She developed moderate ovarian hyperstimulation syndrome which was treated with anticoagulant therapy. The subsequent course of the twin pregnancy was normal until the 17th week of gestation when she presented to hospital because of a sharp pain in the right lower abdomen which ceased after admission. Case: Except for a single incident of vomiting, patient had no other subjective symptoms. The clinical examination showed tenderness of the lower right abdominal segment on palpation. The surgeon and the urologist found no signs of an acute surgical or urologic condition, and laboratory findings were within normal reference ranges for pregnant women. Two days after admission the pain reappeared; it was now much stronger and colic-like. The pain was initially located supraumbilically but subsequently spread diffusely across the lower abdomen. Abdominal guarding was present and laboratory findings showed an increase in inflammatory parameters. An enlarged and edematous right ovary was found on transvaginal ultrasound. Conclusion: Exploratory laparotomy via a vertical midline abdominal transection revealed a torqued necrotic right ovary with elements of inflammation and inflammatory adhesions involving the entire pelvis. The patient underwent right-sided ovariectomy and adhesiolysis. Recovered was normal and the patient was delivered of healthy twins in the 37th week of gestation.

Folicular reserve changes in torsion-detorsion of the ovary: an experimental study

OBJECTIVE

We assess follicular reserve changes by follicle count in torsion-detorsion rat model.

STUDY DESIGN

30 albino rats were randomly divided into 3 groups: sham group (SG), detorsion after 24-hour torsion group (24hTG) and detorsion after 72-hour torsion group (72hTG). Ovaries were torsioned and fixed. They were untwisted 24 and 72 h later. Oophorectomies were performed at 14th day after detorsion. Tissue damage scoring and follicle counts were evaluated microscopically.

RESULTS

Tissue damage scores (TDSs) were higher in 72hTG and 24hTG compared to SG. In addition, as we increase torsion duration, TDSs also increased. There was no statistically significant difference in follicle numbers (primordial, primary, secondary and tertiary).

CONCLUSION

Duration of torsion and intensity of ovarian damage do not affect follicular reserve in a rat model. Regardless of their macroscopic appearance, ovaries maintain their follicle reserves after torsion. Thus, surgeons should be reassured and encouraged to untwist torsioned ovaries rather than removing them.

Repeated ovariopexy failure in recurrent adnexal torsion: combined approach and review of the literature

Adnexal torsion is a well-known but poorly recognized gynecological emergency. Most cases are in the reproductive age group and many are related to ovarian and paraovarian masses. Adnexal torsion can also occur, however, in normal-looking ovaries with elongated utero-ovarian ligaments. The authors describe the case of a young woman presenting with a sixth recurrence of right adnexal torsion with polycystic ovaries. She had had two failed ovarian fixation efforts in the third and fifth laparoscopies. A combined ovarian fixation method is described, fixing the ovary to the pelvic side wall and shortening the utero-ovarian ligament, at elective surgery one month after the detorsion operation. Ovarian fixation after adnexal torsion is not standardized and best method of fixation remains unresolved.

Complication of laparoscopic detorsion of adnexal mass

Detorsion of an ischemic adnexal mass has recently been advocated for most cases of twisted adnexa. Usually, the affected ovary regains some or all of its vitality and function. However, when the ovary is completely necrotic, it may form an abscess if it contains tissue components that cannot be eliminated by the peritoneal immune system. We report a case of pelvic abscess formation in a detorsed ovary that previously contained an unsuspected dermoid cyst. We call for an extensive inspection of the detorsed ovary before ending the laparoscopic operation, and if it remains necrotic and is suspected of containing a dermoid cyst, it should be removed promptly.

Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger

STUDY OBJECTIVE

To evaluate the treatment by laparoscopic surgery of adnexal disease occurring in young girls.

DESIGN

Retrospective analysis (Canadian Task Force classification II-1).

SETTING

Department of gynecology at a general hospital.

PATIENTS

Twelve consecutive girls aged 15 years or younger.

INTERVENTIONS

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Seven patients had dermoid cysts, and three of these were associated with adnexal torsion. Two patients had ruptured lutein cysts with ovarian bleeding, and one of them was pregnant. Torsion of the tube with paraovarian cyst, torsion of normal ovary, and serous cystadenoma were noted in one patient each. Although the underlying diseases varied, the chief symptom in each of these patients was lower abdominal pain. Because the symptom is nonspecific, the clinical features were confusing, especially in emergency cases; in two patients with adnexal torsion with dermoid cysts and one patient with adnexal torsion of a normal ovary, there was substantial delay in diagnosis, and salpingo-oophorectomy was required as a result.

CONCLUSION

Even in young girls, laparoscopic surgery can be performed in an acceptable manner using regular instruments designed for adults.

Ovarian torsion

Ovarian torsion is a rare problem in the pediatric age group that must be included in the differential diagnosis of any girl with abdominal pain or a pelvic or abdominal mass. Clinical presentation is nonspecific, and diagnosis is based on a high index of suspicion. Ultrasound scan remains the most useful investigation, but blood flow on Doppler examination does not exclude ovarian torsion. Current recommendations of treatment strongly support ovary conservation, and macroscopic appearance of the ovary is not a reliable indicator of the degree of necrosis and potential for ovary recovery. For children with ovarian torsion, laparoscopic detorsion should be performed with strong consideration of oophoropexy. An underlying ovary lesion such as mature teratoma or functional cyst is found in most cases; however, the risk of cancer in these patients is extremely low. If there is concern of a mass or underlying pathology, then follow-up ultrasound, resolution of edema and interval laparoscopic treatment may be required.

Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: Case report and review

OBJECTIVE

To introduce a new surgical approach, oophoropexy to prevent recurrent adnexal torsion.

DESIGN

Case report and review of the literature.

SETTING

The obstetrics and gynecology department of a university hospital.

PATIENT(S)

A 29-year-old pregnant patient who had three events of torsion of the adnexa after stimulation.

INTERVENTION(S)

Laparoscopic oophoropexy.

MAIN OUTCOME MEASURE(S)

Incidence of torsion.

RESULT(S)

No more torsion events were registered during the ongoing pregnancy.

CONCLUSION(S)

Laparoscopic oophoropexy is recommended in emergency situations to increase adnexal salvage and to prevent a recurrence.

Adnexal torsion: a report on forty-five cases

OBJECTIVES

To evaluate the clinical findings, evolution of treatment and ovarian function following conservative therapy.

STUDY DESIGN

A case series of 45 patients presenting with adnexal torsion between January 1989 and June 1999. All patients were surgically treated, either conservatively or radically. Patients who had received conservative treatment, interviewed by phone and underwent ovarian sonographic examination.

RESULTS

Adnexal torsion is more frequent in young women with adnexal pathology. Conservative therapy by laparoscopy has gained increasing preference as a surgical procedure. It is safe and preserves ovarian function.

CONCLUSIONS

Conservative therapy by laparoscopy is recommended to preserve ovarian function in young women.

Laparoscopic surgery during pregnancy

In the last decade, operative laparoscopic procedures are performed increasingly in both gynecology and general surgery. The major advantages of this newer minimally invasive approach are: decreased postoperative morbidity, less pain and decreased need for analgesics, early normal bowel function, shorter hospital stay, and early return to normal activity. With the advancement of laparoscopic surgery, its use during pregnancy is becoming more widely accepted. The most commonly reported laparoscopic operation during pregnancy is laparoscopic cholecystectomy (LC). Other laparoscopic procedures commonly performed during pregnancy include: management of adnexal mass, ovarian torsion, ovarian cystectomy, appendectomy, and ectopic pregnancy. The possible drawbacks of laparoscopic surgery during pregnancy may include injury of the pregnant uterus and the technical difficulty of laparoscopic surgery due to the growing mass of the gravid uterus. Also, the potential risk of decreased uterine blood flow secondary to the increase in intraabdominal pressure and the possible risk of carbon dioxide absorption to both the mother and fetus should be taken into account. To date, data on laparoscopic surgery during pregnancy are insufficient to draw conclusions on its safety and exact complication rate. This is due to the few cases reported and the lack of prospective studies. Furthermore, there is a common tendency to underreport unsuccessful cases. Finally, most reports in the literature come from centers and surgeons with special interest, experience, and skills in laparoscopy, and their results may not reflect the real complication rates. We have reviewed the pertinent English literature from the last decade. The cumulative experience suggests that laparoscopic surgery may be performed safely during pregnancy, although more studies are needed to establish its exact rate of adverse events.

Conservative management of adnexal torsion in premenarchal girls

STUDY OBJECTIVE

To evaluate treatment of premenarchal girls with torsion of the adnexa.

DESIGN

Retrospective review of medical records (Canadian Task Force classification II-2).

SETTING

Tertiary care, university-affiliated hospital.

PATIENTS

Eight premenarchal girls (age range 3-12 yrs) with twisted adnexa.

INTERVENTION

Laparoscopic detorsion and follow-up with B scan and Doppler ultrasound imaging.

MEASUREMENTS AND MAIN RESULTS

Duration of complaints ranged from 8 to 72 hours (mean 34.6 hrs) and the interval from admission to surgery ranged from 6 to 24 hours (mean 18.7 hrs). Four patients had torsion of normal-appearing adnexa. The other four had ovarian neoplasms. Two had cystic mature teratomas (dermoid cysts) and one a serous cystadenoma that required additional operation. The fourth girl had a simple ovarian cyst that was aspirated laparoscopically. Seven girls (87%) had normal-appearing ovaries on follow-up ultrasound. In one patient, a small ovary was seen, with no intraovarian blood flow on color Doppler.

CONCLUSION

Although the diagnosis of torsion of the adnexa in premenarchal girls is difficult and usually delayed, laparoscopic detorsion seems to be an effective adnexa-sparing approach. We suggest that laparoscopy should be the treatment of choice and that detorsion, rather than adnexectomy, be performed more often in these patients.

Adnexal torsion and pulmonary embolism: case report and review of the literature

The classical teaching was that twisted adnexa should be resected and not untwisted, so as not to increase the risk of pulmonary embolism (PE). A patient recently was seen who developed PE after adnexal resection. Because this complication followed the conventional management of salpingo-oophorectomy, the literature was examined for cases of adnexal torsion and PE to see if the operative management (untwisting vs. excision without untwisting) could be implicated as a contributing factor. Three hundred nine cases of adnexal torsion managed by untwisting and 672 cases treated by adnexectomy without detorsion (untwisting) were found. The incidence of PE after adnexal torsion was 0.2 percent, and this incidence was not increased when the adnexa were untwisted. Therefore, we conclude that detorsion of twisted adnexa does not increase the risk of PE, compared with excision without untwisting. PE does occur in cases in which adnexal resection is performed without untwisting. Thus, detorsion of twisted adnexa should be considered at laparoscopy or laparotomy without fear of increasing the incidence of PE.

Laparoscopic detorsion allows sparing of the twisted ischemic adnexa

STUDY OBJECTIVE

To determine the safety and outcome of laparoscopic detorsion in the management of the twisted ischemic, hemorrhagic adnexa.

DESIGN

Retrospective chart review and prospective follow-up (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Fifty-eight women with twisted black-bluish ischemic adnexa encountered at laparoscopy.

INTERVENTION

Laparoscopic detorsion with adnexal sparing.

MEASUREMENTS AND MAIN RESULTS

All patients had a benign immediate postoperative course. Transient temperature elevation occurred in seven women (12.1%). No signs of pelvic or systemic thromboembolism were detected in any patient. Long-term follow-up included transvaginal ultrasound, which revealed follicular development in the previously twisted adnexa in 54 women; normal macroscopic appearance at incidental subsequent surgery in 9; and in vitro fertilization with retrieval of oocytes from the previously twisted side in 4.

CONCLUSION

Laparoscopic detorsion of the twisted ischemic, hemorrhagic adnexa is a safe procedure with minimal postoperative morbidity and a potential for the ovary to recuperate fully with preservation of normal function. Laparoscopic adnexa-sparing procedures should be performed in place of traditional salpingo-oophorectomy in women with this disorder who desire future fertility. (J Am Assoc Gynecol Laparosc 6(2):139-143, 1999)

Adnexal torsion

We performed a retrospective audit of 24 cases of adnexal torsion managed at National Women's Hospital from 1996 to 1997 inclusive. There have been several reports in the recent literature of ovarian conservation in cases of ovarian infarction secondary to torsion in women desiring further fertility (1-3). In our review 50% (12 of 24) of patients were treated by oophorectomy or salpingo-oophorectomy and most of these women desired further fertility. In spite of torsion being suspected in 73% (17 of 24), the time interval between admission and operation varied from 0.5 to 52 hours with a mean of 8 hours; 46% (11 of 24) were treated laparoscopically without recourse to laparotomy. As expertise increases, we consider that adnexal torsion will be increasingly managed laparoscopically. These results suggest that more urgent surgery should be scheduled if ovarian torsion is suspected, and in view of recent reports in the literature greater consideration should be given to conservation of infarcted ovaries if further fertility is required.

Adnexal torsion in adolescents: prompt diagnosis and treatment may save the adnexa

Adnexal torsion, although infrequent, may have a devastating effect on the future reproductive performance of adolescents and young women. However, clear variables predicting a favorable operative outcome have not yet been identified. In this retrospective study the authors analyzed the charts of 72 adolescent girls hospitalized for acute lower abdominal pain. In 13 cases (18%) torsion of the adnexa was found and six of them ended with reproductive compromise expressed by either adnexectomy or salpingectomy. We have found that in the cases of adnexal torsion, the time factor, from admission until final diagnosis and treatment, was the only significant variable affecting the operative results. A shorter time until the operation, resulted in less harm to the reproductive organs involved. Therefore, we conclude that whenever an adnexal torsion is suspected, a quick diagnostic laparoscopy followed by an operative procedure when needed, may contribute to better reproductive performance in the future.

Long-term follow-up of the twisted ischemic adnexa managed by detorsion

OBJECTIVE

To examine our assumption that although the twisted adnexa appears ischemic-hemorrhagic, it can safely be revived by detorsion with preservation of ovarian function.

DESIGN

Patients' records were obtained from a computerized database and reviewed. The preoperative diagnosis of adnexal torsion was based upon patients' symptoms, clinical examination, laboratory investigations, and ultrasound scanning.

SETTING

Gynecology department at a large teaching hospital receiving primary referrals of public sector patients.

PATIENTS

In 40 patients who presented with signs and symptoms suggestive of ovarian torsion, "black-bluish" ischemic adnexa were encountered at surgery.

INTERVENTIONS

All patients were managed by unwinding of the adnexa: laparotomy in 26 cases and operative laparoscopy in 14. In 13 patients detorsion only was performed, in 15 detorsion and cystectomy were carried out, and in 12 patients detorsion was done and ovarian cysts aspirated.

MAIN OUTCOME MEASURES

Postoperative course, mean hospitalization period, follow-up pelvic examination, ovarian folliculogenesis on ultrasound examination, and oocyte retrieval and fertilization.

RESULTS

The size of the twisted ovary ranged from 4 to 20 cm (mean, 9.5 cm). The postoperative course was uneventful, except for transient temperature elevation in five patients. The mean hospitalization period was 6.5 days (range 5 to 10 days) after laparotomy and 1.8 days (range 1 to 3 days) after laparoscopy. Three patients were lost to follow-up. In 37 patients, pelvic examination was normal. A normal sized ovary, with follicular development, was demonstrated sonographically in 35 of 37 patients. In 6 of 7 patients, macroscopically normal adnexa were visualized at subsequent laparotomy or laparoscopy. In two patients undergoing IVF, oocytes were retrieved and fertilized from the detorted ovary. The patency of the fallopian tube was demonstrated in four cases.

CONCLUSIONS

This new "adnexal-sparing" approach should be applied instead of the traditional salpingo-oophorectomy in young women with twisted ischemic adnexa.

Laparoscopic detorsion of adnexa in childhood: a case report

A case of adnexal torsion in premenarchal child is presented. Prompt diagnosis was made with the use of pelvic ultrasound and laparoscopy. The later was used for establishing the diagnosis and furthermore for untwisting the adnexa. We suggest that laparoscopy should precede laparotomy and that conservative detorsion should be done more liberally in the young patient.

Laparoscopic unwinding of twisted ischemic hemorrhagic adnexum after in vitro fertilization

We present a case where, for the first time, unwinding of ischemic hemorrhagic adnexum was performed successfully through the laparoscope without the need to operate. Aspiration of ovarian fluid before detorsion facilitates the procedure; follow-up showed spontaneous follicular growth. We conclude that laparoscopic detorsion of ischemic adnexum is feasible. Apparently, oocytes are not damaged by the torsion and the ovary resumes normal function. This procedure should be considered in women during the reproductive age and in every case where malignancy can be ruled out.

Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy

A series of 201 cycles of ovarian hyperstimulation syndrome (OHSS) in 154 women were reviewed. Pregnancy occurred in 75 of 201 cycles. Twelve pregnant women (16%) presented with torsion of hyperstimulated ovary, but only 3 out of 126 patients (2.3%) who did not conceive had torsion. Because diagnosis of adnexal torsion is usually uncertain and surgical intervention is likely to be delayed, these infertile women risk losing their ovaries. The clinical picture of torsion of adnexa in patients with OHSS is presented here. The combination of ovarian enlargement, abdominal pain, nausea, progressive leukocytosis, and anemias might indicate torsion of adnexa. Although during operation the adnexa appears dark, hemorrhagic and ischemic, we suggest that it can be saved by simply unwinding it. In 11 such cases intraoperative unwinding of the adnexa was performed, and in 8 patients it was the only operative procedure. No postoperative complications were noted and in all the cases the ovaries were proven functional by ultrasonography. We concluded that torsion of hyperstimulated adnexa in patients who conceived after gonadotropin therapy, is a special entity that requires more attention to achieve early diagnosis. Nevertheless even with delayed diagnosis, the ovary can still be saved.