IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 8 Ver. III (Aug. 2014), PP 23-25
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A Case Report: Twisted Ovarian Cyst in Pregnancy

Dr.Debraj Basu1, Dr.Samrat Chakrabarty 2, Dr.Subrata lall Sil3,Dr.Varsha
Saboo4, Dr. Vidyasagar Sau5
1. DGO, MS. RMO-cum Clinical Tutor, Dept of Gynae.& Obst.,RG Kar Medical College
2. MD. Ast. Professor,Dept.of Gynae.& Obst.. Murshidabad MC
3. Professor, Dept. Of Gynae. & Obst.,R.G.Kar MC
4. PG Trainee, Dept.of Gynae. & Obst., RG Kar MC
5.PG Trainee, Dept. of Pathology,RG Kar MC

Abstract: Ovarian torsion encountered during pregnancy carries significant risk to a pregnant woman
and intrauterine foetus. In this case we report a 24 -year-old secondgravida with 14 weeks of
pregnancy presenting with torsion of the left ovarian cyst. She presented to the Gynae. emergency with
acute pain abdomen. She was diagnosed to have torsion of ovarian cyst with pregnancy and later
emergency laparotomy followed by cystecomy was carried out. Her histopathology report showed a
benign mucinous cystadenoma. Her pregnancy was followed up. She delivered a healthy female baby at
term. Although the safety of antepartum surgical intervention has been accepted, abdominal surgery
will always carry some risks to a pregnant woman and unborn foetus and so, before management ,
risks involved must be taken into consideration.
Key words: ovarian cyst torsion, pregnancy, mucinous cystadenoma

I. Introduction
Torsion of ovary is the total or partial rotation of the adnexa around its vascular axis or pedicle.
Ovarian torsion accounts for about 3% of gynaecologic emergencies. Predisposing factors are moderate size,
free mobility and long pedicle. Most common ovarian tumours with torsion are dermoid( benign cystic
teratoma) and serous cystadenomas. Complete torsion causes total blockade of venous and lymphatic
supply that leads to venous congestion, haemorrhage and necrosis, subsequently cyst becomes tense and
may rupture. Patient usually presents with acute pain lower abdomen and pelvic examination may reveal
a tender cystic mass separate from the uterus. The risk of ovarian torsion rises by 5 fold during
pregnancy. Incidence is 5 per 10,000 pregnancies1,2 . Torsion of ovarian tumors occurs
predominantly in the reproductive age group. The majority of the cases presented in pregnant
(22.7%) than in non-pregnant (6.1%) women3.Here, we report a case of torsion of ovarian cyst during
second trimester of pregnancy with no known predisposing factors.

II. Case Report

A 24 year old second gravida who delivered her first child by caesarean section 6years back presented
in the emergency with pain abdomen and vomiting for one day. She was carrying a 14 weeks pregnancy and on
examination her fundal height was corresponding to 14-16 weeks of gestation. Additionally a huge cystic mass
felt in left lumbar region extending upto the umbilicus separate from the uterus. There was no tenderness on
palpation. USG showed a single viable fetus of 14 weeks maturity and a septated cyst (13.83 7.8) cm in left
lumbar region to under the umbilicus probably originating from left ovary. She was put on a conservative
management. Routine blood and urine investigations, repeat USG and serum CA125 levels(9 IU/ml) was done.
Repeat USG also showed septated cystic lesion in left lumbar region which was slightly larger in size this time;
(15.014.2 9.3) cm. All other investigation reports were within normal range. As the patient was stable,
laparoscopic removal of the cyst was planned but before that she again had an episode of acute pain abdomen
after 7 days of admission. Diagnosing this change of symptoms as torsion of ovarian cyst emergency laparotomy
had to be done.

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 A Case Report: Twisted Ovarian Cyst in Pregnancy

Fig.1-Ovarian cyst after torsion with gangrenous changes

During laparotomy (15 15) cm blackened cystic mass ( Fig.1)was found in the left adnexa which was
twisted around its pedicle. Left fallopian tube was found gangrenous,attached to the cyst. The cyst was cut in
between the clamps,without untwisting its pedicle as it was necrosed and secured by 1-0 vicryl. Uterus was
found to be 14-16 weeks in size. Right sided fallopian tube and ovary were healthy. Her post operative period
was uneventful and she was discharged on 4th postoperative day in stable condition. Histopathological
examination of the specimen showed benign mucinous cystadenoma of ovary(Fig.2).

Fig.2: Histopathological section of tumour showing benign mucinous cystadenoma

She was followed up in the antenatal clinic where rest of her antenatal period was essentially
uneventful. Her follow up USG scans showed normal growth and development of the fetus. She underwent an
elective caesarean section at term and delivered a healthy 2.6kg girl baby. Both the mother and the baby were
discharged in good health on Day 7.

III. Discussion
The diagnosis of twisted ovarian cyst, which is an acute abdominal emergency, can be
made in the majority of cases, although the symptoms are nonspecific for ovarian torsion. Changes in
intra-abdominal pressure seem to start torsion in some cases, and this may account for cases seen
during pregnancy or the puerperium .The usual symptoms of torsion of an ovarian cyst are acute,
violent, colicky pains in the lower abdomen, distention and nausea, often with vomitting. Abdominal
tenderness is usually present, and localized over the site of the cyst, although sometimes it become
generalized. Abdominal rigidity is also found in most cases indicating either the blood supply of
the ovary is involved or that haemorrhage has taken place. To make a correct diagnosis of twisted
ovarian tumour speacially in pregnancy ultrasonographic confirmation is needed. When pregnancy is
present ovarian cyst usually is found alongside pregnant uterus,though presence of abdominal rigidity make
palpation of such a mass difficult. The use of colour Doppler sonography, with the main sign of the
absence of intraparenchymal ovarian blood flow indicative of adnexal torsion, a decreased blood flow if present
can be a result of incomplete torsion.
The commonest type of ovarian tumours in pregnancy are cystic teratoma, paraovarian cysts,serous
cystadenoma,corpus luteal cysts etc1,3. In this case however the histopathology reveals mucinous cyst adenoma
which is very uncommon for ovarian torsion even in non-pregnant condition. About 15-20% of all ovarian

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 A Case Report: Twisted Ovarian Cyst in Pregnancy

tumors are mucinous cystadenomas. They often become very large and can fill up the entire abdomen and are
usually multi-septated, cystic masses with thin walls and contain varying amounts of solid tissue. Benign
mucinous cystadenomas compose 80% of mucinous ovarian tumors 4 and 20-25% of benign ovarian tumors
overall. The peak incidence occurs between 30-50 years of age. Benign tumors are bilateral in 5-10% of cases.
Differential diagnosis of ovarian cyst torsion in pregnancy includes: uterine leiomyomas, non
preganant horn of bicornuate uterus, appendiceal abscess, diverticular abscess, pelvic kidney,
retroperitoneal tumours, ectopic pregnancy and retroverted gravid uterus3 . Complications of the
ovarian cysts in pregnancy are torsion of the cyst, rupture, infection, malignancy, impaction of cyst in
pelvis causing retention of urine, malpresentation of foetus and during labour obstructed labour 3. Most
ovarian masses can either remain uneventful or resolve throughout pregnancy and that the incidence of
the above risks are actually low5,6. Ovarian torsion, occurs most frequently in the first trimester,
occasionally in the second, and rarely in the third7.
Cysts w i t h less than 6 c m diameter and appearing benign on ultrasound are generally treated
conservatively as mostly they undergo spontaneous resolution. Corpus luteal cysts regress by 12 to 16
weeks1,8. Cysts more than 10 centimetres in size are usually resected due to increased risk of torsion,
rupture or malignancy and laparoscopic removal is recommended. However they may require
emergency exploratory laparotomy for rupture, torsion or infarction in as many as 50% cases4 .
If the ovarian cyst is diagnosed in the first trimester, it is better to wait till 16 wks when the
implantation of pregnancy is more secure and also the cyst may disappear spontaneously. Persisting
tumours are treated by cystectomy or ovariotomy as indicated. Ovarian tumour or cyst can be easily
removed till 28 wks of gestation thereafter not only it becomes hard to access but also operation may
precipitate preterm labour. Ovarian cyst if ruptures, or undergoes torsion or if it shows evidence of
malignancy, immediate surgery is needed, irrespective of the period of gestation4.Previously untwisting
of the pedicle was avoided to prevent emboli and toxic substances related to hypoxia, from
entering peripheral circulation, but recently, re-establishing ovarian circulation by untwisting, has
shown to improve circulation in viable ovarian tissue with no systemic complications1,2 . Obviously in
cases where ovarian cysts have undergone gangrenous changes, untwisting are not tried, which was
present in the present case.

IV. Conclusion
In this case an early diagnosis might have helped to conserve patients adnexa. Though it is an
extremely rare problem in pregnancy, adnexal torsion should be taken into consideration in the differential
diagnosis of abdominal pain. Treatment options are limited to surgery, either by laparoscopy or
laparotomy, but the former becomes more difficult after second trimester. In our case we performed a
laparotomy with Pfannenstiel incision, and did not attempt to untwist the adnexa because of widespread
necrosis9.

References
[1]. Kolluru V, Gurumurthy R, Vellanki V, Gururaj D.Torsion of ovarian cyst during pregnancy: a case report.Cases Journal
2009;2:9405. http://dx.doi.org/10.1186/1757-1626-2-9405 PMid:20090873 PMCid:2809077
[2]. Ventolini G, Hunter L, Drollinger D, Hurd WW: Ovarian torsion during pregnancy.
[http://www.residentandstaff.com/issues/arti cles/2005-09_04.asp].
[3]. Lee CH, Raman S, Sivanesaratnam V:Torsion of ovarian tumors:a clinicopathological study.Int JGynaecol Obstet1989,
28:21-25.
[4]. Hart WR (January 2005). "Mucinous tumors of the ovary: a review". Int. J. Gynecol. Pathol. 24 (1): 4 25. PMID 15626914
[5]. Yen CF, Lin SL, Murk W, Wang CJ, Lee CL, Soong YK, Arici A: Risk analysis of torsion and malignancy for adnexal mases
duringpregnancy. Fertil Steril 2009, 91(5):1895-902.
[6]. Schmeler KM, Mayo-smith WW, Peipert JF, Weitzen S, Manuel MD,Gordinier ME: Adnexal masses in pregnancy: surgery
compared with observation. Obstet Gynecol 2005, 105:1098-103.
[7]. Hibbard LT: Adnexal torsion. Am J Obstet Gynecol 1985,152:456-461
[8]. Duic Z, Kukura V, Ciglar S, et al.: Adnexal masses in pregnancy:a review of eight cases undergoing surgical management. Eur J
Gynaecol Oncol 2002, 23:133-134.
[9]. E. KARAALp , N.YUcEL , F. DEMIRcI , E. AYDIN, B. KARAKOc : Adnexal torsion in a first-trimester pregnant patient
without any predisposing factor: A case report; Gztepe Tp Dergisi 28(1):58-60, 2013 doi:10.5222/J.GOZTEPETRH.2013.058

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