EP23.60: Ovarian torsion in pregnancy

Ovarian torsion during pregnancy is an emergency. Delayed diagnosis and treatment may result in ovarian necrosis and fetal loss. A 33-year-old woman, gravida 3 para 1, presented at Early Pregnancy Unit with lower abdominal cramps. She was 6+2 weeks amenorrhea, UPT was positive, no per vaginal bleeding or abnormal discharge. Ultrasound scan noted an IUGS corresponding to 6+ weeks gestation. Viable fetal pole concurred with 5+ weeks gestation. A 7.2 x 5.5 x 6.8cm clear cyst was demonstrated in the right ovary. She was managed conservatively and advised to return if unwell. The next day she presented at Emergency Department for sudden onset of sharp right lower abdominal pain, pain score 8/10; associated with 4 episodes of vomiting. Ultrasound scan noted single viable fetus corresponding to 6 weeks gestation; low level echoes noted in the right cyst. Venous vascularity was seen in the ovarian stroma. However, the echogenicity of ovarian stroma had changed. It exhibited heterogeneity and transonicity suggesting edema had occurred. A diagnosis of ovarian torsion was made. Left ovary appeared normal, moderate amount of fluid was seen in the pelvis. She was admitted, given I/V panadol stat. Her pain subsided but turned intense again by night time. She underwent diagnostic laparoscopy, KIV detorsion, KIV cystectomy, KIV salpingo-oophorectomy. Intraoperative findings: Right ovary enlarged with corpus luteum twisted around the ovarian ligament twice, ovarian cyst was decompressed. Repeated Ultrasound findings the following day demonstrated: single viable fetus corresponding to 6+ weeks gestation; a 4.2 x 1.6 x 3.7cm cyst with irregular outline was demonstrated in right ovary, arterial and venous vascularity noted in ovarian stroma. Left ovary appeared normal. Moderate amount of fluid was seen in POD as well as adnexal regions. In conclusion, concise description of sonographic observations provide constructive inference for diagnosis.