Ovarian Torsion in Early Pregnancy : Navigating Diagnostic Challenges and a Cascade of Post-Cystectomy Complications

 

Authors : S Dubey, K Vats, V Giri (Supervising Consultant Obstetrician & Gynaecologist)

 

Introduction : 

❖ Ovarian torsion is a gynaecological emergency, 5 times more

common in pregnancy, posing risks of severe morbidity and

potential foetal mortality.

❖ This case highlights significant diagnostic and management

challenges in early pregnancy.

❖ Learning Objective: To underscore the complexities of managing

ovarian torsion and its sequelae in pregnant patients.

Presentation

14 weeks Gestation :

❖ Patient:

31-year-old, Gravida 4, Para 2+1

❖ Symptoms:

Acute right lower abdominal pain,

nausea and vomiting.

❖ History:

Known right adnexal dermoid cyst.

❖ Assessment:

Hypotension, tachycardia.

 

Initial Diagnosis & Management :

❖ Diagnostic Laparoscopy:

Confirmed torsed right ovarian cyst (13 cm).

❖ Procedure:

Immediate cystectomy performed.

 

Post-operative Haemorrhage :

❖ Event: Massive post-operative haemorrhage – causing Haemoglobin

to drop to 62 g/L.

❖ Investigation: CT angiogram revealed a large right adnexal hematoma

of size 10x10x11 cm.

❖ Intervention: Blood transfusions and stabilisation – discharge.

Infected Hematoma & Further Major Surgery

21 weeks Gestation :

❖ Re-presented with worsening abdominal pain, elevated inflammatory

markers.

❖ Imaging:

• MRI: Large, complex right adnexal chronic hematoma.

• Ultrasound-guided Aspiration: Revealed infection Finegoldia magna &

Staphylococcus species

❖ Intervention: Laparotomy confirmed 15cm infected hematoma, with 9cm

matted tubo-ovarian mass, necessitating right salpingo-oophorectomy and

drainage.

 

Foetal Management & Delivery

27 - 33 weeks Gestation:

❖ 27 Weeks: 70 ml APH - Admission for stringent monitoring.

❖ Intervention: Corticosteroids administered for foetal lung maturity.

❖ 32 Weeks: Preterm Premature Rupture of Membranes (PPROM).

❖ Outcome: Preterm vaginal delivery of a live baby at 33+3 weeks.

 

Discussion :

❖ Dermoid cysts larger than 5cm are a key predisposing factor for

ovarian torsion in pregnancy.

❖ Torsion is more common in the 1st trimester.

❖ Ultrasound and MRI are safe diagnostic tools; laparoscopy is the gold

standard for management in early pregnancy.

❖ Critical Need: Meticulous postoperative monitoring and serial foetal

growth scans are essential.

 

Conclusion & Key Learning Points :

❖ Ovarian torsion in pregnancy demands immediate recognition and

intervention to mitigate severe maternal and foetal risks.

❖ Heightened awareness and preparedness among healthcare

professionals are crucial for managing adnexal masses in pregnancy.

❖ Clinical Pearls:

• Prioritize considering ovarian torsion in pregnant patients with abdominal

pain, especially if adnexal cysts are known.

• Be prepared for a cascade of serious post-operative complications

(internal bleeding, haematoma formation, infection).

• Ensure multidisciplinary care and close foetal surveillance post-

intervention due to risk of miscarriage, stillbirth and preterm birth.