Torsion of the ovary, tube or both is estimated to be responsible for only a small number of all gynaecological emergencies, but is a common diagnostic challenge in the emergency setting. It commonly occurs between the 6 th and 14 th weeks of pregnancy 1. Fertil Steril. ical evaluation for diagnosing ovarian torsion Ovarian Torsion: Diagnostic Features on CT and MRI With Pathologic Correlation Shauna Duigenan1 Esther Oliva2 Susanna I. Lee1 Duigenan S, Oliva E, Lee SI 1Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, Ellison 234, 55 Fruit St, Boston, MA 02114. Consideration is particularly imperative in a patient with known risk factors for the disease, such as ovarian mass, prior pelvic surgery, or pregnancy. Acute ovarian torsion is a gynecological emergency and should be excluded on ultrasound. The US appearance of the ovary raised high suspicion of left ovarian torsion. The vascular pedicle is also engorged, and there is a small amount of free fluid in the Pouch of Douglas. Gravid uterus, with a singleton mobile early gestation, not specifically assessed. gravid uterus with single intact gestational sac with a viable embryo with normal active pulsations of about 8 weeks of gestation, markedly enlarged (85 cc) with twisted pedicle and stromal edema with cystic changes and peripheral hypoechoic zone, all ovarian parenchyma are devoid of vascularity, suggestive of ovarian edema with impending cortical necrosis, Doppler study revealed twisted left ovarian pedicle with no detected vasculature along the ovarian parenchyma, consistent with left, mild free fluid is noted at the pelvis and right iliac fossa, normal size (3 cc) and sonographic features. Douglas Rogers, Ragheed Al-Dulaimi, Maryam Rezvani, Anne Kennedy, Akram Shaaban, Peripheral hypervascularity of the corpus luteum with ovarian edema (CLOE) may decrease false positive diagnoses of ovarian torsion, Abdominal Radiology, 10.1007/s00261-019-02091-3, (2019). O&G - Clinical Conditions - Ovarian - Gynae. 8 Ultrasound whirlpool sign in ovarian torsion. Smorgick N, Pansky M, Feingold M, Herman A, Halperin R, Maymon R. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Although mortality decreased by nearly 90% from 1979 to 1992, ectopic pregnancy remains the leading cause of death during the first trimester of pregnancy, with a 9%–14% mortality rate (,1,,2). Interestingly, arterial flow with normal waveforms was detected in both the ovary and its pedicle, suggesting either an incomplete torsion, or an element of torsion-detorsion. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Left ovary is markedly edematous, T2 hyperintense with T2 shine through on DWI/ADC. a, bColor flow on Doppler US images demonstrates the twisted pedicle (arrows) in a 12-year-old girl with a large, mature cystic teratoma (T) arising from the left adnexa, representing the lead point for left adnexal torsion - "Pediatric ovarian torsion: a pictorial review" Ultrasound features are consistent with left paraovarian cyst with acute left ovarian torsion and coexisting gravid uterus with normal early pregnancy of 8 weeks. Failure to consider ovarian torsion in the differential diagnosis is not uncommon, given the relative infrequency of this condition. It is estimated that about 2.7% of surgical emergencies in women are comprised by ovarian torsion. Note that the affected ovary contains the corpus luteum, and this is an established risk factor for torsion in early pregnancy. Ovarian torsion during pregnancy is an uncommon complication with high fetal mortality if not immediately treated. Magnetic resonance imaging demonstrated ovarian enlargement and edema. The torsion of a pedunculated subserous leiomyoma is a rare complication of uterine leiomyoma in pregnancy but should be considered in a pregnant woman with acute onset abdominal pain. Diagnosis can be difficult and is mainly based on clinical symptoms and imaging techniques such as ultrasound and MRI. 1. It is caused by hormonal overstimulation by hCG, and is therefore usually bilateral. Secondary signs include free pelvic fluid, an underlying ovarian lesion, reduced or absent vascularity and a twisted dilated tubular structure corresponding to the vascular pedicle. Ovarian torsion is a medical emergency. However, heightened awareness and suspicion of this condition are needed for timely intervention. MRI and ultrasound appearance of ovarian torsion in a 12 week pregnant patient. Radiology 1985;154(3):773–775. In those with ovarian torsion, the most frequent sonographic signs were ovarian edema, abnormal ovarian blood flow, relative enlargement of the affected ovary, and the presence of free fluid around the ovary or in the Douglas pouch (Table 2). Unable to process the form. Uterine adnexal torsion: sonographic findings. Graif M, Itzchak Y. Sonographic evaluation of ovarian torsion in childhood and adolescence. After a right adnexectomy was performed, the patient proceeded to full-term pregnancy. No cysts or lesions. Normal right ovary, located posterolaterally relative to the uterus. Ovarian torsion is the fifth most common gynecologic surgical emergency (,1). Check for errors and try again. Up to 80% of these cases occur in patients who are at the reproductive age. 12 weeks pregnant. Introduction. Sonogr… Ovarian torsion during pregnancy is an uncommon complication with high fetal mortality if not immediately treated. Most cases are caused by dermoid and functional ovarian cysts. In this article, we discuss and illustrate the normal appearance and arterial flow … P28.03: Ovarian torsion in pregnancy: ultrasound characteristics and histopathology M. Rincon Maternal and Fetal Medicine and Radiology, Oregon Health & … Pelvic pain for three days. 1 (2): 108-110. Adnexal torsion is defined as rotation of > 45° in the long axis of the adnexae. The presence of arterial flow within the ovary suggest either an incomplete torsion, or a torsion-detorsion scenario. Torsion of the ovary is a true gynecological emergency, and up to one-fifth of ovarian torsion occurs during pregnancy. ADVERTISEMENT: Supporters see fewer/no ads. Hormonal overstimulation can occur in gestational throphoblastic disease, PCOS or in patients receiving hormonal therapy. Its occurrence during gestation is reported as 2%, accounting for 2.7% of surgical emergencies in pregnant women. Without surgical intervention, the ovary may be lost; therefore, the diagnosis is important. The main feature of torsion is ovarian enlargement due to venous/lymphatic engorgement, edema, and hemorrhage. Although this sign is specific for ovarian torsion, yet it had been variably reported as seen in 13–88% of patients with ovarian torsion , , . Ovarian torsion during pregnancy is a fairly uncommon complication with a high patient morbidity and fetal mortality if not immediately treated. In this study, the classic whirlpool sign was depicted in 2 incidences only in all cases (14.28%), and abnormal coils and loops were found in another two (14.28%). Ultrasound is the initial imaging modality of choice. If not treated quickly, it can result in loss of an ovary. Ovarian torsion refers to complete or partial twisting of the vascular pedicle in the suspensory ligament, leading to obstructed lymphatic flow followed by obstructed venous flow and finally obstructed arterial flow. Ovarian torsion is an uncommon cause of acute abdominal pain in nonpregnant women but is more common during pregnancy. However, rendering an accurate diagnosis of ovarian torsion is challenging. Fig. 2009 Dec. 92(6):1983-7. Initial ultrasound was normal. Early recognition and restoration of blood flow are important to avoid irreversible ovarian damage. Although diagnostic ultrasound is a frequently used imaging tool in patients with suspected OT, the mere presence of blood flow on Doppler ultrasonography of the adnexa has a poor … Ectopic pregnancy occurs when a blastocyst abnormally implants outside the endometrium of the uterus. Evangelia Vlachodimitropoulou Koumoutsea, Manish Gupta, Antony Hollingworth, Anwen Gorry, Ovarian Torsion in the Third Trimester of Pregnancy Leading to Iatrogenic Preterm Delivery, Case Reports in Obstetrics and Gynecology, 10.1155/2016/8426270, 2016, (1-3), (2016). The varied imaging features and nonspecific symptoms of ovarian torsion can lead to a delay in identification, with misdiagnosis being common. MRI and ultrasound appearance of ovarian torsion in a 12 week pregnant patient. It usually occurs due to enlarged corpus luteum cyst. Adnexal torsion is commonly unilateral, with a slight (3:2) right-sided predilection (presumably due to the protective effects of the sigmoid colon on the left) 6,8. A high index of suspicion should be maintained, particularly if there is tenderness or mild swelling of an ovary containing a corpus luteum in early pregnancy. Ovarian torsion is a surgical emergency that can lead to impaired or lost fertility if the diagnosis and intervention are delayed. It is relatively uncommon at an incidence of approximately 1/1000 pregnancies, but may affect upwards of 16% of pregnancies achieved through ovarian hyperstimulation. The color Doppler showed persistent arterial vascularity in the left ovary. Mild symptoms and low clinical suspicion, in addition to risks associated with pregnancy prevented early laparoscopic examination, though torsion was considered. Ovarian Torsion. The main feature of torsion is ovarian enlargement due to venous/lymphatic engorgement, edema, and hemorrhage. 1 Ovarian torsion … In this case, the cyst arises near the left ovarian pedicle suggestive of paraovarian cyst. Young R, Cork K. Intermittent Ovarian Torsion in Pregnancy. [Abstract/Free Full Text] The CT and MRI features of ovarian torsion are illustrated with gross pathologic correlation. The presence of arterial flow within the ovary suggest either an incomplete torsion, or … Background: To determine if asymmetric ovarian edema on non-contrast MRI can be used to distinguish torsed from non-torsed stimulated ovaries in pregnant women. An ultrasound was performed for correlation with the initial ultrasound from 1 week ago, which was normal (not shown). The … A corpus luteum is identified within this, as was seen on the preceding ultrasound (not shown). Secondary signs include free pelvic fluid, an underlying ovarian lesion, reduced or absent vascularity and a twisted dilated tubular structure corresponding to the vascular pedicle. The delayed presentation (with initial US normal) highlights the difficulty sometimes encountered in making the diagnosis, particularly in the setting of pregnancy, and with intermittent detorsion. It is located in the pouch of Douglas and is enlarged to approximately 50cc. (2017) Clinical practice and cases in emergency medicine. 51 When present, it is often associated with severe pain. Ovarian hyperstimulation syndrome is a relatively rare condition. 51 Ovarian torsion occurs most commonly in the 1 st and 2nd trimesters, attributable to increased ligamentous laxity, rapid uterine growth, and a greater number of functional cysts present in early pregnancy. It is important to consider torsion when ovarian masses are discovered in pregnant patients with severe abdominal or pelvic pain . Paraovarian cysts account for ~10-20% of adnexal masses and can be complicated by rupture, torsion, or hemorrhage. AJR Am J Roentgenol 1988;150(3):647–649. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Etiology and pathophysiology. Known early pregnancy. ADVERTISEMENT: Supporters see fewer/no ads. 1 week history of severe left iliac fossa pain. [Abstract/Free Full Text] Warner MA, Fleischer AC, Edell SL, et al. Ovarian torsion is a gynecologic emergency whose ultrasound features have been well described [ 1 ??? It commonly occurs between the 6th and 14th weeks of pregnancy 1. Overall, the incidence of ovarian torsion during pregnancy is about 1 in 5000 pregnancies. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Current ultrasound confirms a edematous, enlarged left ovary (volume 54cc) with multiple small follicles and a corpus luteum displaced to the periphery. The classic clinical presentation overlaps that of appendicitis and includes nausea, vomiting, and pelvic pain. Note that the affected ovary contains the corpus luteum, and this is an established risk factor for torsion in early pregnancy. The incidence of ectopic pregnancy has increased from 0.37% of pregnancies in 1948 to approximately 2% of pregnancies in 1992 (,1). Unable to process the form. Sonogr… A difference in diameter of the ovarian veins, with thinning of the twisted side and compensatory dilatation of the contralateral side for drainage of increased uterine blood flow, may be a useful imaging sign for the diagnosis of ovarian torsion during pregnancy. The pelvic ultrasound showed significant enlargement of the left ovary exhibiting a large anechoic cyst with edema of the ovarian stroma and free intraperitoneal fluid effusion. Edematous, T2 hyperintense left fallopian tube is identified, best appreciated on the sagittal T2 images. However, in women presenting with acute pelvic pain, bowel or urologic causes represent the more common causes and will often lead to CT or MRI (the latter in pregnant … Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. Ultrasound is the initial imaging modality of choice. 12 ]. Ovarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. 1 Torsion more commonly occurs on the right rather than the left with an incidence of 3:2. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Progressive ovarian enlargement supported surgical intervention, which confirmed the presence of torsion. Adnexal torsion is commonly unilateral, with a slight (3:2) right-sided predilection (presumably due to the protective effects of the sigmoid colon on the left) 6,8. Ovarian torsion is the total or partial rotation of the adnexa around its vascular axis. It can also be seen in pregnancy, but seldom in a normal single pregnancy. Methods: In this retrospective study, our radiology database was searched for women who were pregnant and who had undergone ovarian stimulation and underwent MRI abdomen/pelvis from 1/2000-12/2012. It usually occurs due to enlarged corpus luteum cyst. Check for errors and try again. A twisted pedicle, although not often detected on imaging, is … Acute ovarian torsion is a gynecological emergency and should be excluded on ultrasound. Ovarian torsion affects approximately 7% of known ovarian masses in pregnancy .
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