ABSTRACT

CORRESPONDING AUTHOR:
Dr. Banashree Nath,
Room No. 26, Doctor’s Hostel,
Silchar Medical College and Hospital,
Ghoongur, Silchar- 788014,
Assam, India.
E-mail: nathbanashree@gmail.com

ABSTRACT: Adnexal torsion during pregnancy is a rare event and bilateral adnexal torsion is even rarer. Hence this case is reported. A 20-year-old woman, Gravida 2, Para 1 presented in the second trimester of pregnancy with marked abdominal distension and pain. Transabdominal ultrasonographic examination revealed bilateral huge ovarian cysts and live fetus in utero of 14 weeks gestational age. Laparotomy revealed massive bilateral cysts with torsion on both sides. Right sided saphingo-oophorectomy and left sided cystectomy was done. Patient was followed up who delivered a healthy baby at term. Hence prompt diagnosis and management is essential in adnexal torsion especially in bilateral involvement not just for the index but also for future pregnancies.

KEYWORDS: Adnexal Torsion, Bilateral, Pregnancy.

INTRODUCTION: Adnexal mass in pregnancy occur with an estimated incidence of 2% to 10%.¹ Torsion of adnexa is common during pregnancy with 5-fold increase in incidence.² Early diagnosis and treatment ensures salvage of ovarian tissue because a delay of 36-48 hrs. is enough to bring irreversible necrosis and damage of the organ.³ Here we report a unique case of bilateral torsion of adnexa during the second trimester of pregnancy with irreversible damage to right adnexa.

CASE REPORT: A 20 yrs. old primipara came with complaints of pain abdomen for 4 days along with cessation of menstruation for 31/2 months. She was afebrile and physical examination revealed uterine size of 12+ weeks along with huge mass palpable in suprapubic area having smooth surface and unrestricted mobility. Investigations showed white cell count of 17,000/mm3 whereas all other reports were within normal limit. Abdominal ultrasound of whole abdomen revealed normal intrauterine gestation of approx. 14 wks. 5 days ± 1 wk1d with bilateral ovarian cysts. The cysts had internal echogenicity but no internal papillation.

Right ovary measures 10 × 6 × 5 cm and left ovary measures 8 × 5 × 5 cm. There was absence of vascular flow on the right side. In view of these findings decision for exploratory laparotomy was taken. Laparotomy revealed bilateral huge ovarian cysts with intact capsule and regular borders. There was adnexal torsion with 4-5 twists around pedicle on right side with hemorrhage and necrosis of ovarian mass and the fallopian tube. Whole mass was black-bluish in color.

On left side there was one and a half twist around pedicle but the vitality of the tissue was intact. Right sided salphingo-oophorectomy was done as no viable ovarian tissue was found and the tube was necrosed. On left side, untwisting of the adnexa was done followed by cystectomy. Patient was put on tocolytics during the procedure and thereafter continued for 48 hrs. Post-operative period was uneventful. Patient was discharged on 8^th post-operative day. Histopathological examination revealed the specimens to be corpus luteal cyst on left side and hemorrhage cyst on the right side. The patient delivered at 41 weeks a healthy male baby weighing 3.2 kg.

DISCUSSION: Bilateral adnexal torsion is a rare event and the presence of this rare complication along with pregnancy is even rarer. A search in the pubmed with keywords adnexal torsion, bilateral, and pregnancy revealed no publication though bilateral torsion have been reported in premenarchal girl⁴ as well in a postmenopausal woman.⁵ To the best of our knowledge this is the first reported case of bilateral adnexal torsion associated with pregnancy.

In adnexal torsion there is twisting of adnexa around its vascular axis. There is enlargement of the ovary primarily due to the obstruction of lymphatic and venous drainage which is followed by ischemic necrosis due to gradual reduction in arterial blood flow. This leads to gangrene of the organ that may subsequently be infected, even death may occur in neglected cases.^6.7

Management of adnexal torsion in pregnancy remains controversial. Any complication during pregnancy has been traditionally managed by laparotomy. However laparoscopy has recently emerged as preferred surgical technique until early second trimester.⁸

 There is however limitations in terms of availability of this expensive equipment as well as surgical expertise required in performing the procedure. Laparotomy was chosen as the procedure in this case anticipating penetrative injuries with the in sufflation needle and peritoneal spillage following possible accidental rupture of cysts as the ovarian masses were huge. Adnexal torsion with necrosed and nonviable right adnexa left us with no option but to proceed with adnexectomy.

In conclusion early diagnosis and prompt surgical intervention in cases of adnexal torsion is necessary to save ovarian tissue more so in bilateral involvement and pregnancy which has implications for future fertility apart from continuation of the present pregnancy.

CONSENT: Written informed consent was obtained from the patient for publication of this Case report and the accompanying image.

Fig. 1: Bilateral torsion of adnexa with gravid uterus and nonviable right ovarian mass

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