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CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 4  |  Page : 360-362  

Polycystic ovarian syndrome leading to ovarian torsion in a 19-year-old


1 Department of Obstetrics and Gynecology, PGIMS, Rohtak, Haryana, India
2 Department of Obstetrics and ynecology, PGIMS, Rohtak, Haryana, India

Date of Web Publication2-Aug-2018

Correspondence Address:
Kriti Agarwal
Sanghi Hospital, Chotu Ram Chow, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_137_17

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  Abstract 


Ovarian torsion (OT) is the fifth most common gynecological emergency with a reported prevalence of 2.5%–7.4%. A 19-year-old unmarried girl, known the case of the polycystic ovarian syndrome (PCOS) was referred with sudden onset left-sided lower abdominal pain for the past 7 days, associated with vomiting. On examination, lower abdominal tenderness, exclusively to the left side was present. Ultrasound showed a bulky left ovary of 6 cm × 8 cm × 6 cm with no vascularity and fluid in POD. Laparoscopy revealed a gangrenous left ovarian cyst of 8 cm × 8 cm, twisted five times over the fallopian tube which was adherent to lateral pelvic wall and omentum. Left oophorectomy was done. In all patients of PCOS with acute abdomen, ovarian torsion should be included in differential diagnosis, and early recourse to laparoscopy is the key for prevention of the dreaded complication of the gangrenous ovary and ultimately oophorectomy.

Keywords: Ovarian, pcos, torsion


How to cite this article:
Singhal SR, Agarwal K, Dahiya K, Hooda R. Polycystic ovarian syndrome leading to ovarian torsion in a 19-year-old. Med J DY Patil Vidyapeeth 2018;11:360-2

How to cite this URL:
Singhal SR, Agarwal K, Dahiya K, Hooda R. Polycystic ovarian syndrome leading to ovarian torsion in a 19-year-old. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Oct 22];11:360-2. Available from: http://www.mjdrdypv.org/text.asp?2018/11/4/360/238157




  Introduction Top


Ovarian torsion (OT) is the fifth most common gynecological emergency with a reported prevalence of 2.5%–7.4% in patients undergoing emergency surgery for acute pelvic pain.[1],[2] As symptoms of OT are nonspecific, often a delayed diagnosis leading to potentially life-threatening complications such as thrombophlebitis or peritonitis. Risk factors for ovarian torsion include pregnancy, assisted conception, ovarian stimulation, previous abdominal surgery, and tubal ligation.[2],[3] However, torsion is frequently associated with ovarian pathologies that result in enlarged ovaries, most common being ovarian dermoid; although, other structures include parameso/tubal cysts, follicular cysts, endometriomas, and serous/mucinous cystadenoma.[4] We present a case of 19-year-old unmarried female, known case of PCOS presenting with OT leading to the gangrenous ovary.


  Case Report Top


A 19-year-old unmarried girl, known case of polycystic ovarian syndrome was referred with sudden onset left-sided lower abdominal pain for the past 7 days, which was severe in intensity, squeezing type, relieved temporarily by analgesics, associated with on and off vomiting episodes without history of fever, altered stool patterns, vaginal bleeding, urinary complaints, or abnormal vaginal discharge. She was managed conservatively with analgesics and anti-emetics for a week by a private practitioner. Menstrual cycles were regular and associated with dysmenorrhea. She was diagnosed with polycystic ovarian syndrome (PCOS) 3 years back and took combined oral contraceptive pills for 1 year and then lost to follow-up since 1½years. Vital signs were within normal limits. Hirsutism was present. On abdominal examination, left-sided lower abdominal tenderness was present. Her full blood counts and serum biochemistry were within normal limits. Ultrasound showed a bulky left ovary of 6 cm × 8 cm × 6 cm with no vascularity and fluid in POD. CA125-20 IU/L. With a preoperative diagnosis of OT, she was taken up for laparoscopy. Intraoperatively, gangrenous left ovarian cyst of 8 cm × 8 cm, the  Fallopian tube More Details was twisted five times over, and the ovary was adherent to the lateral pelvic wall and omentum [Figure 1] and [Figure 2]. Detorsion of the ovary was tried, but the necrotic appearance did not improve, and bleeding was observed. Therefore, left oophorectomy was done. Histopathological examination confirmed areas of congestion and hemorrhage consistent with a diagnosis of OT. Postoperative period was uneventful, and she was discharged on the 2nd postoperative day.
Figure 1: Intraoperative photograph showing uterus, left ovarian cyst (concealed by adhesions to the omentum) and twisted five times over the fallopian tube

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Figure 2: Intraoperative photograph showing gangrenous left ovary

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  Discussion Top


OT can occur at any age from prepubertal to postmenopausal with the greatest incidence in women 20–30 years of age.[3] The normal mobility of the fallopian tube can lead to rotation of the ovary along with its vasculature leading to obstruction of venous outflow, infarction and eventual necrosis, infection, peritonitis, or even loss of the adnexa. About 70% of ovarian torsion occurs on the right side, due to the longer utero-ovarian ligament on this side. Moreover, the limited space due to the presence of the sigmoid colon on the left side and hypermobile cecum on the right side also contributes to the laterality incidence.[5] However, in our case, it was left-sided, which is a less common presentation.

Diagnosis of OT is challenging as the clinical parameters yield low sensitivity and specificity. Sudden onset pain occurs in 59%–87%, sharp or stabbing in 70%, and pain radiating to the flank, back, or groin in 51% of patients.[6],[7] Nausea and vomiting are common in 59%–85% of cases and low-grade fever in 20%.[7] Other nonspecific symptoms including nonmenstrual vaginal bleeding and leukocytosis, reported in about 4.4% and 20% of cases, respectively.[6] These symptoms are common to many other differential diagnoses in unmarried females including hemorrhagic cyst, renal colic, urinary tract infection, endometriosis, gastrointestinal infection, appendicitis, and diverticulitis. Although our patient presented with acute left-sided abdominal pain and vomiting, early diagnosis could not be made due to the late referral.

Imaging is frequently used in the management of an acute abdomen. However, the diagnostic contribution of ultrasound scan to the diagnosis of ovarian torsion remains controversial. Nonspecific ultrasound findings include heterogeneous ovarian stroma, “string of pearls” sign, and free fluid in the cul-de-sac.[8] However, ovarian enlargement of >4 cm is the most consistent ultrasound feature in ovarian torsion, the greatest risk occurring in cysts measuring 8–12 cm.[9],[10] Dual blood supply from ovarian and uterine arteries provide persistent arterial blood flow. In addition, torsion may cause symptoms related to venous engorgement before arterial blood supply is compromised. Therefore, ultrasound with or without Doppler, may be misleading, contributing to a subsequent delay in management. If torsion is suspected clinically, laparoscopy should be done without delay at an earlier stage, when the ovary is still salvageable. In our case, ultrasound was done at a very late stage, wherein no blood flow was observed, and this was immediately followed by laparoscopy.

Conventionally in the past, radical treatment by adnexectomy was the standard approach to OT in cases of ovarian decoloration/necrosis, due to concern that untwisting of the adnexa might precipitate pulmonary embolism from a thrombosed vein.[2] In a study conducted by Rody et al., conservative management of OT regardless of the macroscopic appearance of the ovary was suggested.[4] A cystectomy is usually performed for suspected organic cysts for histological examination. In case of difficult cystectomy due to the ischemic edematous ovary, some authors recommend a re-examination 6–8 weeks following the acute episode and secondary surgery later if necessary.[4]

In our case, although the patient was known the case of PCOS and had taken treatment for the same, she was lost to follow-up since 1½ years, which might have led to increase in ovarian size and subsequently OT. Moreover, the patient presented 1 week after the onset of acute pain which led to worsening of torsion and ultimately an unsalvageable gangrenous ovary, for which radical treatment by oophorectomy had to be done.


  Conclusion Top


We suggest that in all patients of PCOS with acute abdomen, OT should be included in differential diagnosis and early recourse to laparoscopy is the key for prevention of the dreaded complication of the gangrenous ovary and ultimately oophorectomy. Moreover, these girls should be on regular follow-up to assess ovarian enlargement as an edematous ovary on ultrasound that appears larger on successive is more suggestive of ovarian torsion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anteby SO, Schenker JG, Polishuk WZ. The value of laparoscopy in acute pelvic pain. Ann Surg 1975;181:484-6.  Back to cited text no. 1
    
2.
Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152:456-61.  Back to cited text no. 2
    
3.
Huchon C, Fauconnier A. Adnexal torsion: A literature review. Eur J Obstet Gynecol Reprod Biol 2010;150:8-12.  Back to cited text no. 3
    
4.
Rody A, Jackisch C, Klockenbusch W, Heinig J, Coenen-Worch V, Schneider HP, et al. The conservative management of adnexal torsion – A case-report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2002;101:83-6.  Back to cited text no. 4
    
5.
Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;180:462-5.  Back to cited text no. 5
    
6.
White M, Stella J. Ovarian torsion: 10-year perspective. Emerg Med Australas 2005;17:231-7.  Back to cited text no. 6
    
7.
Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med 2008;27:7-13.  Back to cited text no. 7
    
8.
Michele B, Giovanni S, Paolo T, Roberta Z, Vincenzo M. Adnexal torsion. Ultrasound Clin 2008;3:109-19.  Back to cited text no. 8
    
9.
Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics 2008;28:1355-68.  Back to cited text no. 9
    
10.
Peña JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril 2000;73:1047-50.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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