Introduction
The ovary is a gland in the reproductive system that produces ova (eggs) and plays an important role in reproduction and hormone production (estrogen and progesterone). It is a small, oval-shaped organ in the lower abdomen on either side of the uterus. The ovary is also responsible for fertility, pregnancy, and menstrual cycles. Various ovarian conditions range from minor to severe and can affect a woman’s fertility and general health. Ovarian torsion results when the ovaries or fallopian tubes twist on the tissues supporting them. It usually occurs in women during the early reproductive years but has a higher incidence in pregnancy and post-partum periods. Ovarian torsion must be promptly diagnosed and treated as early as possible to avoid future complications.
What Is Ovarian Torsion?
Ovaries are supported by multiple structures in the pelvic region. Ovarian torsion is uncommon due to twisting or a partial to complete rotation of the ligaments supporting the adnexa, which cuts off blood supply to the ovary. Twisting of these ligaments can cause severe pain, edema (swelling), venous congestion, and artery compression, leading to blood supply loss to the ovary. The most common cause of ovarian torsion is the corpus luteum cyst, which mostly regresses spontaneously by the second trimester of pregnancy. It occurs due to enlargement of the ovary secondary to cysts or neoplasms. It has a higher incidence in pregnancy (approximately 20 percent), especially between the sixth and fourteenth weeks of gestation. It is more commonly seen in the right ovary rather than the left. If a portion of the fallopian tube is torted along with the ovary, it is called adnexal torsion. Ovarian torsion can be considered a true surgical emergency as it can result in necrosis, ovary loss, and infertility (failure to achieve pregnancy) if not managed appropriately.
What Are the Symptoms of Ovarian Torsion During Pregnancy?
The signs and symptoms of ovarian torsion can mimic other intra-abdominal conditions.
The pain threshold varies among individuals, especially if they have associated conditions that can make diagnosing it challenging for healthcare professionals. Some of the symptoms of ovarian torsion in pregnancy include:
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Infrequent but significant abdominal pain and tenderness.
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Pain is usually sudden, unilateral, and worsens intermittently over many hours. However, some women may experience sharp or stabbing pain bilaterally in the lower abdominal region.
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Nausea and vomiting.
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Fever.
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Adnexal or pelvic mass.
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Occasional abdominal cramping for several days or weeks.
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Abnormal bleeding.
What Are the Risk Factors for Ovarian Torsion During Pregnancy?
A few risk factors for ovarian torsion during pregnancy include:
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The growth of corpus luteal cyst (a fluid or blood-filled mass).
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Enlarged uterus.
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Fertility treatment.
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Hormonal medications.
How Does Ovarian Torsion Impact Pregnancy?
Ovarian torsion in pregnancy can cause high patient morbidity and may also lead to fetal mortality and potential loss of fertility. Ovarian torsion significantly impacts the female, especially during pregnancy, as it causes acute pain and discomfort, which can be distressing and require medical attention. It disrupts hormone production, which can potentially affect pregnancy. Ovarian torsion results in compromised blood flow to the ovary, leading to ischemia (reduced blood flow) and necrosis of the ovary or loss of ovarian function if not treated appropriately. Considerable damage to the ovary may require oophorectomy (ovary removal) or threaten pregnancy. However, if the ovary is functional, it may not impact the current pregnancy but could have serious consequences on the fertility of the patient. Ovarian torsion usually requires surgical treatment to untwist the ovary and restore the blood supply. This decision can be complex depending on the procedure and effects of anesthesia on the mother and the fetus.
How Is Ovarian Torsion Managed During Pregnancy?
Ovarian torsion requires a high level of clinical suspicion from the healthcare expert, depending on the strong history and physical examination and supporting imaging and laboratory tests, to avoid missing this potentially harmful diagnosis. Ultrasound is the common diagnostic modality employed in the determination of ovarian torsion. It mostly reveals a unilateral ovarian enlargement that may appear complex, solid, or cystic, with or without fluid accumulation in the pouch of Douglas. If the ovaries are unable to be visualized by an abdominal or vaginal ultrasound, magnetic resonance imaging (MRI) can be recommended.
Surgery is the treatment of choice recommended for ovarian torsion. Still, the decision to proceed during pregnancy is complex, as the well-being of both the mother and fetus needs to be considered. The risk of fetal loss is minimal during the first trimester and with modern anesthetic techniques. Performing surgery during the second or third trimester may be associated with the risk of premature labor. Studies have reported that preterm labor has occurred in about 26 percent of women during the second trimester and in 82 percent of women during the third trimester of those who have had surgery for ovarian torsion. Adnexal masses are the most common indications for surgical intervention during pregnancy. The major consideration is to decide whether laparoscopy or laparotomy needs to be performed.
Ovarian torsion can be treated by laparoscopy during the first trimester, and laparotomy is usually preferred in the second and third trimesters. Laparoscopy is a minimally invasive procedure involving small, key-hole incisions in the abdomen. A tiny video camera and surgical instruments are inserted through these incisions in an attempt to untwist the ovary and restore blood flow. On the contrary, laparotomy involves larger incisions that are made under the navel to expose the ovary and untwist it. The doctor observes the ovary through computerized images to ensure adequate blood flow and monitor the patient and the fetus. The ovary must turn pink from black or purple after being untwisted. If it shows necrosis (tissue death), the ovary requires removal. However, it may be associated with a risk of increased pain and wound complications. Medications such as Acetaminophen and Ibuprofen are prescribed to decrease the pain and discomfort after the procedure. Lifting heavy weights and intense physical activities must be avoided for a few weeks after surgery.
Conclusion
Ovarian torsion is a rare but severe complication that can occur during pregnancy and pose a risk to the mother and the fetus. It occurs when the ovary rotates or twists around its supporting ligaments, squashing the accompanying blood vessels and lymphatics. Its incidence increases fivefold in pregnancy or to about five in every 10,000 women. Ovarian torsion must be considered in any pregnant female with sudden onset of severe lower abdominal pain. Therefore, pregnant women experiencing the symptoms of ovarian torsion must seek consultation with a gynecologist, as early and prompt intervention is highly essential to protect the fetus and the fertility of the patient.
