Gynecology
7 min read

Adnexal Torsion: Surgical Considerations in Early and Late Pregnancy

Adnexal Torsion: Surgical Considerations in Early and Late Pregnancy
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Table of Contents

    Procedure Summary

    • Adnexal torsion is defined as complete or partial rotation of the ovary or fallopian tube on its vascular pedicle.
    • One in 500 women will require a laparoscopy during pregnancy, with adnexal torsion being the most common gynecologic indication.
    • The risk of torsion decreases as the pregnancy progresses.
    • Torsion in pregnancy presents the same way as in non-pregnant patients, most commonly with acute abdominal pain, nausea, and vomiting.
    • The majority of risk factors for adnexal torsion are related to reproduction.

    Presented By

    Affiliations

    University of Toronto, St. Michael’s Hospital

    See Also

    What is Adnexal Torsion?

    • Adnexal Torsion is the rotation of an ovary and part of the fallopian tube, causing reduced blood flow and potential tissue damage.
    • Risk Factors include being of reproductive age, having ovarian cysts, pregnancy, and certain fertility treatments.
    • Symptoms include severe one-sided lower abdominal pain, nausea, and sometimes a palpable abdominal mass.
    • Diagnosis and Treatment involve symptoms, examination, ultrasound, and surgery, often urgently due to the risk of ovarian damage.

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    Video Transcript

    This video reviews the surgical considerations for patients with adnexal torsion in early and late pregnancy. Adnexal torsion is defined as complete or partial rotation of the ovary and/or fallopian tube on its vascular pedicle. One in 500 women will require a laparoscopy during pregnancy, with adnexal torsion being the most common gynaecologic indication. The risk of torsion decreases as the pregnancy progresses. Torsion in pregnancy presents the same way as in non-pregnant patients, most commonly with acute abdominal pain, nausea, and vomiting.

    Presentation and Risk Factors of Adnexal Torsion

    The majority of risk factors are related to reproduction. Let’s review a case.

    Case Review: Adnexal Torsion in Early Pregnancy

    Our first patient is a 30-year-old G1P0 who presented with sudden onset of intermittent right lower quadrant pain. Initial ultrasound demonstrated arterial and venous Doppler flow. While we often consider the absence of flow to be pathognomonic for a diagnosis of torsion, this is a late sign.

    Diagnostic Signs and MRI Findings

    Other important considerations include ovarian enlargement or oedema, seen with the red arrow, and the string of pearls appearance of multiple peripheral follicles, indicated in blue, which occurs due to transudation of fluid secondary to oedema. The patient went on to receive an MRI, which demonstrated an asymmetrically enlarged and oedematous right ovary with a corpus luteum and multiple tiny peripherally located follicles.

    There was also a tortuous tubular T2 hyper-intense structure, known as the whirlpool sign, which demonstrates a twisted vascular pedicle. A diagnosis of adnexal torsion was made. It should be noted that there is limited evidence for use of CT in these cases. Adnexal torsion is considered a surgical emergency. We will now review the preoperative, intraoperative, and postoperative considerations specific to patients in early pregnancy.

    Preoperative Considerations for Adnexal Torsion in Early Pregnancy

    Preoperatively, a multidisciplinary approach is required. In addition to a regular consent, it is important to counsel the patient that surgery is considered safe in all trimesters when there is a clear indication. Surgery in pregnancy is not considered an RH sensitising event. Thus, programmes should be reserved for usual indications, such as antepartum haemorrhage. DVT prophylaxis is recommended for all surgeries in pregnancy.

    If the surgery is less than 45 minutes, sequential compression devices are sufficient. Otherwise, pharmacologic prophylaxis in the form of low molecular weight heparin should be considered. Last, a fetal heart rate should be documented before and after the procedure. In early pregnancy, patients can be placed supine up until 16 weeks, after which left lateral tilt is recommended. We elected to enter the intra-abdominal cavity via varus needle in the left upper quadrant, but Hasson and optical trocar entries are also considered safe.

    Intraoperative Considerations for Adnexal Torsion in Early Pregnancy

    No uterine manipulator should be inserted, so as not to disrupt the pregnancy. And care should be taken to manipulate the uterus as little as possible intra-abdominally as well. Detorsion of the pedicle can be performed as usual, and the ovary can be tucked back behind the uterus. An oophoropexy was considered, but due to concern of bleeding and the need for oophorectomy, we elected not to do so.

    Postoperative Considerations for Adnexal Torsion in Early Pregnancy

    Postoperatively, it is important to once again document a fetal heart rate. As well, if the patient is less than 12 weeks gestation and it is believed that the corpus luteum may have been disrupted, progesterone supplementation should be prescribed in order to support the pregnancy. To summarise the clinical pearls of adnexal torsion in early pregnancy, first, do not let the pregnancy scare you from operating. The principles are much the same with a few additional considerations.

    Summary of Key Considerations for Adnexal Torsion in Early Pregnancy

    Do not use a uterine manipulator or perform an oophoropexy. Do enter via the left upper quadrant in order to avoid injuring the gravid uterus. And do give progesterone supplementation until 12 weeks gestational age.

    Case Review: Adnexal Torsion in Late Pregnancy

    We will now review a case of torsion in late pregnancy. This patient is a 37-year-old G5P0 who presented to obstetrical triage at 32 weeks gestation with acute abdominal pain. Originally diagnosed as fibroid degeneration, with uncontrolled pain, additional investigations were conducted.

    Preoperative Considerations for Adnexal Torsion in Late Pregnancy

    Once again, we will review this approach as preoperative, intraoperative, and postoperative. In late pregnancy, the multidisciplinary team is of utmost importance, with collaboration between MFM, anaesthesia, and paediatrics. Consents in this case must include the risk of preterm labour and possible fetal distress, necessitating an urgent caesarean section. Given that the fetus is viable, tocolytics, corticosteroids, and magnesium sulphate should be considered for the usual obstetrical indications.

    A pre and postoperative fetal heart rate assessment is required. Fetal heart rate can be monitored throughout the procedure, if possible, in accordance with the ACOG guidelines, which include the following. The fetus is viable, the surgery can be interrupted, the patient has consented, and a skilled obstetrician is able to perform an emergent caesarean section, if required, for fetal indications. In this case, a paediatrics team, obstetrical nurses, and a C-section tray should be present in the OR.

    Intraoperative Considerations for Adnexal Torsion in Late Pregnancy

    Patients should be placed in a left lateral tilt. Again, we elected to use a left upper quadrant entry with uterine deviation to prevent injuries. Ports should be placed on the ipsilateral side of pathology, significantly more cephalad than the traditional placements, given that the pathology has moved out of the pelvis. The gravid uterus takes up much of the abdominal cavity. It is therefore essential that ports are placed in a very controlled manner under direct visualization.

    The adnexa have migrated out of the pelvis, and all the structures are quite close together. Once one port is inserted, be sure to use a grasper to provide counter-traction for the placement of additional ports to mitigate the risk of uterine injury. The adnexa is carefully detorted. A five-millimetre, 30-degree scope can be very helpful in these cases to help manoeuvre around the gravid uterus and alternate between ports as needed. Although it may be tempting to pexy the ovary to the round ligament, there is no evidence that this reduces the risk of recurrence.

    Postoperative Considerations for Adnexal Torsion in Late Pregnancy

    Postoperative considerations include monitoring for signs and symptoms of preterm labour. Once again, consider tocolytics, corticosteroids, and magnesium sulphate depending on obstetrical indications. The clinical pearls in late pregnancy are similar to those in early pregnancy with a few added considerations. Ensure your ports are placed on the ipsilateral side of the pathology to minimise passing instruments over the uterus. Involve MFM in pediatrics and consider consent and preparation for a possible caesarean section depending on the clinical context.

    In summary, the approach to adnexal torsion in early and late pregnancy can be divided into preoperative, intraoperative, and postoperative considerations. Using this stepwise approach, surgery can be safely performed in patients at all stages of pregnancy. If you would like a more detailed account of what was discussed in this video, please see this table.