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Video Description
Adnexal torsion in the third trimester of pregnancy is rare but associated with significant risk of maternal and fetal morbidity if left untreated.
Laparoscopy is considered the preferred surgical approach for treatment of adnexal torsion but has not been described beyond 34 weeks’ gestation. Here we illustrate a case of right adnexal torsion in the setting of a known ovarian cyst successfully treated with laparoscopic detorsion and cystectomy at 35+5 weeks gestational age.
Pre-operative consultations, port placement, surgical steps and post-operative monitoring with the help of a multidisciplinary team are presented.
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McMaster University
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What is Conservative Laparoscopic Treatment of Adnexal Torsion at 35+5 Weeks’ Gestation?
Conservative Laparoscopic Treatment of Adnexal Torsion at 35+5 Weeks’ Gestation” is a medical procedure used to manage a condition called adnexal torsion in a woman who is 35 weeks and 5 days into her pregnancy. Adnexal Torsion:
- Is a condition where the ovaries, Fallopian tubes, or surrounding tissues in the reproductive system (collectively known as the adnexa) become twisted.
- Disrupts blood flow to the ovaries and can cause severe pain and other health issues.
- Is a medical emergency and requires prompt treatment to prevent damage to the ovaries and Fallopian tubes.
What are the risks of Conservative Laparoscopic Treatment of Adnexal Torsion at 35+5 Weeks’ Gestation?
Conservative laparoscopic treatment of adnexal torsion at 35 weeks and 5 days of gestation involves specific risks due to the advanced stage of pregnancy and the nature of the surgery. Risks may include:
- The enlarged uterus makes the surgery technically challenging.
- There’s a risk of inducing preterm labor or premature birth due to surgical stress.
- Fetal safety is a paramount concern, requiring careful monitoring throughout the procedure.
- Standard laparoscopic procedures may need modifications to accommodate the late-stage pregnancy.
These risks necessitate a careful decision-making process, weighing the urgency to treat the adnexal torsion against the potential threats to the mother and fetus. The procedure should ideally involve a multidisciplinary team including obstetricians, surgeons, and anesthesiologists experienced in dealing with high-risk pregnancies.
Video Transcript: Conservative Laparoscopic Treatment of Adnexal Torsion at 35+5 Weeks’ Gestation
We present a case of conservative laparoscopic treatment of adnexal torsion at 35 plus 5 weeks gestational age.
Adnexal torsion is the partial or complete rotation of the ovary and or fallopian tube on its vascular pedicle. Impaired venous drainage followed by compromised arterial blood flow causes congestion, oedema, ischemia, and leads to necrosis of the adnexa. Prompt diagnosis and surgical intervention are vital to preserve ovarian function.
Pregnancy is associated with an increased risk of torsion. Approximately 10 to 22% of adnexal torsion cases occur during pregnancy, with higher reported rates in the presence of an adnexal mass. Torsion is most commonly diagnosed in the first trimester with lower incidence later in pregnancy as functional ovarian cysts resolve and there is decreased adnexal mobility next to an enlarging uterus.
If left untreated, adnexal torsion in pregnancy can lead to adnexal infarction, peritonitis, sepsis, spontaneous abortion, or preterm birth. Multiple case reports in series have described adnexal torsion in the third trimester but laparoscopic management has not been described beyond 34 weeks.
We report on a case of right adnexal torsion in the setting of known ovarian cyst successfully treated with laparoscopic detorsion and cystectomy at 35 plus 5 weeks.
This 35-year-old G3T1A1L1 was known to have a simple right ovarian cyst with no associated symptoms. She presented at 35 plus 4 weeks with severe lower right quadrant pain and associated nausea and vomiting. Foetal heartrate was normal.
Blood work revealed a stable haemoglobin and no leukocytosis. Pelvic ultrasound revealed a right ovarian cyst measuring 9.7 x 6.3 x 6.1 cm with minimal septations and no arterial or venous flow. Obstetrical ultrasound revealed a normal biophysical profile with no evidence of placental abruption.
The working diagnosis was right adnexal torsion and after counselling she was brought to the operating room for a laparoscopic ovarian detorsion with possible cystectomy at 35 plus 5 weeks.
Preoperative consultations with the anaesthesia and obstetrics teams were arranged. Neonatology was made aware in case there was need for urgent preterm delivery.
After induction of general anaesthesia, the auscultated foetal heartrate was normal. Abdominal exam and bedside ultrasound were then used preoperatively to plan port placement.
Pneumoperitoneum was established with various needle insertion at Palmer’s point. A 12 mm optical trocar was then inserted at Palmer’s point to avoid the gravid uterus. There additional ports were then placed under direct visualisation.
On inspection of the peritoneal cavity, note was made of the gravid uterus. The right ovary with the ovarian cyst measuring 8 to 9 cm in diameter appeared oedematous, blue, and dusky. On closer inspection the right ovary was confirmed to be twisted around its IP ligament.
The right adnexa was then detorted. We then proceeded with cystectomy. Monopolar energy was used to incise the ovarian cortex and create a plane between the ovary and cyst. We then proceeded to dissect the cyst free from the ovary using traction and countertraction.
In the process the cyst was inadvertently ruptured. Bipolar cautery was used sparingly to achieve haemostasis at the bed of the ovarian cyst. Then an Endoloop was used to reapproximate the edges of the ovarian tissue.
Evidence of reperfusion was noted on inspection. The abdominal cavity was irrigated copiously prior to trocar removal and closure.
Estimated blood loss was 100 ml. The patient was extubated and taken to the recovery room in stable condition.
Foetal heartrate was normal in the PACU. Close monitoring on labour and delivery overnight revealed a normal foetal heartrate and no uterine activity. By postoperative day two, the patient’s pain was managed with oral acetaminophen and bowel and bladder functions were normal. Obstetrical ultrasound was normal and she was discharged home.
Pathological assessment of the specimen revealed a benign cyst with extensive haemorrhage and necrosis at the cyst wall consistent with torsion. Peritoneal wash was negative for malignant cells. The patient went on to have an induction of labour at 39 plus 3 weeks gestational age resulting in an uncomplicated spontaneous vaginal delivery of a live female infant.
In summary, adnexal torsion should always be part of our differential diagnosis when a pregnant patient presents with abdominal pain regardless of gestational age. Conservative laparoscopic surgical treatment of adnexal torsion is safe in pregnancy, illustrated here at 35 plus 5 weeks gestational age. A multidisciplinary approach is vital in ensuring proper perioperative monitoring of the patient and foetus.