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6.8 Diagnosis
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adnexa are enlarged. Mild OHSS could be suspected in these patients, delaying the correct
diagnosis and treatment. There is an overlap in
the grey-scale appearance of ovaries in mild
OHSS and OT. Ovaries in mild OHSS are
enlarged, with prominent, heterogeneous stroma,
and contain multiple 1–2 cm follicles, many
containing hemorrhages. Torsed ovaries are also
enlarged, with prominent, heterogeneous central
stroma and multiple, small peripheral follicles
[84]. Also, in OHSS, both ovaries could be
enlarged and symmetrical, contrary to the situation with AT [73].
Although the absence of Doppler ow
(Fig.6.3) has a high specicity for arterial occlusion and AT [54, 71], the presence of ow
(Fig.6.4) should not exclude AT (low sensitivity)
[80–83, 85, 86]. This depends on the stage of the
torsion and the degree of vascular compression.
During the early stage of torsion, the venous and
lymphatic obstruction starts. Arterial ow may
only be decreased at this stage. Doppler US cor-
159
Fig. 6.4 Doppler sonogram shows intrauterine pregnancy and left ovarian cyst with the ow to the ovary,
intraoperatively found to be ovarian torsion. (Reproduced
with permission from [76] under the CC Attribution
License)
rectly diagnoses AT in the general female population in 40–60% of surgically conrmed cases
[14, 86, 87]. With OHSS, ovaries often show an
increase in diastolic blood ow; thus, decreased
blood ow may indicate AT in patients with
OHSS [86, 88]. Furthermore, the reduction in
diastolic ow is diagnostic of OT in patients with
OHSS.In the hyperstimulated ovary, the diastolic
ow is usually increased [89]. However, a torsed
ovary may demonstrate normal venous and arterial ow entirely symmetric for the normal side
[84].
Fig. 6.3 Doppler mapping of the left adnexa showing the
absence of vascular ow. (Reproduced with permission
from [85])
The decision for surgical evaluation should
not rely only on the results of the Doppler
ow investigation. It should also consider
past medical history, clinical appearance,
and laboratory assessment [14, 73]. Close
monitoring is necessary to achieve timely
management with a conservative approach.
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ab
6 Adnexal Torsion
Fig. 6.5 (a) CT (coronal view) at 32weeks of pregnancy
shows calcications of the right adnexal mass being ovarian teratoma [52]. (b) Postpartum right ovary slightly
6.8.3 Abdominal CT
Abdominal CT is rarely performed during pregnancy [52]. Most cases underwent a CT scan in
puerperium [47]. Based on CT ndings, the correct preoperative diagnosis of AT in a general
female population is 34% [90]. The most common but nonspecic nding of OT is an enlarged
ovary (Fig.6.5) (>4 cm in maximal dimension)
with or without a mass [47, 52].
6.8.4 Abdominal MRI
MRI is useful in diagnosing OT in the second and
third trimesters of pregnancy when the ovaries
enlarged and located anterior to the uterus. (Reproduced
with permission from [47] under the CC BY 3.0)
are difcult to visualize on US [91]. Also, if the
diagnosis cannot be established, especially in
cases with OHSS, an emergent abdominopelvic
MRI could dene the AT.The MRI appearance of
AT includes a hemorrhagic Fallopian tube. This
twisted ovarian tumor can result in hemorrhagic
infarction with the lack of enhancement in the
multiple internal septa of the tumor [92]. Solid
ovarian tissue appears enlarged and edematous
(Fig.6.6).
Currently, the diagnosis of AT is missed in
15–35% because of nonspecic clinical features and uncommon objective ndings [24,
49, 68]. More frequent MRI use in doubtful
cases could increase preoperative diagnostic
accuracy.
6.9 Treatment
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161
a
b
c
d
Fig. 6.6 Eight weeks of pregnancy with acute adnexal
torsion without hemorrhagic infarction. (a) Transaxial
T2-weighted single-shot turbo spin-echo MRI shows
hyperintense swollen ovarian medullary stroma (star) and
prominent cortical follicle (curved arrow) in the torsed
enlarged right ovary. (b) 3.5 cm unilocular cystic mass
(arrowhead) in the normal-appearing ovary was pathologically conrmed as a corpus luteal cyst. (c) Transaxial
6.9 Treatment
Early diagnosis and prompt surgical intervention result in ovarian and adnexal preservation
from infarction. In elective settings, because of
the high incidence of adverse pregnancy outcomes associated with emergency surgery,
some recommend elective removal of all nonacute masses that persist until 16 weeks
or≥6cm regardless of appearance on imaging
studies, unless it is suspected to be a leiomyoma [94].
diffusion-weighted MRI shows hyperintense swollen
ovarian medullary stroma (star). (d) Apparent diffuse
coefcient value indicating the region of interest of
1.83±0.11×10−3mm2/s in the ovarian medulla (star) and
1.57 ±0.14 × 10−3 mm2 in the ovarian cortex (circle),
respectively. (Reproduced with permission from [93] CC
Attribution 4.0 International (CC BY 4.0))
6.9.1 Operative Principles
Laparoscopy is recommended for both diagnosis
and treatment of adnexal torsion unless clinical
severity warrants laparotomy.
(SAGES guideline)
6.9.1.1 Abdominal Access
Without classic symptoms and no denitive diagnostic tests or studies, surgical exploration of the
pelvis provides a denitive diagnosis (Fig.6.7).
Laparoscopy has become the preferred surgical
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6 Adnexal Torsion
• severe ischemia with a dark red or black tube
and ovary, and partial recovery after the pedi-
cle is untwisted (Fig.6.8),
• gangrenous adnexa without recovery (>48h).
Only the gangrenous adnexa needs complete
removal of the adnexa; the rst two situations can
be conservatively treated with detorsion and preservation of the ovary, even after severe ischemia
has occurred [22]. In <10min, vascular recovery
of the ischemic ovary is completed [54, 71].
Fig. 6.7 Laparoscopic view of torsion of the enlarged left
adnexa. (Reproduced with permission from [59])
approach for diagnosing and managing AT in
pregnancy [95]. It results in shorter operative
time and hospitalization, reduced narcotics consumption, minimized fetal exposure to analgetics, greater patient comfort, and lower discomfort
of stretching and distension incisions and scars
due to the rapidly growing uterus compared to
laparotomy [12, 20, 23]. Therefore, abdominal
wall dehiscence or herniation during labor rates
is lower. A panoramic view of the pelvis reduces
intraoperative uterine manipulation, decreasing
postoperative uterine irritability, miscarriage
rate, and preterm labor.
It is mostly done during the second trimester
[12], but can be effectively completed up to
34–35 gestational weeks [96, 97]. For gasless
laparoscopic surgery (GLS), see Sect. 3.2.2.2.
6.9.1.2 Adnexal Preservation or
Resection
Traditionally, AT was treated aggressively with
salpingo-oophorectomy of the involved side;
unwinding the torsion was condemned for fear of
releasing a potentially fatal embolus [98, 99].
This was not conrmed [22, 100], and current
conservative operative management involves
unwinding the adnexa and assessing its viability.
Once torsion is unwound, the adnexa show one of
the following:
• no evidence of ischemia or mild ischemia
with immediate and complete recovery
(Fig.6.7),
(Para)ovarian cyst requires complete cystectomy for a histological diagnosis [100]
and prevention of recurrence. Untwisting
the pedicle of the cyst should be avoided to
prevent emboli and toxic substances related
to hypoxia from entering peripheral
circulation.
Routine ovariopexy after detorsion does not
seem warranted because the risk of retorsion is
very low when a cause is found and treated [100].
Despite the necrotic, hemorrhagic, or bluishblack appearance of a torsed ovary, detorsion
saves over 90% of these ovaries, and ovarian
function recovers [20, 22, 23, 82, 101]. Even with
complete ischemia, gross appearance does not
correlate with the outcome, and detorsion within
24 h did not show an increase in free radical
reperfusion injury [102]. The delay of intervention for 36h results in signicant congestion and
necrosis [102]. Assessment of ovarian viability,
such as US visualization of follicular development, inspection during a subsequent procedure,
observed response to stimulation during IVF, and
documentation of fertilization of oocytes from
the ovary, has consistently shown that the ovary
does recoup function after torsion and detorsion
[20, 22, 23, 26, 101]. Furthermore, conservative
management with detorsion is encouraged
because an increased risk of thromboembolism
has not been associated with detorsion procedures [20, 23]. In the general female population,
overall morbidity with salpingo-oophorectomy
(12%) was signicantly higher than in the con-
a
b
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163
c
Fig. 6.8 (a) Torsioned right ovary; (b) detorsion of the ovary; (c) 3min after detorsion; (d) normal left ovary. ut uterus,
ff free uid. (Reproduced with permission from [54] under the CC BY 3.0)
servatively treated group (3%) [103].
Adnexectomy can be avoided, and fertility preserved [59]. After unwinding, aspiration of ovarian cysts, if present, is recommended [85].
Since the successful laparoscopic nonresectional management of AT in the general female
population by Mage et al. in 1989 [100] and
Bider et al. in the pregnant population in 1991
[49], its use has been more common in pregnancy. Approximately 60% are treated with laparoscopy during pregnancy, mostly in the rst
trimester (75%) [68], with cases in the early third
trimester [85]. The patients who underwent laparoscopy had a signicantly smaller ovarian mass.
After laparoscopic detorsion, 24h of postoperative observation is recommended [104, 105]. The
operative procedures include detorsion followed
by cystectomy in 80%, oophorectomy in 10% for
masses >12 cm, and simple detorsion in 10%
[68]. Detorsion is successful between 50% and
100% [14, 48, 49]. The distribution of different
procedures is presented in Fig.6.9.
d
6.9.1.3 Underlying or Concomitant
Disease
Particular attention should be placed on AT in
patients with OHSS. First, the diagnosis is
delayed due to other symptoms and signs of
OHSS that can mask AT, making AT’s
prognosis worse. Second, moderate or severe
OHSScan present with symptoms and signs of
increased intra-abdominal pressure or even
abdominal compartment syndrome (see
Chap.22).
There are cases of AT with concomitant other
emergent abdominal conditions, such as contralateral tubal ectopic pregnancy (Fig.6.10) [106,
107] or acute appendicitis [63]. In contralateral
tubal ectopic pregnancy cases, it is important to
make an early diagnosis and laparoscopic exploration to save the detorsed adnexa because salpingectomy or adnexectomy is commonly
indicated in the contralateral adnexa due to ectopic pregnancy. Such procedure preserves
fertility.
164
Surgical procedures
AD AD+CF AD+C AD+SO
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AD+C
14%
6 Adnexal Torsion
AD+SO
14%
AD
48%
AD+CF
24%
Fig. 6.9 Type of the surgical procedures in adnexal torsion during pregnancy. AD adnexal detorsion, CF cyst
fenestration, C cystectomy, SO salpingo-oophorectomy.
(Reproduced with permission from [12] under the CC BY
Attribution License)
Fig. 6.10 Adnexal torsion (A) and concomitant contralat-
eral ectopic pregnancy (C). B uterus. (Reproduced with
permission from [107])
6.9.2 Operative Techniques
6.9.2.1 Detorsion/Unwinding
Laparoscopy
A small incision of 2cm is made in the left upper
abdominal quadrant (Fig.6.11), and a 10mm tro-
Fig. 6.11 Trocar position depends on the upper limit of
the uterus. Trocars for laparoscopic detorsion of adnexal
torsion are inserted in the same vertical body lines and
positioned 2–4cm cranial of the upper limit of the uterus.
(Modied and reproduced with permission from [85])
car is introduced as an open (Hasson) technique
on the left side of the epigastrium.
Pneumoperitoneum is induced with an insufation volume of CO2 of 1 L/min and an intraabdominal pressure of 10mm Hg. The patient is
kept in a horizontal position. Secondary trocars
are inserted at opposite sites, one in the right
upper abdominal quadrant and the other on the
extreme left of the middle abdominal quadrant.
These secondary trocars are inserted under direct
laparoscopic control. Two atraumatic probes are
introduced into these trocars: one on the left side,
allowing washing and gentle pressure on the
uterus in a brief lateral Trendelenburg position,
and the other probe elevating the twisted adnexa,
pushing it contralaterally to the direction of rotation. The aid of two probes without grasping the
tissue avoids bleeding. Serial manipulations
achieve the unwinding of the adnexa. The release
of pressure ensures the normal positioning of the
adnexa. The lateral Trendelenburg position is then
abandoned, and after abundant washing, the procedure is stopped for 10min, with disination of
the abdominal cavity. Once the procedure is
cd
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165
resumed, the pedicle of the ovary and the tube are
examined. An improvement in color and a
decrease in edema should be noted. These signs
establish the beginning of the recovery of the
adnexa, which should turn pink shortly after the
procedure. Aspiration of ovarian cysts, if present,
is recommended. However, this is not always possible since cysts are often lled with clotted blood.
Cardiotocography should be carried out dur-
ing the entire procedure [85].
Single Incision Laparoscopic Surgery
Recently, AT was treated by single incision laparoscopic surgery (SILS, LESS, SSA) [108, 109].
a
An advantage of SILS is laparoscopy with open
abdominal wall access, minimizing the possibility of intra-abdominal injury. It is suitable until
20weeks gestation, when the uterus is below the
umbilicus (Fig. 6.12a). A single port is introduced through a 2–3cm vertical umbilical incision to the peritoneal cavity (Fig.6.12b). Layer
by layer, the peritoneal cavity is entered; then, 0
polyglactin 910 sutures are placed at each side of
the fascia (as stay sutures to help in nal closure
at the end of the procedure). The SILS device is
inserted into the transumbilical incision. The cyst
or adnexa are resected intra- or extracorporeally
(Fig.6.12c) [108].
b
Fig. 6.12 (a) The site of the twisted ovarian mass at the
right upper quadrant (circle) and the pregnant uterus location (dotted line); (b) the transumbilical SILS device
insertion; (c) extracorporeal ovarian cystectomy; (d) closing the skin incision. (Reproduced with permission from
[108] under the CC BY 3.0)
166
ef
bc
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6 Adnexal Torsion
The SILS advantages include better cosmesis
(Fig. 6.12d) because of a hidden umbilical scar
and the need for fewer trocar incisions, a possible
decrease in morbidity related to the visceral and
vascular injuries during trocar placement, reduced
risk of postoperative wound infections and hernia
formation, and elimination of multiple trocar site
closures. Another potential merit of SILS is reducing postoperative pain and narcotic use.
6.9.2.2 Ovariopexy (Oophoropexy)
In cases where ows return to normal, performing oophoropexy to eliminate retorsion is controversial. Although some studies advocate
oophoropexy to prevent a recurrence, a consensus has not been reached.
a
Germain et al. in 1996, described oophoropexy in the general female population to prevent
recurrence by “triplication” of the utero-ovarian
ligament [110]. The ligament is plicated and
shortened with a running stitch; ovariopexy,
where the ovary is sutured to the posterior aspect
of the uterus or the lateral pelvic wall; and oophoropexy, where the utero-ovarian ligament is
sutured either to the posterior aspect of the uterus
or to the lateral pelvic wall (Fig. 6.13).
Oophoropexy, although not evaluated in randomized trials, has been done in women of all ages
and during pregnancy. Although not commonly
done, laparoscopic oophoropexy has good results
and is recommended for childhood torsion and in
women after an oophorectomy for prior OT [39,
d
gh
Fig. 6.13 Oophoropexy of the recurrent torsion of the
left ovary at 15weeks’ gestation. (a) Intraoperative nding after ovarian detorsion; (b–e) shortening of the proper
ovarian ligament by suturing the distal and proximal end
of the ligament for prevention of recurrent ovarian torsion
in pregnancy; (f–h) ovarian xation for the remaining
proper ovarian ligament. (Reproduced with permission
from [113])
6.9 Treatment
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167
110–113]. Although oophoropexy has been per-
formed successfully in pregnant women, it was
felt that the increased vascularity of the area precluded performing this procedure. The ligament
is shortened to reduce recurrence from a lengthy
utero-ovarian ligament. A grasping forceps is
passed through an Endoloop and then used to tent
up the utero-ovarian ligament in the midsection.
The pretied endoscopic knot is tightened, pulling
the ovary close to the uterus and shortening the
utero-ovarian ligament [34].
In a review from 2004, 78 cases of AT during
pregnancy were reported. The operative access
was laparoscopy in 74% and laparotomy in 18%.
Sixty-two percent were treated by preserving the
ovary. This included unwinding the adnexa with
or without cystectomy. In 38%, an oophorectomy
or adnexectomy was performed. An oophoropexy
was done in two cases [113].
6.9.2.3 Laparotomy
A Pfannenstiel incision is used with a known preoperative diagnosis [76]. A low midline incision
is recommended with an uncertain diagnosis or
signicant bleeding. When McBurney’s gridiron
incision is made for suspected acute appendicitis,
it sufces for the operations on the right adnexa
[45].
A simple cystectomy is done for an ovarian
cyst when malignancy is excluded. When possible, the entire ovary is delivered from the abdominal cavity and surrounded by moist laparotomy
pads to avoid intra-abdominal spillage of cyst
contents if a rupture occurs. The thin ovarian capsule is carefully incised, usually with a scalpel.
Blunt dissection is used to separate the cyst from
the ovarian tissue. Electrosurgery can be used on
the internal ovarian surfaces for hemostasis, but
should not be used near the cyst wall to minimize
the risk of cyst rupture [114].
Rupture is inevitable in some ovarian cysts,
particularly endometriomas and functional cysts,
such as luteomas. If a dermoid is accidentally
ruptured, every effort should be made to avoid
spilling the irritating sebaceous contents into the
peritoneal cavity. If this occurs, prolonged peritoneal irrigation with warmed saline will prevent
peritonitis. Likewise, prolonged irrigation with
warmed saline is judicious if the “chocolate”
contents of an endometrioma or the uid content
of a potentially malignant cyst spill within the
peritoneal cavity. It remains to be determined if
these precautions avoid the detrimental effect of
intraoperative rupture on stage I ovarian cancer
[115].
Regardless of rupture, all cysts should be
completely opened after removal, and the internal surface of the cyst wall should be examined
for excrescences. When present, a microscopic
examination of frozen sections can help determine if intraoperative staging is required. The
denitive diagnosis must await careful examination of permanent sections in all cases.
The ovary does not require precise reconstruction as was thought in the past. Reapproximation
with internal sutures may help subsequent reformation of the normal ovarian prole. However,
sutures on the external ovarian surface should be
avoided to minimize the subsequent risk of adhesion formation [116].
6.9.3 Obstetric Management
6.9.3.1 Prevention andTreatment
ofPreterm Labor
See Chap. 4.
6.9.3.2 Hormonal Pregnancy Support
Ovariectomy during the rst trimester necessitates 17 alpha-hydroxyprogesterone caproate
250mg IM weekly for 4 weeks as progestogen
support for the pregnancy [76]. After this
period, progesterone is produced by the placenta. Nevertheless, the persistence of pregnancy is possible even after an early lutectomy
[13, 117].
Relaxin mediates the lengthening of the pubic
ligament, cervical softening, vaginal relaxation,
and inhibiting myometrial contractions. Relaxin
in the plasma of pregnant women is believed to
originate exclusively from the corpus luteum.
Plasma levels peak at approximately 1 ng/mL
between 8 and 12 weeks’ gestation. After that,
they decline to lower levels that persist until the
term. Relaxin inhibits contractions of nonpreg-
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6 Adnexal Torsion
nant myometrial strips, but not those of uterine
tissue taken from pregnant women. It also affects
cervical remodeling through cell proliferation
and modulation of extracellular matrix components such as collagen and hyaluronan [118,
119]. There are no studies about the inuence of
relaxin after ovariectomy during pregnancy.
6.9.3.3 Ovarian Function
Follow-up Doppler US after detorsion shows the
ovary’s ow and developing follicles that indicate a normal functioning ovary [71]. This is
important for subsequent pregnancies [76]. The
rst follow-up Doppler US should be made on
the rst postoperative day. The patient can be discharged if the ow is restored and normal.
6.10 Prognosis
A reduced fertilization rate had been attributed to reduced ow in the ovarian artery
after ovarian detorsion.
A reduced fertilization rate of 40% for oocytes
aspirated from a detorsed ovary is signicant,
compared to 93% from the unaffected ovary.
Seventy-ve percent of oocytes from the unaffected side and 64% from the affected side developed into blastocysts [120]. In a repeat IVF
procedure, retrieved oocytes from laparoscopically detorsed ovaries could be subsequently fertilized. Therefore, detorsion is recommended as
the procedure of choice for ischemic ovaries [23].
6.10.1.2 Delivery
After treatment for AT, the subsequent course of
pregnancy is generally favorable; spontaneous
abortion rates of 8.3–16.6% [12, 14, 26] and preterm birth of 4.8% [12] do not appear to be
increased. In one large study, there were 60% of
term deliveries, 15% of preterm deliveries (third
trimester), 5% missed abortions, and 20% of
elective abortions in the rst trimester. There is
no difference in pregnancy outcomes between
laparoscopy and laparotomy [12]. CS for common obstetric indications was indicated in 27%,
and 73% underwent vaginal deliveries [68].
6.10.1 Maternal Outcome
6.10.1.1 Preservation ofFertilzation
The time between hospital admission and surgery
is 6–15.5h and may be signicantly shorter in the
rst trimester. However, several days may pass
between the start of symptoms and surgery [26,
48, 59]. In the laparoscopic era, acute symptoms
or persistence of complaints means early surgery
(<24h), and treatment is still in time to preserve
fertility [59]. Patients in the second and third trimesters are operated on signicantly later than in
the rst trimester. This difference may be due to
difculty assessing the ovaries on palpation and
during US examination or because patients with
suspected OT are more readily operated on in
early pregnancy when the risk from the (laparoscopic) surgery is minimal [48]. In one large
study, 50% had surgery within 24 h and 85%
within 72h [68].
6.10.1.3 Risk ofRecurrence
Laparoscopic xation of the adnexa (ovariopexy)
or shortening of the utero-ovarian ligament can
be done to avoid the recurrence of AT, but this
should be the exception rather than the rule [33,
34, 111, 113]. The reported recurrence is 19.5%
for pregnant and 9.1% for nonpregnant women;
however, 73.2% of pregnant women and 20.8%
of nonpregnant women had been treated with
ART before torsion [14]. There was no recurrence in a study with ve patients during the subsequent course of the pregnancy [59]. Torsion
recurrence is higher in patients with OHSS [33,
121].
6.10.2 Fetal Outcome
Delivery at the term of healthy babies occurs in
61–83% [14, 48, 49]. In twin pregnancies, fetal
survival is near 100% [52]. The mean birth
weight is slightly over 3,000g [122, 123].
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