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5 Fetal Trauma
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Part II
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Gynecology
Adnexal Torsion
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6
Abstract
Adnexal torsion is one of the most common
nonobstetric gynecologic, acute abdominal
conditions in pregnancy. Due to the growing
uterus, adnexa are pushed from the pelvic to
an abdominal position making them more
prone to torsion. With the widespread use of
assisted reproductive technologies resulting in
ovarian hyperstimulation syndrome, adnexal
torsion is even more common. Due to the
often nonspecic clinical presentation, differential diagnosis is wide with some sidespecic differential diagnoses. Sonography
has high diagnostic sensitivity and specicity,
and abdominal MRI is used in uncertain cases.
Its use is increasing because it accurately distinguishes acute appendicitis from adnexal
torsion. The treatment is operative with
increased use of nonresectional procedures. If
malignancy is not suspected or proved, an
additional reason for early operative detorsion
is ovarian salvage in early pregnancy, which
hormonal role is essential for the normal progression of pregnancy.
6.1 Introduction
When a pregnant woman has violent diarrhea,
there is a danger of her miscarrying in a pregnant
woman if the breasts suddenly lose their fullness,
she has a miscarriage.
If in a woman pregnant with twins, either of her
breasts lose its fullness, she will part with one of
her children; and if it is the right breast which
becomes slender, it will be the male child, or if the
left, the female.
When women, in a moderate condition of the body,
miscarry in the second or third month, without any
obvious cause, their cotyledons are lled with
mucosity, and cannot support the weight of the
fetus, but are broken asunder.
In women that are about to miscarry, the breasts
become slender; but if again they become hard,
there will be a pain, either in the breasts, or in the
hip-joints, or the eyes, or in the knees, and they will
not miscarry.
Women with a child who are seized with fevers, and
who are greatly emaciated, without any (other?)
obvious cause, have difcult and dangerous labors,
and if they miscarry, they are in danger.
(Hippocrates, 400BC).
Evaluation of a patient during pregnancy with
acute abdominal pain should always include a
search for surgical and gynecologic disorders.
Parsons, in 1958, stated that 40% of women in
the general population who present with symptoms of pain in the lower abdomen and pelvis do
not have the gynecologic disease [1].
Preservation of reproductive capability (childbearing, hormonal function, and sexual health)
impacts a woman’s wellness. This critical issue
should be considered in the surgical management
of acute gynecologic problems.
Adnexa is the anatomical area adjacent to the
uterus and contains the fallopian tube, ovary,
associated vessels, ligaments, and connective tissue. Adnexal torsion (AT) is a total or partial rota-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
G. Augustin, Acute Abdomen During Pregnancy, https://doi.org/10.1007/978-3-031-26021-6_6
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6 Adnexal Torsion
tion of the adnexa around its vascular pedicle
resulting in ischemia.
6.2 Historical Perspective
Morgagni rst described AT in 1748 and
Rokitansky in 1850. Kuestner, in 1891, rst
described an ovarian torsion (OT) in a nonpregnant female [2]. Hartmann, in 1898, rst
described AT in pregnancy [3], then Pinard in
1901 [4], Nicholson J. Eastman (President of
American College of Obstetricians and
Gynecologists, (1961–62) in 1927 [5], GreenArmytage in 1929 [6], and Sheldon in 1936 [7].
In 1909, Gifford Nash published a case of isolated torsion of paraovarian cyst during early
pregnancy [8], and Fleming, in 1920, published
an ovarian cyst in the fth month of pregnancy
[9], both without AT.Due to the adherence and
the size of the ovarian cyst, Fleming resected the
involved left Fallopian tube.
6.3 Incidence
The prevalence is probably underestimated primarily due to spontaneous detorsion [10, 11] or
ovarian autoamputation without other symptoms
or complications (Fig.6.1). Surgical treatment of
AT constitutes 2.7% of all gynecological emergent surgeries during pregnancy [12]. The preva-
lence of AT is 1–5/10,000 spontaneous
pregnancies [12, 13]. Isolated OT has reported an
incidence of 1–10/10,000 spontaneous pregnancies [14–16].
Torsion of hydatids of Morgagni involving the
ipsilateral Fallopian tube causes acute abdominal
pain in adolescents; AT constitutes approximately
25%. However, the condition is uncommon in
adult females [18], representing a marginal part
of ATs, rarely during pregnancy (see Chap. 7).
However, AT has been reported in 7–28% of
all pregnancies complicated by adnexal masses
[19–24]. AT is an essential concern of pregnancyassociated adnexal masses and had a much higher
incidence (13.8%) than malignancy (3.4%) [25].
The reported incidence of adnexal tumor torsion
varies widely, ranging from 0.8% [26] to 53.8%
of tumors undergoing antepartum surgery [27].
In an 80-year review, Jubb collected only 34
cases of ovarian cancer during pregnancy [28]. In
1973, Munnell emphasized the infrequent association between ovarian cancer and pregnancy at
1/18,000 pregnancies [29]. More recent comprehensive reports summarized the incidence of
0.18–2.8/10,000 pregnancies [30, 31]. It is uncertain whether the incidence of ovarian cancer associated with pregnancy rises. However, since the
childbearing age among older women increases,
cancer incidence is also likely to rise during pregnancy. In one study, 98% were elective cases with
only one emergent operation for AT [32]. Bilateral
torsion is infrequent, simultaneously or sequentially, with few cases reported [33, 34].
An incidence of AT with adnexal mass
decreases as the gestational age increases [14, 33,
35]. In contrast, torsion of the normal adnexa
during pregnancy or the postpartum period is
extremely rare, without known incidence.
Fig. 6.1 Macroscopic appearance of incidentally found
autoamputated ovary in the cul-de-sac during Cesarean
section for the lack of labor progress. (Reproduced with
permission from [17])
6.4 Risk Factors
6.4.1 Adnexal Mass
Depending on the method and denition of a
clinically signicant adnexal mass, the prevalence of pregnancies complicated by an adnexal
mass is 1–8% [36–39]. Approximately 5% of
6.4 Risk Factors
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155
these represent malignant tumors, making ovarian cancer the fth most common cancer diagnosed during pregnancy (see Chap. 8) [40]. The
incidence of simple or complex ovarian cysts in
pregnancy is 5–8%, of which 0.7–3.8% undergo
torsion [39, 41, 42]. Table 8.1 lists adnexal
masses unique to pregnancy, while Table 8.2
shows the incidence of histopathologically conrmed ovarian tumors during pregnancy. The
most common tumor in pregnancy is benign cystic teratoma (22–40% of all ovarian tumors) [43].
Therefore, it is the most common tumor found
with AT.Torsion occurs in 19% and ruptures in
17% of mature cystic teratomas in pregnancy
Table 6.1 Pathological ndings of ovarian torsion in
pregnant women
Pathological nding
Teratoma 30
Corpus luteum cyst 20
Follicular cyst 15
Serous cystadenoma 15
Endometrioma 10
Mucinous cystadenoma 5
Reproduced with permission from [68]
a
Two cases undergoing detorsion were without pathologi-
cal results
a
(%)
[44]. Complete torsion causes a venous and lymphatic blockage, leading to stasis, venous congestion, hemorrhage, and necrosis. The cyst/
tumor becomes tense and may rupture. Whether
the type of tumor has a predilection for isolated
tumor torsion or AT in pregnancy is unknown.
Adnexal masses of 6–8cm have a higher
risk of adnexal torsion [25].
An explanation could be that a larger ovarian
mass hardly goes into a torsion due to the mass
effect. AT before the tenth week and after the 20th
week of gestation had a tumor 6–8cm. However,
tumors with larger diameters could undergo AT
within the tenth and 17th week of gestation, likely
because the adnexal tumor had been carried out of
the pelvic cavity by the gravid uterus and had a
larger surrounding environment. After the 20th
week, the incidence of AT declines [25].
6.4.2 Anatomic Variations
ofAdnexa
Table 6.2 Differential diagnosis of right-sided and left-
sided adnexal torsion (side differences in italic)
Right-sided Left-sided
Renal colic Renal colic
Renal or urethral calculi/
obstruction
Ectopic/heterotopic
pregnancy
Hemorrhagic/corpus
luteum cysts
Pyosalpinx/hydrosalpinx Pyosalpinx/hydrosalpinx
Pelvic inammatory
disease
Ovarian hyperstimulation
syndrome
Nonpregnant horn of
bicornuate uterus
Bowel obstruction/
perforation
Periappendicular
abscess/inltrate
Meckel’s diverticulitis
Ileocolic Crohn’s disease
Ovarian vein thrombosis
Renal or urethral calculi/
obstruction
Ectopic/heterotopic
pregnancy
Hemorrhagic/corpus luteum
cysts
Pelvic inammatory
disease
Ovarian hyperstimulation
syndrome
Nonpregnant horn of
bicornuate uterus
Bowel obstruction/
perforation
Sigmoid diverticulitis/
abscess
The torsion of normal ovaries is due to hypermobile ovarian ligaments, long ovarian ligaments, or
other inherent ovarian mobility. Other mechanisms include abrupt changes in intra-abdominal
pressure with vomiting and coughing, adnexal
venous congestion during pregnancy, and sudden
acceleration/deceleration movements [45–47].
The location changes of the adnexa and the uterus
(i.e., the ovaries emerging from the pelvis by the
increasing size of the uterus) may predispose the
ovaries to twist by allowing them greater mobility [48]. The main histopathologic ndings are
follicular or corpus luteum cysts [49].
6.4.3 Assisted Reproductive
Technologies
The increased use of assisted reproductive technologies (ART), such as controlled ovarian
hyperstimulation, invitro fertilization (IVF), and
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6 Adnexal Torsion
intracytoplasmic sperm injection, increase the
risk of AT, particularly when ovarian hyperstimulation syndrome (OHSS) develops. The increased
risk of AT with OHSS is due to the bilaterally
enlarged ovaries with multiple follicular or lutein
cysts in hyperstimulated patients, especially in
those who become pregnant with persistent cysts.
There is no side predilection [50]. Even bilateral
AT was described [50, 51].
OHSS is the risk factor in 50% of twin
pregnancies from ART [52].
The incidence of AT with OHSS in nonpregnant is 2.3% and 16% in pregnant women [26].
However, 12–25% of all AT occurs in pregnant
women, often combined with ART and its complications. The incidence is low for oocyte donation cycles (0–0.2%) and IVF cycles (0–0.13%).
However, the incidence increases to 6% with
stimulation for ART and to 16% with OHSS [13,
26, 42, 53–57]. However, even when AT occurs
simultaneously with OHSS, the incidence varies
between 1 and 33% [33]. Seventy percent of torsions occur in multiple pregnancies [53, 54, 58].
The incidence of fresh embryo transfer is 0.35%
[59]. There are cases with OHSS treated successfully, but patients developed AT in the more
advanced pregnancy [53]. The proportion of
patients with a twin pregnancy and ART in the
<28 weeks group was signicantly higher than
that in the ≥28weeks group [60].
6.4.4 Pregnancy andTrimester
Most ATs occur in the rst (by some 70%
[62]) or second trimester of pregnancy, with 5.9–
10% in the third trimester [13, 25, 26, 45, 59,
63–66]. Conception by ART is prone to rst tri-
mester AT [62]. The puerperal patient is more
prone to AT because of the rapid anatomic
changes in the pelvis, accompanied by the involution of the uterus. At the same time, the uteroovarian ligament remains disproportionately
stretched, allowing the normal-sized ovary
increased space to move and twist. This is most
common during the rst postpartum week [47,
67], although it can occur after 3 weeks postpar-
tum [25]. Probably the women start to move,
bend, and lift more. Sudden movement/rotation is
a risk factor for AT.
The gravid uterus generally experiences
dextrorotation, and 80% of AT in preg-
nancy are right-sided [59, 62].
No signicant differences between <28weeks
group and≥28weeks group in terms of the size
of the adnexal mass, the cycles of AT, and the
duration from onset to operation exist [61].
6.5 Pathology
It is important to dene the pathologic cause of
AT. Table 6.1 shows the pathology of adnexal
masses causing torsion in pregnancy. If the mass
is benign, there is no need for additional surgical
or oncologic therapy.
Pregnancy is a risk factor for (recurrent) AT or
isolated OT without ovarian mass, despite the
method of conception and gestational age at the
time of torsion. Recurrent torsion is more frequent in multicystic ovaries [14, 35]. The risk of
OT rises by ve times during pregnancy [25], and
prevalence decreases in late pregnancy [13], as
well as isolated OT [14, 15]. Ectopic pregnancy
can also be found on the contralateral side, presenting with AT [61].
6.6 Clinical Presentation
6.6.1 Medical History
The presenting complaint of AT is abdominal
pain, in more than 80% of patients, abrupt in
nature, very severe, in the right or left lower
abdominal quadrant, with no relieving factors,
including analgesics [52, 69–71]. It is often
described as sharp and “knifelike,” although it
6.8 Diagnosis
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can be colicky and persists for 24h [26, 72, 73].
Abdominal pain is usually followed by nausea
and vomiting [52]. The pain is proportional to the
degree of circulatory obstruction; complete
obstruction interrupting venous return results in
sudden severe pain with nausea and vomiting
developing rapidly. In addition to abdominal
pain, ank pain is commonly present [54, 67],
and the pain may radiate to the back or groin.
There may be a history of waxing and waning
pain if the adnexa has been twisting and untwisting or has undergone partial torsion, causing vascular slowdown but not thrombosis [26, 57, 74].
The infundibulopelvic ligament may twist and
untwist by itself, reducing and increasing the
pain. There may be a history of some jarring or
movement that has caused the torsion, such as
exercise before the onset of the pain or even just
turning over in bed. Patients could have adnexal
masses diagnosed before or even during pregnancy. Commonly, there is no history of vaginal
bleeding or discharge, diarrhea, constipation,
fever, or urinary complaints [52, 71].
6.6.2 Physical Examination
Signs of peritoneal irritation, considered fundamental for the diagnosis, are present in 43% of
pregnant women and 19% of nonpregnant women
[14, 33, 75]. Pelvic examination usually reveals a
tender mass on the affected side. If the patient
had normal adnexa before the torsion, she might
not have a mass present until later in the torsion
when edema and swelling of the adnexa have set
in. Therefore, serial examinations may be necessary for a patient suspected of AT.The pain is
usually lower with a twisted ovarian cyst than
with acute appendicitis. It is more continuous and
followed early by a mass that rapidly increases in
size. Patients rarely have evidence of abdominal
guarding or rebound tenderness on physical
examination. Patients are mostly afebrile [52,
54]. A low-grade fever may occur [71], but sig-
nicant fevers point to another cause of pain.
Tachycardia with normal blood pressure, pulse,
and temperature indicate a noninammatory condition [76]. The extent of bleeding depends on
the degree and duration of torsion. Hemorrhagic
infarction occurs later but never with a large
amount of hemoperitoneum. Bimanual examination denes mass felt through the fornix separately from the uterus. Tenderness is present, and
mass is not moving with movements of the cervix. If not advanced pregnancy, the cervix is
closed without signs of bleeding or discharge
[71]. In advanced pregnancy, cervical dilation
can be present. Uterine contraction or preterm
labor, in addition to abdominal pain, is found in
advanced pregnancy [52, 53].
6.7 Dierential Diagnosis
AT should always be a differential diagnosis of
acute pelvic/abdominal pain in women, especially
those with pelvic masses diagnosed by examination or ultrasound (US). The differential diagnosis
differs for right-sided and left-sided AT mostly
due to surgical conditions (Table6.2) [70, 73, 77].
Gynecologic/Obstetric and urologic differential
diagnoses are the same for both sides. The differential diagnosis of AT is challenging in combination with OHSS, as abdominal pain, nausea, and
vomiting are symptoms of hyperstimulation or
pregnancy. The abdomen is already distended and
tender because of the enlarged cystic ovaries [74].
Low-grade fever can accompany AT, but with
high fever, inammatory conditions such as tuboovarian abscess, pyosalpinx, or pelvic inammatory disease (see Chap. 13) or non- obstetric
inammatory conditions should be suspected.
6.8 Diagnosis
6.8.1 Laboratory Findings
Serum leukocyte levels are commonly normal
[71], especially in the early phase. Leukocytosis
may be present [54] but is not predictive, primarily because of common physiologic leucocytosis
of pregnancy [33, 72, 73]. In the general female
population, it is present in 56% [69]. Leukocytosis
may change with OHSS.If necrosis and infection
of the twisted organ occur, then higher fever and
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6 Adnexal Torsion
higher (or progression of) leukocytosis may be
present. βHCG should be routinely checked in
suspected or proven cases of AT because pregnancy is a risk factor for AT (see Sect. 6.4.4),
especially if additional risk factors for ectopic
pregnancy are present (see Chap. 9).
Hemoglobin/hematocrit is commonly normal
[54, 71]. Physiologic anemia of pregnancy complicates the interpretation. With a AT lasting
12–24 h, a small decrease in values can be
observed due to transudation of the blood-stained
uid or (hemorrhagic) cyst rupture [46] or hemorrhagic infarction. Urinalysis is normal [54].
6.8.2 Transvaginal Ultrasound
The transvaginal US often shows an enlargement
of the ovaries and polycystic changes without
this being evidence of torsion. It is extremely rare
for AT to occur with a mass <5 cm [59, 78].
Nonetheless, a large mass might sometimes be
missed in the third-trimester presentations when
a large uterus can hide the adnexa. The ovarian
parenchyma is initially congested because of
varying degrees of ovarian arterial, venous, and
lymphatic occlusion with AT (Fig.6.2), and hemorrhagic infarction occurs later [20, 79]. US ndings associated with the diagnosis of AT include
a predominantly solid-appearing ovary, unilateral
ovarian enlargement, peripheral cystic structures,
and marked stromal edema and pelvic uid [57,
79–83].
OHSS presents a signicant differential diagnostic problem. Twisted adnexa is usually characterized by a solid-appearing ovary on US,
organ enlargement, ovarian peripheral cystic
structures, and marked stromal edema and pelvic
uid. These characteristics are routinely present
in a hyperstimulated ovary, and usually, both
Fig. 6.2 Different ultrasound images of twisted ovaries
in pregnancy. (a) A transabdominal scan of an enlarged
ovary with a 20mm simple unilocular cyst. The ovarian
parenchyma appears edematous; (b) transabdominal scan
of an enlarged 130×92mm ovary with multicystic com-
ponents; (c) transabdominal scan of an enlarged 65mm
ovary without cystic components. The ovarian parenchyma appears edematous; (d) laparoscopic view of torsion. Arrowheads point to the twisted ovarian pedicle.
(Reproduced with permission from [48])
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