Objective
The purpose of this study was to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women.
Study Design
We conducted a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed.
Results
Recurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women; 83.3% of pregnant women delivered at term. Laparoscopic detorsion was the main surgical procedure.
Conclusion
Presentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.
Adnexal torsion is considered a true gynecologic emergency. The twisting of the ovary and the tube around its own ligamentous support may cause ongoing ovarian tissue congestion because of decreased venous return at first, which is followed by partial or complete arterial occlusion that leads to ischemia and eventually to ovarian necrosis. Variability in the degree of vascular compromise as well as collateral vasculature and the rapidity of achieving detorsion may all play a role in preserving the ovary and its function during this ischemic insult. Between 70-80% of adnexal torsions occur during women’s reproductive years, and it is estimated that 12-25% of women with torsion are pregnant. Adnexal torsion in pregnancy is a rare event, with a cited incidence of 1-5:10,000 in spontaneous pregnancies. After ovarian stimulation in assisted reproductive technologies (ART), the incidence rises dramatically to 6% and reaches as high as 16% in cases of ovarian hyperstimulation.
Adnexal torsion must be considered when a pregnant woman presents with pelvic or abdominal pain. Although it occurs more commonly in the first and early second trimesters, adnexal torsion may occur at any gestational age and must be promptly evaluated and treated in order to preserve ovarian tissue and future function.
Most of the clinical data on this unique entity are found in small case series and anecdotal case reports. The aim of this study was to report our 10 years of experience with adnexal torsion in a relatively large population of pregnant women and to compare the group data with an even larger group of nonpregnant women with adnexal torsion.
Materials and Methods
This retrospective case-control study was performed in the gynecology departments of Tel Aviv Sourasky and Sheba Medical Centers, both university-affiliated tertiary referral hospitals. Medical records from 1999-2008 that contained the ICD-9 code for torsion of ovary, fallopian tube, or adnexa were extracted, and the records of all pregnant women who were admitted and diagnosed with adnexal torsion (confirmed by laparoscopy or laparotomy) were evaluated. We also retrieved the medical charts of consecutive nonpregnant women with surgically confirmed adnexal torsion during the same period; this was the control group.
The following characteristics of all the study participants were assessed: demographics; medical, surgical, obstetric, and gynecologic history; signs, symptoms, and physical examination findings at evaluation; laboratory and ultrasonographic findings (including Doppler blood flow); findings at surgery; administered treatment; immediate follow-up summary, and treatment and pregnancy outcome. Sonographic evaluation was performed by the gynecologic ultrasound unit’s technicians and physicians, none of whom were involved in clinical decision-making. The ultrasonographic examinations were performed by a 6.5-MHz vaginal probe or a 3.5-MHz abdominal probe. Surgery was performed by attending senior physicians and residents of the gynecologic departments.
Approval for this study was obtained from both institutions’ ethics committees.
The Fisher’s exact test was used for the assessment of proportions, and the Student t test was applied for continuous variables. A 2-sided probability value of < .05 was considered to be significant.
Results
A total of 186 charts with the ICD-9 code for torsion of ovary, fallopian tube, or adnexa were identified and retrieved from the 2 participating hospital databases during the study period. Among them were 41 pregnant women and 77 nonpregnant women with surgically confirmed adnexal torsion. Demographic data are summarized in Table 1 . Seven of the 41 pregnant women had recurrent episodes of adnexal torsion in the same pregnancy, and 1 woman had adnexal torsion in 2 consecutive pregnancies, which yielded 49 episodes of adnexal torsion in pregnant women for evaluation. Eighty-two percent of the adnexal torsion episodes occurred during the first trimester. Seven nonpregnant women also had recurrent episodes of adnexal torsion, which yielded a total of 84 episodes of adnexal torsion in the control group. The rates of recurrent adnexal torsion for the pregnant and nonpregnant women were 19.5% and 9.1%, respectively ( P = .14). Seventy-three percent of the pregnant women conceived through ART. Twenty percent of the nonpregnant women had a history of fertility treatments ( Table 1 ).
| Characteristic | Pregnant women with confirmed torsion | Nonpregnant women with confirmed torsion | P value |
|---|---|---|---|
| Women, n | 41 | 77 | |
| Age, y a | 30.1 ± 4.2 | 30.04 ± 8.8 | NS |
| Surgical history, n (%) | |||
| Laparoscopy | 8 (19.5) | 15 (19.4) | NS |
| Laparotomy | 0 | 3 (3.9) | |
| Past torsion, n (%) | 4 (9.7) | 13 (16.8) | NS |
| Primiparous, n/N (%) | 23/41 (56) | 42/77 (54) | NS |
| Assisted reproductive technology, n/N (%) | 30/41 (73.2) | 16/77 (20.8) | .0001 |
| Ovulation induction by clomiphene citrate, n/N (%) | 4/30 (13.3) | 3/16 (18.7) | NS |
| Ovulation induction by gonadotropins, n/N (%) | 10/30 (33.3) | 6/16 (37.6) | NS |
| In vitro fertilization, n/N (%) | 16/30 (53.3) | 7/16 (43.7) | NS |
| Gestational age at diagnosis, wk a, b | 10.5 ± 6.6 (5-33) | ||
| Total torsion episodes, n | 49 | 84 | |
| Recurrent torsion, n/N (%) | 8/41 (19.5) | 7/77 (9.1) | .14 |
a Data are given as mean ± SD;
Symptoms and signs of adnexal torsion at evaluation and laboratory and imaging data are summarized in Table 2 . Most of the pregnant (81.6%) and nonpregnant women (85.7%) complained of acute abdominal or pelvic pain that lasted for several hours and arrived at the emergency room within 24 hours from the onset of pain. The pain was described as acute, sharp, and intermittent or constant. Gastrointestinal symptoms, such as nausea and vomiting, were present at rates of 63.2% and 42% in the pregnant and nonpregnant women, respectively ( P = .019). At physical examination, 48 of 49 of the pregnant women (98%) and 78 of 84 of the nonpregnant women (93%) had considerable lower abdominal or pelvic tenderness, although peritoneal irritation signs, such as rebound tenderness and guarding, were present in only 21 of 49 of the pregnant women (42.8%) and 16 of 84 of the nonpregnant women (19%; P = .004).
| Signs and symptoms | Pregnant women | Nonpregnant women | P value |
|---|---|---|---|
| Acute abdominal/pelvic pain for <24 h, n/N (%) | 40/49 (81.6) | 72/84 (85.7) | NS |
| Gastrointestinal symptoms: nausea/vomiting, n/N (%) | 31/49 (63.2) | 35/84 (42) | .019 |
| Abdominal/pelvic tenderness, n/N (%) | 48/49 (97.9) | 78/84 (93) | NS |
| Presence of peritoneal signs, n/N (%) | 21/49 (42.8) | 16/84 (19) | .004 |
| White blood cell count, cells/mL a | 12000 ± 4100 | 11530 ± 4140 | NS |
| Ovarian diameter by ultrasonography, mm a | 70 ± 23 | 67 ± 23 | NS |
| Positive Doppler blood flow, n (%) b | 11/18 (61.1) | 14/31 (45.1) | NS |
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