Adnexal masses affect 4% of pregnancies. In this case study, the complication occurred three times during a triplet gestation.
A 34-year-old P1011 at 19 5/7 weeks with a dichorionic triamniotic triplet gestation conceived through IVF presented to us with severe right lower quadrant and right inguinal pain, nausea, and vomiting. Her history included infertility, diagnostic laparoscopy, and a previous full term pregnancy achieved through IVF with cesarean delivery.
On admission this woman was afebrile with unremarkable vital signs. An abdominal exam revealed moderate right lower quadrant tenderness without rebound or guarding and no costovertebral angle tenderness. Her cervix was closed, and there was no vaginal bleeding; lab values were normal. A sonogram showed a viable triplet pregnancy with a prominent right ovary approximately 5.8×3.6×4.5 cm. Vascular flow was documented around the ovary but it was technically difficult to determine if flow was present within the ovary. The appendix and left ovary were not well visualized and the kidneys were unremarkable. Abdominal x-ray was negative for nephrolithiasis.
Our patient delivers a repeat performance
About 10 weeks later, our patient presented once again with colicky abdominal pain, only this time it was on the left side. On physical examination, we found left-sided abdominal tenderness without rebound or guarding and no costovertebral angle tenderness. Urinalysis and laboratory tests were normal and fetal heart rate tracing of all three fetuses were reassuring. The patient was initially experiencing contractions but these resolved after 0.25 mg of subcutaneous terbutaline; the cervix was long and closed.
Ultrasound revealed a viable triplet gestation with the left ovary measuring 4.4×2.0×1.9 cm; color Doppler indicated nonpulsatile flow. Given her clinical presentation and history, the patient was taken to the OR because we suspected left ovarian torsion. A left paramedian incision revealed the left ovary to be enlarged, non-necrotic, and torsed twice around its vascular pedicle. The left ovary was fixed with a single suture of 3.0 chromic placed through the ovarian stroma and posterior uterus. (We used absorbable rather than permanent suture to stabilize the ovary in this ongoing pregnancy because we felt that permanent suture would have created undue tension on the vascular pedicle as the uterus continued to grow.)
Postoperatively, the patient did well and initial uterine irritability was treated with 24 hours of magnesium sulphate followed by 48 hours of indomethacin. She was discharged home on postoperative day 5.
The patient presented once again, this time at 33 and 6/7 weeks, with recurrent colicky left lower quadrant pain. Repeat ultrasound was consistent with intermittent torsion. The patient underwent a repeat cesarean section with delivery of three viable male infants. The left ovary was torsed three times around its vascular pedicle and was fixed to the round ligament with 0 vicryl suture. Postoperatively, the patient did well and there was no clinical evidence of retorsion. She was discharged home on postoperative day 4.
It is often difficult to diagnose ovarian torsion in pregnancy and requires a high index of suspicion. Symptoms of adnexal torsion are nonspecific and evaluation of the gravid abdomen is typically more difficult than in the nonpregnant patient. Although surgery during pregnancy can be dangerous, increasing the risk of maternal morbidity, fetal loss, and premature birth, pregnant patients are also at high risk for ovarian torsion, especially in the setting of ovarian stimulation and multiple gestations.3 Color flow Doppler U/S of the adnexa can help make an accurate differential diagnosis; however, normal flow does not exclude torsion because of the dual ovarian blood supply from the ovarian artery and a branch of the uterine artery.4