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Objective: To report a case of recurrent ovarian torsion during a multiple-gestation pregnancy and successful
treatment via transabdominal ultrasoundguided ovarian cyst aspiration.
Design: Case report and literature review.
Setting: Tertiary care fertility center.
Patient(s): A 33-year-old gravida 2, para 1 woman with a history of ovarian torsion in a previous pregnancy, who
presented with recurrent ovarian torsion in the 13th week of a multiple pregnancy.
Intervention(s): Ultrasound-guided transabdominal ovarian cyst aspiration and body repositioning to allow for
spontaneous detorsion.
Main Outcome Measure(s): Resolution of the ovarian torsion, as well as preservation of the pregnancy without
surgical intervention.
Result(s): After transabdominal ultrasoundguided cyst aspiration, ovarian detorsion was observed, accompanied
by resolution of the patients acute pain. The remainder of the patients pregnancy was uncomplicated, culminating
in the delivery of healthy infants.
Conclusion(s): Conservative treatment of ovarian torsion via ultrasound-guided transabdominal cyst aspiration and
body repositioning represents a reasonable alternative to surgical intervention in the pregnant patient. (Fertil Steril
2010;94:1910.e1e3. 2010 by American Society for Reproductive Medicine.)
Key Words: Ovarian torsion, multiple pregnancy, ovarian stimulation, ultrasound-guided transabdominal cyst
aspiration
Ovarian torsion is responsible for %3% of all gynecologic emergen- mobile, or pregnancy as the uterus enlarges and rotates, changing
cies (16). Many anatomic and physiologic factors predispose a the position of the ovary (5, 8). The first signs and symptoms
woman to experience torsion of the ovary, but the true etiology is of torsion develop when decreased venous and lymphatic return
not always identified. Pregnant women who conceive as a result of increases the size of the ovary; eventually arterial supply to the
controlled ovarian hyperstimulation are at greater risk for the ovary is restricted as well, leading to ischemia and necrosis if left
development of ovarian torsion (2, 3). With an increasing number of untreated (1, 5, 6). The right ovary is 50% more likely to twist
women undergoing assisted reproductive technology with controlled and cause torsion than the left, implying that the sigmoid colon
ovarian hyperstimulation, it is essential for physicians to suspect may protect against torsion (7, 9). It is crucial to identify torsion
ovarian torsion when confronted with a patient presenting with early to preserve the ovary. However, in cases in which the
acute onset abdominal pain, nausea, and/or vomiting. Torsion can diagnosis is delayed and the ovary is found to be black or bluish
be a severe complication after ovarian stimulation, and it frequently in appearance on surgical examination, the ovary still may be
may accompany ovarian hyperstimulation syndrome (OHSS) (24, 6). salvageable. This implies that full arterial constriction does not
As symptoms are mainly nonspecific, ovarian torsion often may be often occur; rather the edema and venous stasis may cause the
confused with other conditions including a ruptured corpus luteum mottled appearance of the affected ovary (1, 3, 5).
cyst, adnexal abscess, ovarian hyperstimulation, urinary obstruction, The imaging study of choice to diagnose ovarian torsion is Dopp-
heterotopic pregnancy, and appendicitis (2, 6, 7). ler ultrasound, as it may show absent or reduced blood flow to the
Torsion occurs when the ovary twists around its pedicle. This may ovary (6). The ovary appears unilaterally enlarged with edema and
be due to increased length of the infundibulopelvic or ovarian liga- multiple cystic structures that often are accompanied by some
ments, cysts that increase the size of the ovary and make it more degree of ascites (3, 7). Although it is possible to use Doppler
flow to diagnose torsion, it has been shown that Doppler may miss
Received February 8, 2010; revised February 26, 2010; accepted March 8, up to 60% of cases as there is often no change in vascular flow
2010; published online April 18, 2010.
(24). In such cases, a strong clinical suspicion of ovarian torsion
K.M.O.B. has nothing to disclose. K.M.S. has nothing to disclose.
Reprint requests: Kathleen Marie Osterman Boswell, B.S., University of must lead to laparoscopic evaluation. Data suggests that power-
Texas Medical Branch, 1719 Maize Bend Dr., Austin, TX 78727 (FAX: flow Doppler provides a more sensitive assessment of ovarian vascu-
512-335-7511; E-mail: kmoboswell@gmail.com). lar flow than does color-flow Doppler.
1910.e1 Fertility and Sterility Vol. 94, No. 5, October 2010 0015-0282/$36.00
Copyright 2010 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2010.03.020
FIGURE 1
(A) Power Doppler on presentation of patient to the emergency department shows no vascular flow to left ovary. (B) Color-flow Doppler after
aspiration of ovarian cysts and body maneuvering shows no vascular flow. (C) Power Doppler after aspiration of ovarian cysts and body
maneuvering shows resumption of vascular flow, with normal waveform. (D) Color-flow Doppler the day after the procedure shows
resumption of vascular flow with normal waveform.
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1910.e3 Boswell and Silverberg Innovative treatment of ovarian torsion Vol. 94, No. 5, October 2010