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Case 337

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Pregnant woman, 32 years old, 10 weeks of gestation, G5P3A1, at the Emergency Service due to sudden and intense abdominal pain, without other complaints or comorbidities. At the exam: regular general condition, tachycardic, eupneic, afebrile, feeling pain at deep palpation in the left iliac region, with painful decompression. Pelvic examination: pain at palpation of the left annex. Previous obstetric ultrasonography (US): normal gestation of 8 weeks and presence of fetal heartbeats. Pelvic US performed (presented images).

Considering the images and the clinical history described, what is the most likely diagnosis?

a) Ovarian torsion

25%

b) Ruptured ectopic pregnancy

25%

c) Hemorrhagic ovarian cyst

25%

d) Tuboovarian abscess

25%
   

Image analysis

Image 1: Pelvic ultrasonography, transverse view, with anechoic formation, well delimited with thin walls, homogeneous content, at the left annex region, compatible to simple ovarian cyst (yellow demarcation).

 

 

Image 2: Pelvic ultrasonography, sagittal view, with anteverted uterus and single fetus at the fundus region (blue demarcation).

Highlights

- The ovarian torsion is one of the differential diagnosis of acute abdomen, especially when associated to palpation of a mass at the pelvic examination;

-  Ovarian cysts are an important risk factor for torsion;

- 20% of the ovarian torsion cases occur in pregnant women therefore demanding precocious diagnosis and intervention;

- US is the imaging study of choice for initial evaluation, capable of evidencing ovarian cysts and excluding other causes, like ruptured ectopic pregnancy;

- US with Doppler is useful for diagnosis, although the presence of normal ovarian flow at the Doppler does not exclude adnexal torsion;

- Treatment is surgical and must be done immediately after the diagnosis.

References

-  Robertson JJ, Long Brit, Koyfman. Myths in the evaluation and management of ovarian torsion. The journal of Emergency Medicine. 2017;52: 449- 456

- Houry D, Abboutt JT. Ovarian Torsion: fiften-year review. Ann Emerg Med 2001;38:156-9

- Smorgick N, PanskyM, FeringoldM et al. The clinical characteriscs and sonografic findings of maternal ovarian torsion in pregnancy. Fertil Steril 2009;92:1983-7

- Damigos E, johns J, Ross J. An update on diagnosis and management of ovarian torsion Obstetr Gynaecol 2012;14:229-36.).

- Padilla LA, Radosevich DM, Milad MP. Accuracy of the pelvic examination in detecting pelvic mases. Obstetric Gynecolo 2000;96:593-8

- Hasson J, Tsafrir Z, Azem F, Bar-nos Almog B et al.2010. Comparasion of adnexao torsion between pregnat and nonpregnat women. Am J /Obstet Gynecol 202:536. )

- Ghandehari H Kahn D, Glanc P (2015) Ovarian Torsion: Time Limiting Factors for Ovarian Salvage).

- Shadinger LL, Andreotti RF, KurianRL. Pre-operative sonografic and clinical characteristics as predictors of ovarian torsion. J ultrasound Med 20078;27:7-13

Author

Lucas de Oliveira Cantaruti Guida, 6th year medical student at Universidade Federal de Minas Gerais. Email: lucas_cantaruti[at]hotmail.com

Supervisors

Patrícia Gonçalves Teixeira, professor at the Gynecology and Obstetrics Department of Universidade Federal de Minas Gerais.

Email: pgtmedicina[at]gmail.com

Júlio Guerra Domingues, professor at the Anatomy and Image Department of Universidade Federal de Minas Gerais.

Email: juliogdomingues[at]gmail.com

Reviewers

Mateus Nardelli, William Alves, Professor José Nelson Mendes Vieira, Professor Viviane Santuari Parisotto Marino.

Translated by

Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais.

Email: gabriellashiomatsu[at]gmail.com

Test question

UFRJ (2009) - Lígia, 22 years old, at the emergency care unit of Maré presenting sudden and increasing pelvic pain and fever of 37,5°C. Last menstruation 25 days ago and sexual inactivity since 2 months ago. Recent abdominal ultrasonography shows adnexal tumor of 12 cm of diameter, cystic and low perfusion at the Doppler velocimetry. The most likely diagnosis is:

 

a) Corpus luteal cyst

25%

b) Pelvic inflammatory disease

25%

c) Ectopic pregnancy

25%

d) Adnexal torsion

25%

e)

25%
   

Commentics

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