Ovarian Torsion Flashcards

1
Q

Aetiological factors to consider

A
  • Ovarian enlargement, especially ovarian cysts
  • In premenopausal women pregnancy and OHSS increase the risk
  • Consider ovarian malignancy in postmenopausal women
  • Masses >5cm more likely to tort, however once very large they become fixed and are less likely to tort
  • Fixed masses (ie endometrioma, TOA, malignant masses) less likely to tort
  • Right ovary more likely to tort than left (?longer ligament)
  • Previous torsion is a risk factor
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2
Q

Differential Diagnoses to consider

A
  • Gynaecological
  • Ectopic pregnancy
  • Tubo-ovarian abscess
  • Ruptured ovarian cyst/Cyst Haemorrhage
  • Degenerating fibroid
  • Endometrioma
  • Non-gynaecological
  • Appendicitis
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3
Q

History suggestive of Ovarian torsion

A
  • Sudden onset of moderate-to-severe pain (90%)
  • Nausea and vomiting (70%)
  • Known ovarian mass
  • Genital tract bleeding
  • Timing of onset (ie vigorous activity)

Remember history of Endometriosis/endometrioma REDUCE likelihodd
History of TOC with adhesions REDUCE likelihood

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4
Q

Exam findings suggestive of Ovarian torsion

A
  • Low grade fever (20%)
  • Abdominal examination – mass, peritonism
  • Bimanual examination – mass, tenderness
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5
Q

Investigations

A

o Bloods
- FBE (leucocytosis)
- UEC
- bhCG – pregnancy increases risk, also to exclude ectopic
- Consider ovarian tumour markers
o Transvaginal USS (Not essential if clinically peritonitic/acute abdomen and not readily available)
- Enlarged, oedematous ovary or ovarian mass
- Lateral placement of ovarian follicles as displaced by oedema
- Decreased or absent ovarian Doppler flow
- ‘Whirlpool sign’ of twisting ovarian vessels in vascular pedicle

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6
Q

Management of Ovarian torsion

A
  • Initial resuscitation
  • IV insertion with blood draw and IV Fluid
  • Call for help/ Gynae consultant if needed
  • If suspicious mass: Consider Gynae oncology input
  • Discuss with Anaesthetic team
  • Informed consent re LSC
  • Surgery (via laparoscopic approach) is mainstay of treatment
  • Timing
    o Ideally within 36/24 of symptom onset, however evidence of viable oocyctes up to 70 hours after symptom onset
  • Premenopausal patient
    o Confirm torsion by direct visualisation of rotated ovary
    o Instrument uterus
    o Detorsion should be performed even if ovary appears non-viable
    o Consider cystectomy if cyst present, however if very friable ovary may be better to do in second procedure (Risk of recurrent torsion without cystectomy 5%)
    o Consider oophorectomy if:
    § Necrotic gelatinous mass with no improvement after detorsion
    § Suspicion of malignancy
  • Postmenopausal patient
    o Consent for USO if a mass present due to higher chance of malignancy
  • Postoperative
    o Observe for signs of sepsis or peritonitis (especially if ovary may not have been viable)
  • Debrief and follow up planning
  • Prevent recurrence
    o Suppression of ovarian cysts with OCP
    o Oophoropexy
    § Usually in children who have ovarian torsion without ovarian mass
    § Consider in adults with recurrent torsion (and therefore may have abnormally long ligaments)
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