Twisted Ovarian Cyst, Ectopic Pregnancy

Question 1

What are the causes of a twisted ovarian cyst?

Answer 1

• Underlying tumour - mature cystic teratoma
• Lesion

Question 2

Describe the pathology underlying a twisted ovarian cyst.

Answer 2

• Cyst is attached by a pedicle of blood vessels which twist around and increase pressure.
• Venous flow away is decreased and if it twists further then arterial flow into ovary decreases
• Decreased venous return –> congestion (blood is still pumped in)
• Ovary becomes haemorrhagic and necrotic (perfusion isn’t good)
• Usually there has to be underlying pathology for this to happen.

Question 3

What are mature cyst teratomas?

Answer 3

• A type of germ cell tumour –> variety of tissue elements are found
• Mostly skin so large amounts of hair and sebum are produced
• They rarely have carcinomatous areas
• “Dermoid cysts” because mostly cystic

Immature teratomas are mostly solid and more aggressive (less differentiated)

Question 4

True or false?

“With twisted ovarain cyst the perfusion is increased because of increased blood flow into the cyst”

Answer 4

False

With twisted ovarian cysts perfusion is decreased. Paradoxically, even though blood is coming in perfusion isn’t good. The ovary becomes very haemorrhagic and necrotic.

Question 5

True or false?

“Twisted ovarian cysts become very congested due to blood being pumped in continually”

Answer 5

True

Twisted ovarian cysts become very congested due to blood being pumped in continually despite decreased venous return.

Question 6

Where do ectopic pregnancies usually occur and why?

Answer 6

90% in the fallopian tubes

50% because of some inflammation of the fallopian tubes (chronic salpingitis)

Question 7

What is chronic salpingitis? Why does it cause an ectopic pregnancy?

Answer 7

• Chronic inflammation of the fallopian tubes which disturbs the movement of the fertilised ovum
• Ovum implants while still in fallopian tube and grows within it
• Increased pressure –> fallopian tube bursts and leads to major haemorrhage

Question 8

At how many weeks do ectopic pregnancies usually lead to tube rupture?

Answer 8

About 6 weeks after the previous menstrual period.

Question 9

What kind of lesions can cause an ectopic pregnancy?

Answer 9

Identifiable lesions from chronic salpingiis from pelvic inflammatory disease or adhesions from appendicitis, endometriosis , previous laparotomy.

Question 10

When should ectopic pregnancy be considered in the differential?

Answer 10

In women with acute abdominal pain and of childbearing age.

Question 11

What tests are helpful in diagnosis of an ectopic pregnancy?

Answer 11

• Pregnancy test (tests for human chorionic gonadotrophin)
• US
• Culdocentesis with presence of blood

(Histologically - tubal epithelium will be seen alongside chorionic villi)

Question 12

List some sites of ectopic implantation.

Answer 12

• Ovary
• Fallopian tube
• Abdominal peritoneum
• Cornual (uterine) portion of fallopian tube

Question 13

Describe the clinical presentation of an ectopic pregnancy.

Answer 13

• Normal symptoms of pregnancy: morning sickness, amenorrhoea, breast swelling
• Intermittent lower abdominal pain before sudden onset severe pain

Question 14

What causes over 50% of cases of acute salpingitis?

Answer 14

Ascending infection - usually gonorrhoea (gonococcus e.g. neisseria gonorrheae)

Question 15

What type of abscess can form in acute salpingitis?

Answer 15

Abscess with localised tissue necrosis with neutrophils. Acute salpingitis may involve the ovary.