Article published online: 2022-02-09

THIEME
336 Original Article

Perioperative Outcomes in Pregnant Women

Who Underwent Surgery for Adnexal Torsion
Resultados perioperatórios em mulheres grávidas
submetidas a cirurgia para torção anexial
Huseyin Ekici1 Fırat Okmen1 Metehan Imamoglu1,2 Ismet Hortu1,3,4 Ali Akdemir1,3
1 Department of Obstetrics and Gynecology, School of Medicine, Ege Address for correspondence Ismet Hortu, Department of Obstetrics
University, Izmir, Turkey and Gynecology, School of Medicine, Ege University, 35100, Bornova,
2 Department of Obstetrics and Gynecology, School of Medicine, Yale Izmir, Turkey (e-mail: [email protected]).
University, New Haven, Connecticut, United States
3 Department of Stem Cell, Institute of Health Sciences, Ege
University, Izmir, Turkey
4 Department of Molecular Pharmacology and Physiology, Morsani College
of Medicine, University of South Florida, Tampa, FL, United States

Rev Bras Ginecol Obstet 2022;44(4):336–342.

Abstract Objective To evaluate clinical characteristics, maternal and fetal outcomes in preg-
nant women who underwent surgery for adnexal torsion (AT).
Methods All patients, who underwent surgical operation due to AT during pregnancy
at the Department of Obstetrics and Gynecology, School of Medicine, Ege University
between 2005 and 2020 were retrospectively investigated. Main clinical and perioper-
ative outcomes were evaluated.
Results A total of 21 patients who underwent surgery due to AT during pregnancy
were included. Of all patients, 61.9% underwent laparoscopy and the remaining 38.1%
underwent laparotomy. The most common surgical procedure was adnexal detorsion
in both groups (48%). Mean gestational age at the time of diagnosis, duration of
surgery and hospitalization were significantly lower in the laparoscopy group, when
compared with the laparotomy group (p ¼ 0.006, p ¼ 0.001, and p ¼ 0.001, respective-
ly.) One of the patients had an infection during the postoperative period. Spontaneous
Keywords
abortion was only observed in one case.
► adnexal torsion
Conclusion It can be concluded that the surgical intervention implemented for the
► pregnancy
exact diagnosis and treatment of AT (laparotomy or laparoscopy) did not have an
► emergent surgery
unfavorable effect on pregnancy outcomes such as abortion, preterm delivery, and
► perinatal outcomes
fetal anomaly. However, laparoscopy may be superior to laparotomy in terms of
advantages.

Resumo Objetivo Avaliar as características clínicas, e os desfechos maternos e fetais em

gestantes submetidas à cirurgia de torção anexial.

received DOI https://doi.org/ © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights
May 16, 2021 10.1055/s-0042-1742403. reserved.
accepted ISSN 0100-7203. This is an open access article published by Thieme under the terms of the
November 11, 2021 Creative Commons Attribution License, permitting unrestricted use,
published online distribution, and reproduction so long as the original work is properly cited.
February 9, 2022 (https://creativecommons.org/licenses/by/4.0/)
Thieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de
Janeiro, RJ, CEP 20270-135, Brazil
 Pregnant Women Who Underwent Surgery for Adnexal Torsion Ekici et al. 337

Métodos Todas as pacientes operadas por torção anexial durante a gravidez no

Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade
de Ege entre 2005 e 2020 foram investigadas retrospectivamente. Os principais
resultados clínicos e perioperatórios foram avaliados.
Resultados Foram inclusas 21 pacientes operadas por torção anexial durante a gravidez.
De todos as pacientes, 61,9% foram submetidas à laparoscopia e as 38,1% restantes foram
submetidas à laparotomia. O procedimento cirúrgico mais comum foi apenas a destorção
anexial em ambos os grupos (48%). A idade gestacional média no momento do diagnóstico,
a duração da operação e da hospitalização foram significativamente menores no grupo de
laparoscopia em comparação com o grupo de laparotomia (p ¼ 0,006, p ¼ 0,001 e
p ¼ 0,001, respectivamente.) Uma das pacientes teve uma infecção no pós-operatório.
Apenas em um caso observamos aborto espontâneo.
Palavras-chave
Conclusão Pode-se concluir que a intervenção cirúrgica implementada para o
► torção anexial
diagnóstico exato e tratamento da torção anexial (laparotomia ou laparoscopia) não
► gravidez
teve efeito desfavorável nos desfechos da gravidez, como aborto, parto prematuro e
► cirurgia emergente
anomalia fetal. No entanto, a laparoscopia pode ser superior à laparotomia em termos
► resultados perinatais
de vantagens.

Introduction School of Medicine, Ege University (Izmir, Turkey) between

2005 and 2020, were retrospectively investigated. The data
Ovarian torsion is the complete or partial twisting of the related to the demographic characteristics, medical, surgi-
pedicle on its vascular axis, which includes the ovarian cal and obstetric history, findings of the preoperative
arterial and venous vessels, interrupting the blood supply. laboratory and ultrasound examinations, surgery reports,
If the ovarian torsion is accompanied by fallopian torsion, it is anesthesia, and hospitalization were accessed from the
called adnexal torsion (AT). The adnexal detorsion (AD) patients’ antenatal follow-up files. Pregnancy outcomes
surgery constitutes 2.7% of all gynecological emergent sur- such as abortion, gestational age at birth, birth weight,
geries during pregnancy and may affect women of all ages, and congenital anomalies were investigated in detail. This
particularly during the reproductive period.1–3 study was approved by the Local Ethics Committee of the
The AT is rather rare during pregnancy and its incidence is School of Medicine at Ege University (Approval ID: 20–6.1T/
between 1 and 5 in every 10,000 patients, among cases with 54). Patients whose medical records related to pregnancy
spontaneous pregnancy.4,5 Following the implementation of monitoring and delivery were not available were excluded
the assisted reproductive techniques (ART), the number and from the study.
size of the follicular cysts increase along with the dramatic Regarding imaging methods, we used 2-D ultrasonography,
increase in the risk of torsion. The incidence of torsion may with the Voluson-E8 (General Electric Healthcare, Wauwatosa,
increase in up to 8%, particularly among women with ovarian WI, USA), 3–9 MHz Transducer scanner and, less frequently, the
hyperstimulation syndrome.6 Although AT is usually en- magnetic resonance imaging (MRI) Magnetom Symphony
countered in the first trimester, it may also emerge in (Siemens. Erlangen, Germany) 1.5-Tesla scanner. The ultra-
the second and third trimesters.7 sound reports were retrospectively scanned, and the findings
Early diagnosis is crucial for the preservation of the ovarian were divided into three groups: normal ovaries without the
and tubal functions and decrease of the related risks of other presence of cysts or mass, cystic ovaries, and hyperstimulated
morbidities. Since there are no exact diagnostic and imaging ovaries. The evaluation of the ultrasound reports showed that
criteria for the confirmation of the preoperative diagnosis of the short and long axis of the ovaries were measured in all
AT, immediate surgical intervention is also important to patients. Furthermore, the mean ovarian diameter was mea-
preserve ovarian tissue and fertility, and preventing the ad- sured, as the calculation of the ovarian volume was not
verse pregnancy outcomes. Laparoscopy is an effective and possible. The preoperative white blood counts (WBC) and C-
safe surgical method mostly preferred for AT treatment in reactive protein (CRP) values were available for all patients.
pregnant and non-pregnant women in experienced centers.8 The participating patients were divided into groups according
There are only a limited number of studies focused on the to the preferred surgical intervention (laparoscopy and lapa-
course of the AT and its effects on pregnancy outcomes. rotomy) and the trimester during which AT emerged (first
trimester: 5th–14th gestational weeks; second trimester:
14th–28th gestational weeks; third trimester: 28th gestational
Methods
week–term). We evaluated the differences for the surgical
All patients, who had undergone surgery due to AT during characteristics, ultrasound findings, and pregnancy outcomes
pregnancy at the Department of Obstetrics and Gynecology, between the two groups.

Rev Bras Ginecol Obstet Vol. 44 No. 4/2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.
338 Pregnant Women Who Underwent Surgery for Adnexal Torsion Ekici et al.

In patients who went through laparoscopy, the Veress Table 1 Demographic and clinical characteristics of the
needle was inserted into the umbilicus to create pneumo- patients
peritoneum with carbon dioxide gas. In the cases of patients
who had previous surgery in the medical history, had Parameter Results
suspected periumbilical adhesions, and were in advanced Maternal age (years) 30  3.9
gestational weeks ( 15 weeks), the Veress needle was Parity, n (%)
inserted at the Palmer point to create pneumoperitoneum.
Nulliparous 9 (42.8%)
After the intraabdominal pressure reached 10 to 12 mm Hg,
and the 10 to 12 mm primary trocar was placed, the Parous 12 (57.2%)
surgeon decided for the placements of the assistant trocars, Surgical history, n (%)
taking the gestational week and the size of the adnexal Laparoscopy 3 (14.3%)
mass into consideration. The supine position was selected Laparotomy 6 (28.6%)
for first-trimester patients, and left lateral position for
GA at the time of torsion (weeks) 11.9  4.6
the second-trimester patients to avoid aortocaval compres-
GT at the time of torsion
sion syndrome. In the laparotomy group, the decision of the
abdominal incision was made according to the size of the First trimester 14 (66.6%)
uterus, and size and location of the adnexal mass. In the Second trimester 7 (33.3%)
cases of patients who had undergone cystectomy and Mode of conception, n (%)
salpingo-oophorectomy, all resected materials were re-
Spontaneous conception 15 (71.4%)
ferred to the pathological examination. The fetal heartbeat
Assisted reproductive technology 6 (28.6%)
was checked with an ultrasound before and after the
intervention. All operations were performed by experi- Twin pregnancy 1 (4.7%)
enced, high-volume surgeons. Torsion side
The Statistical Package for the Social Sciences (SPSS, IBM Right 13 (61.9%)
Corp. Armonk, NY, USA) software, version 25.0, was used
Left 8 (38.1%)
for the statistical analysis. The normal distribution of the
Preoperative WBC (cells/ µL) 12,368  4,864
numerical variables was analyzed with the Shapiro-Wilk
test (n < 50). The numerical variables were given in mean Preoperative CRP (mg/dL) 1.2  0.8
 standard deviation (SD), or median (min–max). The Abbreviations: CRP, C-reactive protein; GA, gestational age; GT, gesta-
categorical variables were given in numbers and percen- tional trimester; WBC, white blood cell. Notes: Data are given as
tages. The independent binary sample t-test was used in mean  SD and/or percentage.  No cases were seen in third trimester.
normal distribution, and the Mann-Whitney U test was
used in non-normal distribution. The Pearson Chi-square
test and the Fisher exact test were used for the categorical and normal blood flow was observed in 6 patients, who were
variables. surgically diagnosed with AT (false-negative rate: 46%). The
laboratory analysis showed that both preoperative WBC
(12.368  4.864 cells/µL) and CRP (1.2  0.8 mg/dL) were
Results
slightly elevated.
A total of 21 patients who had undergone surgery due to the Regardless of the gestational week, laparoscopy and lap-
AT during pregnancy were retrospectively investigated arotomy were performed in 61.9% (n ¼ 13/21) and 38.1%
throughout the study period. The demographic and obstetric (n ¼ 8/21) of the patients, respectively. The most common
characteristics, as well as laboratory findings, were listed surgical procedures were only adnexal detorsion (48%)
in ►Table 1. The mean gestational week at the time of (►Fig. 1). In one patient, who had AT in her medical history
diagnosis was found to be 11.9  4.6 (range 6–22). In 14 before pregnancy, adnexal fixation was performed to prevent
patients (66.6%) the AT developed in the first trimester, and recurrence. Histopathological examination was performed in
in 7 patients (33.3%) in the second trimester. Six patients patients who underwent cystectomy and salpingo-oopho-
(28.6%) became pregnant after ART implementations (in rectomy: 2 cases had dermoid cysts; 2 cases serous cysts, one
vitro fertilization: 3 cases; ovulation induction: 3 cases), case a paratubal cyst, and 1 case an inflammatory cyst. We
and the remaining patients became pregnant through spon- encountered no intraoperative complications in any patients
taneous conception. and only one second-trimester patient, who underwent
The preoperative imaging examination was mainly per- laparotomy and salpingo-oophorectomy, developed an in-
formed with ultrasonography and, less frequently, with MRI. fection in the postoperative period. The comparison of the
We observed cystic lesions in the adnexa (single, multiple or patients according to the implemented surgical method
cystic teratoma) in 47.6% of the cases, ovarian enlargement (laparoscopy or laparotomy) showed that there was a sta-
without mass or cyst in 38.1% of the patients, and hyper- tistically significant difference between the groups for the
stimulated ovaries in 14.3% of the patients. The mean ovarian gestational week at the time of diagnosis (p ¼ 0.006), dura-
diameter was 77  19 mm (range 52–130). Thirteen patients tion of surgery (p ¼ 0.001), and hospitalization (p ¼ 0.001).
had their blood flow assessed by Doppler ultrasonography There was no statistically significant difference between the

Rev Bras Ginecol Obstet Vol. 44 No. 4/2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.
 Pregnant Women Who Underwent Surgery for Adnexal Torsion Ekici et al. 339

the 37th gestational week or later. The rate of cesarean

section was 52.4% (n ¼ 11/21) and all indications depended
on the routine fetal, obstetric, or maternal factors. The
majority of the patients (95.2%) gave live birth (n ¼ 20/21)
and only in one first-trimester patient, who had undergone
laparoscopy and AD, spontaneous abortion happened two
weeks after surgery. We observed no fetal anomaly in women
who had given live birth. The comparison of patients accord-
ing to the trimester, during which surgery was performed
(first trimester and second trimester), showed that there was
a statistically significant difference between the groups for
the duration of surgery (p ¼ 0.020) and hospitalization
(p ¼ 0.009). There was no statistically significant difference
between these groups for the abortion rates, gestational age
at delivery, birth weight, preterm birth, and cesarean section
(►Table 3).

Discussion
The AT is one of the most common emergent conditions in
obstetrics and gynecology, and it challenges the clinicians
because of the maternal and fetal risks.2 Primarily, AT is
Fig. 1 Type of the surgical procedures in adnexal torsion during suspected because of the nonspecific symptoms such as
pregnancy. AD: Adnexal de-torsion only, CF: cyst fenestration, C:
nausea and vomiting, examination findings (low-grade fever,
cystectomy, SO: salpingo-oophorectomy.
lateralized lower abdominal pain), and imaging method
findings. The definitive diagnosis is done during the surgery.
Although it can occur in any trimester, it is more common in
groups for the gestational week at delivery, birth weight, the first trimester.7 In our study, two-third of the cases were
preterm birth, cesarean section, ultrasound findings, and in the first trimester. The AT is more common in the first
complications (►Table 2). trimester, as the functional ovarian cysts and hyperstimu-
The average gestational age at delivery was 38.1  1.7 lated ovaries are more common in this trimester. It is
weeks (range 34–41 weeks) among women with live birth; relatively rare in the second and third trimesters because
three of the cases (14.3%) had delivered before the 37th these cysts spontaneously regress in these trimesters. Wom-
gestational week, and the remaining 18 cases (85.7%) in en who underwent ovulation induction and in vitro

Table 2 Clinical and operative characteristics of the patients

Variable Laparoscopy group Laparotomy group p-value

GA at the time of diagnosis (weeks) 9.8  3.4 15.25  4.6 0.006
Operation time (min) 61.6  8.3(45–70) 84  13.4(70–100) 0.001
Duration of hospitalization (days) 3.5  1(2–5) 5.7  1(4–7) 0.001
GA at birth (weeks) 38.1  1.7(34–41) 37.7  2(35–40) 0.549
Birthweight (g) 3,043  338 3,010  292 0.821
(2,400–3650) (2,600–3530)
Preterm delivery n/N (%) 1/13 (7.7%) 2/8 (25%) 0.271
Cesarean section, n/N (%) 7/13 (53.8%) 4/8 (50%) 0.676
Ultrasonographic findings n/N
Normal-appearing ovary without cysts 6/13 (46.2%) 2/8 (25%) 0.4
Cystic ovary 5/13 (38.4%) 5/8 (62.5%) 0.387
Hyperstimulated ovary 2/13 (15.4%) 1/8 (12.5%) 0.54
Complications
Intraoperative n/N (%) 0/13 0/8 NA
Postoperative n/N (%) 0/13 1/8 (12.5%) 0.381

Abbreviation: GA, gestational age; NA, Not applicable. Notes: Data are given as mean  SD and percentage. Range is given inside the parentheses.

Rev Bras Ginecol Obstet Vol. 44 No. 4/2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.
340 Pregnant Women Who Underwent Surgery for Adnexal Torsion Ekici et al.

Table 3 Comparison of surgical and obstetric characteristics at first trimester and second trimester

Variable First trimester Second trimester p-value

Operation time (min) 63.4  9.8 (45–80) 84.2  15.1 (70–100) 0.020
Hospitalization (days) 3.7  1.3(2–7) 5.5  0.9 (4–7) 0.009
GA at delivery (weeks) 38.1  1.8(34–41) 37.7  1.7 (35–40) 0.601
Birthweight (g) 3,018  348 3,052  259 0.820
(2,400–3,650) (2,600–3,420)
Preterm delivery, n/N (%) 1/14 (7.1%) 2/7 (28.6%) 0.186
Cesarean section, n/N (%) 7/14 (50%) 4/7 (57.1%) 0.761

Abbreviation: GA, gestational age. Notes: Data are given as mean  SD and percentage. Range is given inside the parentheses.

fertilization are under higher risk of AT. Regarding the week were reported.20 In our study, regardless of gesta-
studies focused on the effects of AT on pregnancy, 73.2%,4 tional age, the majority of the cases (61.9%) was treated
48.5%,9 and 47.9%10 of the study samples consisted of preg- with the laparoscopic approach. Laparotomy was imple-
nancies after ART. In our study, this rate was 28.6% and this mented predominantly between 2005 and 2010 and lapa-
relatively low rate can be explained by the following factors: roscopy became more popular with the increase of medical
implementation of the frozen thaw cycle after the cancella- experience with endoscopic surgery. Like in previous stud-
tion of the embryo transfer in the same cycle in patients with ies, the duration of surgery and hospitalization were
the hyperstimulated ovary; preference of gonadotropin-re- shorter in cases that underwent laparoscopy.21,22 Regard-
leasing hormone antagonists (GnRH antagonists) instead of ing the pregnancy outcomes, no significant difference was
gonadotropin-releasing hormone analogues (GnRH), which observed between laparoscopy and laparotomy. There was
overstimulates the adnexa; early detection of predisposition no need to convert from laparoscopy to laparotomy in any
to ovarian hyperstimulation, and implementation of the patient.
appropriate interventions.11 Some precautions should be taken to decrease complica-
Transabdominal ultrasonography is frequently the pre- tions during pregnancy related to these procedures, as noted
ferred imaging method for AT. Enlarged ovary, solid/cystic/ in the literature. These include left lateral recumbent posi-
complex ovarian mass, pelvic fluid, and edematous ovarian tioning, to minimize compression of vena cava inferior and
stroma with peripherally located small follicles are the most aorta; initial port placement; and the Veress needle insertion
common findings in ultrasonographic examinations.12 The sites should be adjusted according to the gravid’s uterine
Doppler ultrasound modalities have limited use in AT due to size. Safer alternative sites, such as the Palmer point open
the low sensitivity and operator-dependent usage.13 If the technique, can be implemented to prevent devastating com-
findings of the ultrasonographic examination are indefinite, plications. Intra-abdominal pressure should not exceed
MRI may be useful (typically best seen on T2-weighted 15 mm Hg during surgery, to minimize pressure-related
images).14 In general, an ovarian diameter equal to or greater complications. Moreover, the patient’s carbon dioxide levels
than 5 cm is strongly related with AT.15,16 Hasson et al.4 should be monitored with capnography during surgery.23
reported a mean ovarian diameter of 70  23 mm and a false Considering the implemented surgical procedures, AD only
negativity rate of 61% after the ultrasonographic examina- was usually sufficient (48%). In cases of patients with cysts,
tion. In our study, the mean ovarian diameter was cyst fenestration or cystectomy were preferred. Histopatho-
77  19 mm and the false negativity rate was 46% in the logical examination was performed in 28.6% of the patients,
Doppler ultrasonographic evaluation. Several biochemical and the dermoid cyst and serous cyst were the most common
parameters such as leukocytosis, CRP, and erythrocyte sedi- findings. In their study, Seo et al.24 performed the pathologi-
mentation rate were measured in AT cases, and it was found cal examination in 81.8% of the cases, and the most common
that they were not relevant to diagnosis.17,18 In our study, we finding was corpus luteum cyst (42.4%). In principle, only AD
also measured the WBC and CRP parameters and observed or fenestration were performed, particularly in first-trimes-
slightly elevated levels. ter patients, to preserve the ovarian reserve, and cystectomy
The decision for surgery during pregnancy, particularly and salpingo-oophorectomy were avoided. In our study, we
in emergencies, is not always easy depending both on the did not encounter complications in the intraoperative period
circumstances related to surgery and possible effects of and only one patient, who underwent laparotomy, developed
surgery on pregnancy outcomes. In the current literature, it an infection with no negative effects on the pregnancy
was reported that laparoscopy did not increase the rate of outcome.
the maternal and fetal complications, and it can be safely There are some differences between pregnant women
and effectively used in the diagnosis and treatment of AT.19 and non-pregnant women in the management of the AT.
For this procedure, the optimal gestational week is The choice of anesthesia is generally guided by maternal
the second trimester, and several cases who were treated indications, as well as the site and nature of the planned
successfully with laparoscopy up to the 34th gestational surgical procedure. However, most abdominal surgical

Rev Bras Ginecol Obstet Vol. 44 No. 4/2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.
 Pregnant Women Who Underwent Surgery for Adnexal Torsion Ekici et al. 341

procedures, including laparoscopy, require general anesthe- ovarian and tubal functions and prevent the torsion-related
sia and muscle relaxation. Preservation of maternal hemo- complications. The surgical method (laparotomy or laparos-
dynamic stability, uteroplacental blood flow, and avoidance copy) chosen for the diagnosis and treatment does not have
of maternal and fetal hypoxia throughout surgery, as well as any negative effect on pregnancy outcomes like abortion,
avoidance of preterm delivery, are mandatory.25,26 General preterm birth, and fetal anomaly. In cases with small, simple,
anesthesia is used for the vast majority of laparoscopic, non-malignant cystic lesions, adnexal detorsion and cyst
non-obstetric surgeries in pregnancy. Endotracheal intuba- fenestration seem a suitable treatment to preserve the
tion with positive pressure ventilation is favored for several ovarian reserve. Furthermore, according to the results of
reasons: 1. the risk of regurgitation from increased intra- the present study, obstetric outcomes of pregnant women
abdominal pressure; 2. the need for controlled ventilation who underwent surgery for AT are generally favorable. If the
to prevent hypercapnia; 3. the need for relatively high- and surgery can be done via laparoscopy in pregnant cases within
peak airway pressures; 4. the need for muscle relaxation early gestations, postoperative recovery will be better than
(paralysis); and 5. the need for the placement of a nasogas- open surgery.
tric tube. In addition, when selecting anesthetic drugs, the
primary goals are to preserve maternal blood pressure as Contributions
well as uterine blood flow, and to minimize fetal Concept: HE, IH. Design: HE, FO, MI., Data collection: HE, IH,
depression.27 FO. Analysis or Interpretation: AA, HE, FO., Literature search:
There are different studies focused on the obstetric alter- HE, IH., Writing: HE, IH, FO.
ations in laparoscopy and laparotomy surgeries imple-
mented due to AT in pregnant women.4,10,28 Oelsner Conflict of Interests
et al.21 investigated the effects of laparoscopy and laparoto- The authors have no conflict of interests to declare.
my performed during pregnancy on the obstetric perfor-
mance and fetal outcomes, and found that the rates of fetal
anomalies, abortion, and preterm births were comparable in References
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342 Pregnant Women Who Underwent Surgery for Adnexal Torsion Ekici et al.

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