(85) Ovarian Torsion Complicated by Spontaneous Rupture and Hemoperitoneum: A Rare Case

Background: Ovarian torsion is relatively rare but remains one of the most common gynecologic surgical emergencies. It involves complete or partial rotation of the ovary along the supporting ligaments that leads to obstruction of vascular flow and requires urgent intervention in order to prevent necrosis. Although torsion could cause back up of blood into the adnexa, the ovary itself is encased in a dense connective tissue capsule called the tunica albuginea and rupture is exceptionally rare. We discuss a case of torsion that was complicated by ovarian hemorrhage and hemoperitoneum.

Case: In this report, we discuss a case of a 15-year-old female who presented with a one-day history of severe, intermittent right lower quadrant abdominal pain associated with nausea and vomiting. A computed tomography scan found free fluid within the pelvis and abdomen, and an asymmetrically enlarged right ovary with a cyst. Ultrasonography showed minimal peripheral flow on doppler raising suspicion for ovarian torsion. In the emergency department, the patient's complete blood count was within normal limits. Diagnostic laparoscopy revealed hemoperitoneum, a torsed right tube and ovary, and rupture of the right ovary which was concluded to be the source of the hemoperitoneum. Partial oophorectomy was performed, and histology found the ovarian tissue had widespread hemorrhage, focal ischemia, and features consistent with a mesothelial inclusion cyst. In the post-anesthesia care unit, the patient was found to have an elevated white blood cell count and anemic with a hemoglobin level of 11. She recovered uneventfully.

Comments: The main concern for ovarian torsion has been necrosis necessitating removal of the ovary. However, this case demonstrates another complication regarding hemorrhage that could lead to significant morbidity to patients if left untreated. Aside from imaging, there were no clear clinical signs or symptoms to demonstrate the complication of rupture. A mesothelial inclusion cyst, as what was found in our patient, is a rare benign tumor in which few cases have been described in the literature, but it is likely to have increased the risk of torsion and, thus, infarction leading to the spontaneous rupture. In conclusion, ovarian torsion is a common gynecologic surgical emergency that can be complicated by rupture and associated hemoperitoneum even in pediatric nulliparous patients. Close attention should be paid to free fluid within the abdomen and pelvis during imaging. This case highlights the importance of urgent surgical intervention to not only minimize ischemia to the ovary but also prevent rupture and subsequent hemorrhage.