(P82) Ovarian Torsion in a Woman After Hysterectomy: A Case Report

Chief Complaint : A 39-year-old G5P3 woman with a history of obesity presented to an outside emergency department complaining of intermittent right lower quadrant abdominal pain.

History of Present Illness : A 39-year-old G5P3 woman with a history of obesity presented to an outside emergency department for sharp worsening intermittent right lower quadrant abdominal pain radiating to the flank. She had three episodes of emesis at the peak of her pain. She reported running on the treadmill about 1 hour prior to the onset of her pain. About one year prior to presentation, the patient had a hysterectomy with bilateral salpingectomy due to uterine fibroids and abnormal uterine bleeding.

Pertinent Physical Exam: On examination, the patient had RLQ tenderness without rebound or guarding. No peritonitis. Bowel sounds present in all four abdominal quadrants. On pelvic examination patient had tenderness of right adnexa

Pertinent Laboratory Data: laboratory workup was unremarkable
CT scan without contrast revealed possible ovarian cysts
pelvic ultrasound which revealed an enlarged right ovary measuring 6.9 x 3.7 x 4.6 cm with an included 3 cm cyst. Doppler scan demonstrated a normal flow pattern

Case Discussion: Ovarian torsion after a hysterectomy is not a common occurrence, comprising about 8% of the total torsions. [1] However, complications related to it can be life-threatening including ischemia and infection. Ovarian torsion can be a challenging diagnosis due to its nonspecific signs and symptoms. Currently, there is no specific and sensitive testing for diagnosis of ovarian torsion. 
Most of the patients with ovarian torsion present with nausea and vomiting (70%), and approximately 70% of patients present with a sharp abdominal pain [3] . The ultrasound result in our patient was significant for an enlarged right ovary and the presence of a cyst however, the
doppler scan demonstrated a normal flow pattern in our patient. In one study, the specificity of pelvic ultrasound to rule in ovarian torsion was 99.6% but the sensitivity of ultrasound in ruling out ovarian torsion was found to be only 72% [4] . This means that around 28% of ovarian torsions were missed by ultrasound due to absence of abnormal flow patterns. In our case, the patient did have a normal flow pattern causing delay in the diagnosis and appropriate management. Unilateral ovarian enlargement of the affected ovary was discovered to be one of the most common findings in ovarian torsion, which was present in our patient. Additionally, our patient had an ovarian cyst which further increases her chances of having a torsion. 
In this case, largely because the patient had a hysterectomy in the past, the OB-GYN team discharged the patient home despite the concerning ultrasound findings. However, patient’s pain worsened on follow-up appointment, and she eventually came back to the hospital for emergency
laparoscopy and had an unsalvageable torsed right ovary. This case shows that ovarian torsion needs to be considered even in the patients with a prior history of hysterectomy.

References and Acknowledgements (Optional): [1] Asfour V, Varma R, Menon P. Clinical risk factors for ovarian torsion. J Obstet Gynaecol (Lahore) 2015;35:721–5. https://doi.org/10.3109/01443615.2015.1004524.
[2] McWilliams GDE, Hill MJ, Dietrich CS. Gynecologic emergencies. Surg Clin North Am 2008;88:265–83. https://doi.org/10.1016/J.SUC.2007.12.007.
[3] Houry D, Abbott JT. Ovarian torsion: A fifteen-year review. Ann Emerg Med 2001;38:156–9. https://doi.org/10.1067/MEM.2001.114303.
[4] Rostamzadeh A, Mirfendereski S, Rezaie MJ, Rezaei S. Diagnostic efficacy of sonography for diagnosis of ovarian torsion. Pakistan J Med Sci 2014;30:413–6. https://doi.org/10.12669/PJMS.302.4446.