Valvi Durga*, Parulekar SV** Fernandes Gwendolyn***
(*Assistant Professor; **Professor and Head; Department of Obstetrics and Gynecology, *** Associate Professor, Department of Pathology,
Seth G S Medical College and K.E.M
Hospital, .) Mumbai, India
The most important cause of acute abdomen in women in the reproductive age group is torsion of uterine adnexa. Torsion of ovarian mass is quite common. Torsion of paraovarian cyst is very rare. We report a case of torsion of paraovarian cyst in the second trimester of pregnancy, who presented with severe acute abdomen due to torsion of a left adnexa with paraovarian cyst.
Paraovarian cysts are extraperitoneal cysts adjacent to the ovary, below the fallopian tube lying inside the broad ligament. These arise from the mesothelium and are presumed to be remnant of the mullerian and wolffian ducts.[1, 6] They are seen in 10-20% of adnexal masses.[2-4] The cysts commonly occur in the fourth and fifth decades of life but sometimes are seen in premenarchal age group. Small paraovarian cysts are more common and are often found incidentally during an operation for another indication. These cysts are epithelium lined, usually unilocular, and contain clear fluid. An ovarian cyst can also burrow into the broad ligament but in such a case the normal ovary is not identifiable as in a paraovarian cyst. Failure of these cysts to regress over time or with hormonal therapy makes the diagnosis of simple ovarian cysts less likely. In such cases diagnosis can be made by histopathological examination.
A 17 yrs. old unmarried woman, primigravida with 18 weeks’ pregnancy, presented with severe pain in left side of the abdomen for two hours. She had 3-4 episode of vomiting. Her temperature was normal, pulse was 110/minute, blood pressure 100/70 mm Hg. An abdominal examination showed a uterus of 16-18 weeks’ size and a severely tender cystic mass of approximately 17× 12 cm in the left iliac fossa extending up to the left lumbar region. The mass was separately felt from uterus. An ultrasonography (USG) showed a 17× 4.5× 12 cm sized thick walled clear cyst in the left adnexa, extending up to left lumbar region. It was inconclusive about the vascularity. The left ovary could not be identified separately from the mass. A diagnosis of torsion of a left ovarian cyst was made. An emergency laparotomy was done. It showed the uterus of 18 weeks’ size, levo-rotated. There was an approximately 17×12 cm sized bluish black paraovarian cyst in left adnexa with 2 and half turns of the adnexal pedicle. The left ovary was enlarged and black in colour. The left fallopian tube was also black in colour and stretched over the whole length of cyst. They were both necrotic and could not be salvaged. Left salpingo-oophorectomy was done. The patient had an uneventful recovery.
Figure 1. Left salpingo-oophorectomy specimen composed of a large paraovarian cyst, ovary (white arrow) and fallopian tube (yellow arrow). The cyst and the ovary have a dusky, cyanotic and congested appearance due to torsion.
Figure 2. Cut surface of the paraovarian cyst and ovary. The cyst is coated with hemorrhagic reddish-brown material on its inner surface.
Figure 3. Microphotograph of low power view of the paraovarian cyst wall showing a lining of cuboidal epithelium and extensive hemorrhagic infarction of the cyst wall. (H&E X 100)
Figure 4. Microphotograph showing a magnified view of the cuboidal cell lining of the paraovarian cyst. (H&E X 400)
Figure 5. Oil immersion view of the cuboidal cell cyst wall lining. (H&E X 1000)
Paraovarian cysts are the third most common type after benign cystic teratomas and serous cystadenomas in cases of ovarian tumors in pregnancy. Torsion of paraovarian cyst is very rare. It is three times more common in pregnancy than in the nonpregnant state because the uterus fills the pelvic cavity at the end of the first trimester and the cyst has more space to undergo torsion. Since the cyst has no pedicle of its own, when it undergoes torsion, the closely related fallopian tube and ovary undergo torsion with it. Clinically the diagnosis of torsion of paraovarian cyst from torsion of other adnexal masses is difficult. A computerized tomography (CT) scan or magnetic resonance imaging may be useful, but is unwarranted as it would not alter the plan of treatment, and would just delay the definitive treatment. Use of a CT scan is not recommended in pregnancy owing to associated irradiation of the fetus. Therefore definitive diagnosis is made during surgery. In our case a diagnosis of left ovarian cyst torsion was made but it was left paraovarian cyst torsion seen on exploration. It is always considered to be differential diagnosis of acute abdomen in woman. Paraovarian cyst can complicate a pregnancy by hemorrhage, torsion of the pedicle, rupture, or secondary infection. Sometimes it can cause obstruction during labor. A prompt diagnosis and treatment of ovarian torsion enables preservation of fallopian tube, ovarian function and the patient’s fertility. Sometimes color Doppler may be inconclusive about integrity of vascular supply. In such cases the decision of preservation of the ovary can be made during surgery. In our case USG was inconclusive, hence the decision of left salpingo-oophorectomy was made during surgery, the ovary and tube being necrotic. Simple excision of the paraovarian cyst is usually adequate but surgery may be technically more difficult than simple ovarian cystectomy, because these cysts are intimately blended within the peritoneal lining of the broad ligament after torsion. Surgical removal of Paraovarian cysts can be carried out by operative laparoscopy or laparotomy. Laparoscopic management instead of laparotomy of small ovarian cysts during early pregnancy is gaining popularity. However there are no report of laparoscopic removal of a large paraovarian cyst during pregnancy in the world literature.
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