Author information
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
Abstract
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.
Introduction
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.
Case Report
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)
Discussion
Paraovarian cysts are the
third most common type after benign cystic teratomas and serous cystadenomas in
cases of ovarian tumors in pregnancy.[5] 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.[7] Sometimes it can cause obstruction
during labor.[8] A prompt diagnosis and treatment of
ovarian torsion enables preservation of fallopian tube, ovarian function and
the patient’s fertility.[9] 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.[10] 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.[11]
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