Common Gynaecological Emergency Research Articles

Use of Indocyanine Green to Evaluate Ovarian Perfusion After Laparoscopic Detorsion. A Step-By-Step Demonstration Video

Demonstrate the usefulness of using indocyanine green after laparoscopic ovarian detorsion to save the ovary. A step-by-step video demonstration of a surgical technique. Ovarian torsion is one of the most common gynecological emergencies, mainly affecting patients younger than 20 years of age [1], and causes 2% to 7% of acute abdomens [2]. It is not advisable to routinely perform ovariectomy even with a necrotic ovary appearance [1]. Furthermore only in a small percentage of cases (16%) necrosis has been confirmed histologically [2]. Some studies have demonstrated that using indocyanine green to evaluate ovarian perfusion is inexpensive, low risk, and easily reproducible [3-5]. A 17-year-old patient was referred to our hospital for acute abdominal pain. Ultrasound revealed ovarian torsion; therefore, the patient underwent surgical treatment. During laparoscopy, the presence of a right ovarian torsion was confirmed. A lesion compatible with a hemorrhagic corpus luteum of 6 cm was present on the ovary affected. Before ovarian detorsion, indocyanine green was administered intravenously at a 0.5 mg/kg dose. The first aspect noted was the total lack of ovarian vascularization; then ovarian detorsion was performed. At this point, using technology of Rubina (KARL STORZ SE & Co. KG, Tuttlingen, Germany), it was possible to highlight the progressive ovarian revascularization. Ovarian reperfusion occurred starting from the ovarian hilum and ending at the periphery. We proceeded with enucleation of the hemorrhagic corpus luteum by stripping technique, with subsequent ovarian reconstruction with continuous 2-0 monofilament suture. Finally, we fixed the ovary to the stump of the right round ligament. The final view highlights good ovarian vascularization. No complications occurred; the patient was discharged on the first postoperative day. A 6-month follow-up ultrasound confirmed the recovery of the vascularization of ovary. Using indocyanine green represents a valid option to evaluate ovarian perfusion after detorsion. It could help the surgeon decide to save the ovary and thus allow fertility-sparing surgery in more cases.

Adnexal Torsion in the Second Trimester of Pregnancy: A Case Report and Review of the Literature

Acute abdomen in pregnancy is one of the biggest diagnostic and therapeutic challenges today. Despite advances in medical technology, the preoperative diagnosis of acute abdominal conditions is still inaccurate. Torsion of the adnexa, which refers to complete or partial rotation of the adnexa, resulting in obstruction of venous and lymphatic reflux in the ovary, is a common gynecological emergency. Torn adnexa affect both the ovary and the fallopian tube, and rarely affect only one of them. Adnexal torsion occurs more frequently in the first and early second trimester than in the third trimester. It is difficult to diagnose in advanced pregnancy because of nonspecific symptoms and signs of acute abdomen as well as ultrasound limitations due to uterine enlargement complicate diagnosis. Late diagnosis and delayed surgical treatment result in ovarian loss and fetal endangerment. It is important to thoroughly evaluate the adnexa at the 1st ultrasound examination in pregnancy and to monitor the observed formations.

Treatment outcomes of tubal pregnancy with tubal preservation: A meta-analysis.

Ectopic pregnancy is a common gynecological emergency that poses a significant risk of maternal mortality during the first trimester. It also increases the incidence of infertility and repeated ectopic pregnancy. The aim of this study was to evaluate whether there is a difference in the degree of tubal patency between salpingostomy and systemic treatment with methotrexate (MTX), as well as the odds of intrauterine pregnancy and repeat ectopic pregnancy, and the degree of tubal patency in salpingectomy with or without tubal suturing. We searched PubMed, EMBASE, and the Cochrane Library up to April 2023. Four randomized controlled trials were included in the review. We analyzed the combined data using Review Manager 5.3 software and Stata 12.0 software, utilizing a random effects model. When comparing salpingostomy and systemic treatment with MTX, there was no significant difference in the degree of tubal patency (OR = 1.09, 95% CI (0.54-2.38), P = .83). For salpingostomy with or without tubal suturing, there were no significant differences in the rates of intrauterine pregnancy, repeat ectopic pregnancy, and tubal patency degree [(OR = 1.05, 95% CI (0.41-2.68), P = .92), (OR = 0.68, 95% CI (0.19-2.42), P = .92), (OR = 1.68, 95% CI (0.14-20.33), P = .68)]. This meta-analysis demonstrates that systemic treatment with MTX is an effective treatment for patients who wish to preserve their fallopian tubes without undergoing surgery. This form of treatment can help avoid surgical procedures that may damage the fallopian tubes and improve fertility prospects. If choosing surgery, we believe that opting for salpingostomy without tubal suturing could reduce the operation time and minimize damage.

Effectiveness of treatment options for tubal ectopic pregnancy: Asystematic review and network meta-analysis.

Tubal ectopic pregnancy (TEP) is a common gynaecological emergency. Several medical and surgical treatment options exist, but it is not clear which is the safest and most effective treatment. To compare the effectiveness of expectant, medical and surgical treatment options for TEP using a systematic review and network meta-analysis. MEDLINE, EMBASE, and CENTRAL from inception till September 2022. Randomised trials that evaluated any treatment option for woman with a TEP. We performed pairwise and network meta-analyses using a random effect model. We assessed the studies' risk of bias, heterogeneity and network inconsistency. We reported primarily on TEP resolution and treatment failure using relative risk (RR) and 95% confidence-intervals (CI). We included 31 randomised trials evaluating ten treatments (n = 2938 women). Direct meta-analysis showed no significant benefit for using methotrexate compared to expectant management for TEP resolution. Network meta-analysis showed similar effect-size for most conservative treatment options compared to expectant management for TEP resolution (glucose intra-sac instillation vs. expectant RR 0.84, 95% CI 0.63-1.12; methotrexate intra-sac instillation vs. expectant RR 0.91, 95% CI 0.75-1.10; multi-dose methotrexate vs. expectant RR 1.00, 95% CI 0.88-1.15; prostaglandin intra-sac instillation vs. expectant RR 0.75, 95% CI 0.53-1.07; salpingotomy vs. expectant RR 0.99, 95% CI 0.84-1.16; single dose methotrexate vs. expectant RR 0.97, 95% CI 0.85-1.10; single dose methotrexate + mifepristone vs. expectant RR 1.09, 95% CI 0.89-1.33). All treatment options showed a higher risk of failure compared to salpingectomy. There is insufficient evidence to support the use of any medical treatment option for TEP over expectant management.

Artemisinin reduces acute ovarian ischemia-reperfusion injury in rats

Artemisinin (ARS) is well known as an effective agent in the treatment of malaria through the rapid elimination of Plasmodium falciparum parasites. This study aims to investigate the effect of ARS in treating adnexal torsion, one of the most common gynecological surgical emergencies. ARS was administered intraperitoneally once 30 min before unilateral ovarian torsion in two different doses (10 mg/kg vs. 50 mg/kg). Torsion was maintained for 3 h and then held in the detorted state for 3 h. Bilateral adnexectomy was performed to measure antioxidant enzyme activities and oxidant levels on the ipsilateral ovary and to make histopathological and immunohistochemical analyses on the contralateral ovary. Ischemia-reperfusion (I/R) injury dramatically upregulated the activities of CAT, GST, and MDA levels in the ipsilateral ovary, which were all downregulated by ARS treatment. A significant increase in follicular cell degeneration, congestion, and edema in the contralateral ovary was seen in the I/R group, which was significantly reduced with ARS treatment. Furthermore, I/R injury resulted in a significant increase in apoptosis as shown by the increased levels of BAX and CASP-3, and decreased levels of BCL-2 whereas ARS significantly reduced the impact of the injury. Our data, based on a rat I/R injury model, show that both ipsilateral and contralateral ovaries are protected with ARS pretreatment, and 50 mg/kg ARS treatment demonstrates to be more effective than the 10 mg/kg ARS.

Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis.

Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes. We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model. Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55). For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.

Premenarchal ovarian torsion

Ovarian torsion is a common gynecologic emergency seen in women of all ages, mostly in reproductive women, resulting in ischemia and necrosis of the adnexal tissue. However, it is rare in premenarchal girls. This article reviews the limited published literature, and discusses special considerations about premenarchal ovarian torsion.

Laparoscopy versus Laparotomy in the Surgical Management of Ectopic Pregnancy: Integrative Literature Review

Background: Ectopic pregnancy (EP) is a common gynecological emergency in resource-limited countries, where laparotomy is the conventional therapy despite the fact that laparoscopic surgery is considered the best option. There is a lack of prospective randomized evidence comparing laparoscopic surgery with laparotomy in the surgical care of women with REP. Objectives: To summarize current evidences comparing laparoscopy versus laparotomy in the surgical management of ectopic pregnancy. Methodology: PubMed, Web of Science, Science Direct, EBSCO, and Cochrane Library were utilized to identify the articles. In the current review, all pertinent articles related to both our topic and other articles were used. Other articles not related to the objective of the review were excluded. The research team looked through a standardized format in which the data had been extracted. Results: According to PRSIMA guidelines, our study included 13 published studies that were registered to extract final data from a total of 110 studies found after searching the mentioned databases, which were then used for title screening. Some were excluded from screening of abstracts and others due to different inclusion criteria, after full-text review. These 13 studies were used to compare laparoscopy versus laparotomy in the surgical management of EP, establishing that laparoscopic treatment of EP may be the most beneficial method with the highest level of safety and efficacy. Conclusion: Laparoscopic surgery is increasingly being used as the method of choice for treating EPs. When compared to laparotomy, laparoscopic treatment for EP raises concerns about safety, viability and results in fewer postoperative adhesions. Laparoscopy is also more practicable and proven to be more efficient in terms of blood loss, requirement for blood transfusion, need for analgesia, and time of postoperative hospital stay.

Surgical Practice Patterns in the Management of Ovarian Torsion

<h3>Study Objective</h3> Ovarian torsion (OT) is a common gynecologic emergency with the potential for significant lifelong health and fertility sequelae. We aimed to evaluate surgical practice patterns in the management of patients with concern for OT, in particular factors associated with oophorectomy versus ovarian preserving surgery (OPS) and rates of minimally invasive surgery (MIS). <h3>Design</h3> Retrospective cohort analysis <h3>Setting</h3> Tertiary medical center <h3>Patients or Participants</h3> All patients presenting acutely with symptoms concerning for OT who underwent surgical management between 2016-2021. Patients with incidental torsion at the time of scheduled surgery were excluded from this analysis. <h3>Interventions</h3> Evaluation of patient demographics, background clinical context, imaging findings, and surgical variables including primary specialty, surgical approach, procedures performed, and perioperative outcomes. <h3>Measurements and Main Results</h3> One hundred twenty-six-patient underwent 129 surgeries for suspected ovarian torsion. Of this, 75 cases (59.52%) were confirmed to be torsed. In total, 73 (57.9%) patients underwent OPS while 52 (41.3%) underwent oophorectomy. Patients who underwent OPS compared to oophorectomy were noted to be significantly younger (mean age 23.3 vs 29.3, p = 0.012) and have a lower BMI (mean 25.0 vs 29.7, p = 0.011). The proportion of OPS cases varied significantly by subspecialty with OPS performed in 56.9% of cases performed by Obstetrics and Gynecology generalists, 67.7% of cases by minimally invasive gynecologic surgeons (MIGS), 6% of cases by gynecologic oncologists (GO), and 79% of cases by pediatric surgeons. This data is confounded by patient age, fertility goals, and concern for malignancy. 90.28% of OPS cases were performed via a MIS approach while 69.2% of oophorectomies were MIS. MIS rates varied significantly by surgical subspecialty: 88% among generalists, 96.7% among MIGS, 60% among gynecologic oncologists, and 60% among pediatric surgeons. <h3>Conclusion</h3> The surgical management of OT varies widely. Our data supports that age, BMI, and surgical subspecialty influence surgical approach and management.

8744 Factors Associated with Oophorectomy Among Pediatric Ovarian Torsion Patients

<h3>Study Objective</h3> Ovarian torsion (OT) is the fifth most common gynecologic emergency, with one-third of cases occurring in females younger than 20 years-old. We aimed to evaluate factors associated with oophorectomy at the time of surgery for suspected OT in our pediatric population. <h3>Design</h3> Retrospective cohort analysis. <h3>Setting</h3> Tertiary, academic medical center. <h3>Patients or Participants</h3> Patients less than 18 years of age undergoing surgery for suspected ovarian torsion between 2016-2021. <h3>Interventions</h3> Evaluation of patient demographics, presentation timeline, imaging characteristics, and surgical variables associated with oophorectomy as well as perioperative outcomes. <h3>Measurements and Main Results</h3> Forty-five pediatric patients underwent surgical management for suspected ovarian torsion. Five patients were excluded for planned management of antenatally diagnosed ovarian masses, of which 3 underwent oophorectomy. Of the 40 included patients, 26 (65%) were confirmed to be torsed intra-operatively. Seventeen of these patients (66%) underwent ovarian preserving surgery (OPS) while 9 (34%) underwent unilateral oophorectomy (UO). Between the UO and OPS group, there were no differences in age or race. There were no differences in ultrasound findings including absent flow, enlarged ovary, and peripheral follicles; however, the UO group had significantly larger associated ovarian masses (12.48cm vs 8.06cm, p = .015). The median time from presentation to surgical start was 480 minutes (IQR 336-800.75) in the OPS group versus 868 minutes (IQR 257.5-1353.5) in the UO group. There was no association with primary surgical service (Pediatric Surgery versus Gynecology) however time from presentation to OR was significantly faster amongst patients treated by gynecologists (p=0.018). 50% of oophorectomy patients had a minimally invasive approach compared to 78.6% in the OPS group; however, this varied significantly by surgical specialty. <h3>Conclusion</h3> Given the significant sequelae associated with oophorectomy, current standards in surgical management of OT recommend conservative, ovarian-preserving techniques. Our data supports that delayed time to surgery and larger adnexal masses are associated with oophorectomy at the time of surgical management.

Bilateral torsion of an ovarian dermoid cyst in a nullipara, exploratory laparotomy, right ovariectomy and left cystectomy: A case report

Background: Ovarian torsion is a common gynecological emergency prompt diagnosis and treatment results in favourable outcome. This may be unilateral or bilateral in rare cases. However, bilateral Adnexal torsion (AT) is a gynecological emergency which occurs in approximately 2.7-3.5% of women of all ages globally. Aim: To present this uncommon clinical condition and offer management modality. Presentation of case: AC was a 28 -year- old nulliparous woman, who presented to our institution with a history of sudden onset of severe lower abdominal pain and nausea. On physical examination, she was acutely ill-looking, in mild painful distress, and her vital signs were within normal limits. On abdominal examination, there was no distension but there was lower abdominal tenderness, with muscle guarding. A pelvic examination revealed bilateral adnexal tenderness. Ultrasound examination showed a right ovarian cyst of size about 9 × 7 cm poor visualization of the left ovary. An impression of torsion of right ovarian dermoid cyst was made. She had exploratory laparotomy for ovarian torsion, right ovariectomy and left cystectomy. Her post-operative period was uneventful and was discharged in her 6th post-operative day in stable clinical state. Conclusion: We have presented 28-year-old nullipara who had bilateral ovarian and laparotomy with cystectomy. Prompt intervention of similar cases results in better prognosis.

The effect of medical ozone therapy in addition to ovarian detorsion in ischemia reperfusion model

This study aimed to investigate the protective effect of ozone therapy on ovarian reserve, number of ovarian follicles, ovarian morphology in a rat ischaemia reperfusion (IR) injury model. Twenty-four, Wistar Hannover rats were included. The rats were divided into three groups as control, detorsion-only, and ozone therapy + detorsion groups. There was a statistically significant difference in the follicular damage and inflammation scores between the study groups (p = .019, p = .002, respectively). The highest AMH decrease was observed in the detorsion-only group (p = .012). The total damage score was higher in the detorsion-only group than the ozone therapy + detorsion group. Preantral, small and large antral follicle numbers were less in the detorsion-only group than the ozone therapy + detorsion group. The highest postoperative day 7 TAS level was in the ozone therapy + detorsion group. TOS levels did not differ significantly between the study groups. The combination of the ozone therapy with ovarian detorsion is more effective in protecting the ovarian reserve than ovarian detorsion-only. Impact Statement What is already known on this subject? Adnexal torsion is a common gynecological emergency in reproductive-age women. The recommended management is the detorsion of the adnexal pedicle in patients with fertility desire. What do the results of this study add? The combination of the medical ozone therapy with conventional surgical ovarian detorsion is more effective in the protection of the ovarian reserve compared to surgical ovarian detorsion. What are the implications of these findings for clinical practice and/or further research? This study speculates that medical ozone therapy in addition to conventional surgical ovarian detorsion could preserve ovarian reserve and function if confirmed in further clinical studies.

LEFT ADNEXAL TORSION IN ADOLOSCENT: A CASE REP0RT

Adnexal torsion is the fifth most common gynecologic emergency usually associated with benign functional ovarian cysts or benign teratomas.Adnexal torsion usually presents as sudden onset colicky lower abdominal or pelvic pain associated with nausea or vomiting often preceded by jerky movement like weight lifting. If ovarian torsion is suspected, early diagnosis withtimely intervention is necessary to preserve ovarian function and future fertility.This is a case report of 14-year-old girl with history of acute onset lower abdominal pain diagnosed as torsion left ovarian cyst which was managed by emergency laparotomy and left adnexectomy.

A Case-series on Clinical and Surgical Findings of Ovarian Torsion

Background: Ovarian Torsion (OT) is a common gynecological emergency. Clinical presentation is nonspecific, and diagnosis is based on a high index of suspicion. Current recommendations strongly are based on ovarian support. Objectives: To assess clinical findings and therapeutic approach of patients diagnosed with OT. Materials &amp; Methods: In this retrospective study 104 patients with confirmed OT in surgery were investigated. Clinical symptoms, laboratory indices, ultrasonography finding, and therapeutic approach were collected from hospital records of patients from 2001 to 2021. Results: The Mean±SD age of patients was 34.7±14.1 years old. The Mean±SD duration from hospitalization to surgery was 6.4±3 hours. The most common symptom in patients was abdominal pain (100%) followed by nausea and vomiting (76.9%). Ovarian cyst (71.2%) was the most gynecologic etiology of OT. Local tenderness (92.3%) and rebound tenderness (46.2%) were the most prevalent sign in physical examination. Necrotic ovary was found in 60 patients (57.7%) at surgery. Detorsion was possible in only 26 patients (25%). Conclusion: This study revealed that most objective findings in patients were nondifferential. The majority of patients with OT were in the reproductive ages, but just one fourth of them treated with conservative management.

Administration of hemin ameliorates ovarian ischemia reperfusion injury via modulation of heme oxygenase-1 and p-JNK/p-NF-κBp65/iNOS signaling pathway

AimsOvarian torsion is the fifth common gynecological emergency that can affect females of all ages particularly during reproductive age and its management by detorsion leads to ovarian ischemia reperfusion (IR) injury. Therefore, prophylactic measures are required to protect the ovarian function after detorsion. So that, our study aimed to assess the effect and underlying mechanisms of heme oxygenase-1 (HO-1) inducer; hemin against ovarian damage induced by IR injury in rats. Main methodsFemale rats were divided into: sham group, hemin group, ovarian IR (OIR) groups with and without hemin treatment. Serum levels of reduced glutathione (GSH) and interleukin 1 β (IL-1β) were measured in addition to ovarian levels of malondialdehyde (MDA), nitric oxide (NO) and superoxide dismutase (SOD). Ovarian phospho-Janus kinase (p-JNK) levels and gene expressions of HO-1 and inducible nitric oxide synthase (iNOS) were determined. Moreover, histopathological changes and expressions of phospho-nuclear factor kappa B p65 (p-NF-κB p65) and cleaved caspase-3 were done. Key findingsTreatment of OIR rats with hemin led to significant attenuation of ovarian damage through histological examination which was associated with significant increase in ovarian expression of HO-1, ovarian SOD and serum GSH levels with significant decrease in ovarian p-JNK levels, expressions of p-NF-κB p65, iNOS and cleaved caspase-3 in addition to serum IL-1β levels. SignificanceThe protective effect of hemin can be attributed to the increased expression of HO-1 which showed antioxidant, anti-inflammatory and anti-apoptotic effects. Therefore, hemin can be administered to prevent ovarian IR injury which occurs after detorsion.

The role of trimetazidine in ischemia/reperfusion damage treatment in an ovary torsion model experimentally induced in rats

The aim of this experimental animal study was to investigate the histopathological and biochemical efficacy of trimetazidine (TMZ) in decreasing ovary damage in an ovary ischaemia/reperfusion (I/R) model in the rat. A total of 35 Wistar albino female rats were randomly separated into five groups, n = 7 per group: Group 1: Sham (S) was only given a laparotomy procedure. Group 2: Ischaemia (I) group with 2-hour ischaemia using a vascular sutur. Group 3: Ischaemia/Reperfusion (I/R) group with 2 hour ischaemia and 2-hour reperfusion. Group 4: Sham + 10 mg/kg orally TMZ (S + TMZ). Group 5: I/R + 10 mg/kg oral TMZ (I/R + TMZ) group with 2 hours ischaemia and 2 hours reperfusion after the administration orally 10 mg/kg oral TMZ. Two daily doses of TMZ were orally administered to Group 4 (S + TMZ) and Group 5 (I/R + TMZ) for three days. TMZ significantly decreased vascular congestion, haemorrhage, and polymorphonuclear leukocyte infiltration in group 5 compared to group 3 (p < .05). Despite TMZ decreased the malondialdehyde, total oxidant status, and oxidative stress index values, these decreases were not statistically significant (p > .05). TMZ which is an antioxidant agent can efficiently prevent in I/R damage in rat ovaries but further studies are necessary in order to implement it in the clinical settings. IMPACT STATEMENT What is already known on this subject? Adnexial torsion is the most common gynecological emergency and there are no specific clinical, laboratories, or radiological findings for adnexal torsion. Unfortunatelly, the currently accepted treatment is adnexal detorsion. Cytoprotective effects of Trimetazidine (TMZ), an antianginal drug, are well-defined and it has been demonstrated to improve oxidative stress markers and limits membrane damage induced by reactive oxygen species and protects tissues from free radicals with its antioxidant effects. The aim of this study is to investigate the effects of TMZ in experimentally induced adnexal torsion in rats and to investigate possible effects in maintaining ovarian reserve to prevent I/R damage or reperfusion damage. What do the results of this study add? Our study showed that TMZ significantly decreased vascular congestion, haemorrhage, and PMNL infiltration. TMZ decreased the malondialdehyde, total oxidant status, and the oxidative stress index values, but these decreases were not statistically significant. What are the implications of these findings for clinical practice and/or further research? Although various antioxidant drugs and chemicals have been used to protect the ovaries against I/R damage, they have not been demostrated to prevent it completely. TMZ, an antioxidant efficacy agent, has been shown to prevent ovarian I/R damage by suppressing inflammation in terms of histopathological parameters. Further studies involving a greater number of experimental animals are required before using TMZ for the treatment of humans with I/R damage in the clinical setting.

Torsion of ovarian teratoma in a child before menarche

Ovarian torsion is the fifth most common gynecological emergency. It affects women of reproductive age. It frequently results from dermoid and benign functional cysts. Patients suspected of ovarian torsion may be investigated with ultrasonography, computed tomography, magnetic resonance imaging, and diagnostic laparoscopic surgery. Ovarian torsion has rarely been observed in pediatric patients. It is difficult to diagnose early, and surgery is required to preserve fertility. This is the case of an 11-year-old pre-menarche girl who visited our hospital thrice for recurrent abdominal pain and vomiting. During her third visit to the emergency room, the patient underwent abdominal and pelvic computed tomography, which revealed a right dermoid cyst or an epithelial cell ovarian tumor torsion. The patient underwent an emergency laparoscopic salpingo-oophorectomy. Intraoperatively, an edematous and hemorrhagic ovarian torsion, twisted thrice, was identified on the right adnexa. Abdominal pain is a common symptom among children, and it has various causes. Ovarian tumors or torsions are rare among pre-menarche female patients, and these entities do not present with prominent symptoms. Thus, their diagnosis is difficult, as seen in this case. Early diagnosis is necessary to preserve the ovarian function.

ADNEXAL TORSION - STILL A DIAGNOSTIC CHALLENGE

Adnexal torsion is a gynecological emergency. It is dened as the partial or complete rotation of the adnexa around its ovarian vascular axis that may cause an interruption in the ovarian blood ow.1 With a reported prevalence of 2.7% in all cases of acute abdominal pain, adnexal torsion is the fth most common gynecological emergency.2 Early diagnosis is extremely important in all cases for the vitality of ovary but is more signicant in young women since it may dictate future fertility. Diagnosis of ovarian torsion is extremely challenging. Patients can have variable and nonspecic clinical symptoms making the differential diagnosis enigmatic. Hence clinical suspicion and timely intervention are very crucial .We report a case where there was failure to recognize ovarian torsion as a differential diagnosis during initial assessment.

VP05.22: Unexpected transvaginal sonography findings on acute pelvic pain: case report

Acute pelvic pain may be the manifestation of various gynecologic and non-gynecologic disorders. Appendicitis is the most common non gynecological emergency and should be considered if appendix has not been removed. 25% of appendix are found in subcaecal and pelvic area. This type appendicitis usually has symptoms like suprapubic pain and urinary frequency. If there is rectal irritation, diarrhoea may be present. Rectal or vaginal tenderness is found more than abdominal tenderness. Microscopic hematuria and leucocytes may be found. Combination of TVS and TAS increase the success rate of diagnosis in female patients. A 21 yo woman complained suprapubic pain. Dysuria was felt for 1 week. WBC count was high. Erythrocytes and leucocytes were found in urine. Vaginal tenderness was found. Histology findings were consistent with inflamed appendix. Non-classical acute appendicitis should be considered during establish diagnosis of acute lower abdominal pain. TVS has it role to distinguish gynecologic or non gynecologic abnormality or combined. Images TVS: non-compressible, aperistaltic, laminated tubular structure without incomplete thin septae, and filled by appendicolith was visualised with anterioposterior measurements consistently 6 mm or greater; normal right ovary lay on iliaca vessel. Localised perforation may be suspected when there is focal absence of hyperechoic layer of the appendicular wall (the submucosa) or there is a collection fluid in surround of the appendix. TAS: The typical submucosal ring, detectable on transverse section of the inflamed appendix. Laparascopic view: pelvic-subcaecal appendicitis, the appendix lay on medial of right ovary. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Retrospective analysis of ovarian torsion incidence in 5186 women undergoing controlled ovarian hyperstimulation

Aim: Ovarian torsion (OT) is one of the common gynecologic emergencies in reproductive age women. In our study, it is aimed to make a retrospective evaluation of OT cases developed after controlled ovarian stimulation (COH) for in vitro fertilization (IVF) treatment.&#x0D; Material and Methods : This retrospective study was carried out in an IVF clinic between January 2015- December 2020 . Ten cases who definitely diagnosed as OT were included in this study. The medical records of these patients were examined. Data were analyzed according to demographic, clinicopathological, and sonographic findings. &#x0D; Results: Ten of 5186 IVF patients developed OT (10/5186; % 0.19) and all OT cases were PCOS. The mean age of OT patients was 27.3±4.1 and the mean body mass index (BMI) was 23.5±6.2 respectively. The mean number of retrieved oocytes was 21.46 ± 4.12. Laparoscopy was performed in all OT patients for detorsion of the ovaries. It was found that OT occurred more frequently on the right side (8/10;80%).&#x0D; Conclusion: OT is more common in cases with polycystic ovary syndrome (PCOS). The risk of OT is reduced by decreasing gonadotropin dosage as well as retrieved number of oocyte. Also, prefering frozen-thawed embryo transfer can decrease OT risk in PCOS patients.