Ovarian torsion: A case report
Gracelin Jebamalar.G1*, Kalaiyarasi2, Mahalakshmi3
1Staff nurse, Kauvery Hospital, Tennur, Trichy
2Nursing Incharge, Kauvery Hospital, Tennur, Trichy
3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy
Correspondence: M: +919361388804; Email: maha@kauveryhospital.com
Abstract
Ovarian Torsion
Ovarian Torsion occurs when the ovary rotates around its supporting ligaments, twisting the accompanying blood vessels and lymphatics. A portion of the fallopian tube is commonly torsed along with the ovary and that’s the reason for the term ‘adnexal torsion’.
One estimate suggests that up 3% of women presenting to an emergency department with acute abdominal pain may have ovarian torsion. Although most cases occur during reproductive years the age range extends from prenatal to postmenopausal.
Turbo ovarian abscess
A turbo ovarian abscess (TOA) is one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis.
Previously, nearly 20% of hospitalized PID cases were found to have a TOA. Of note, women who are HIV positive with PID generally have a slower clinical resolution of the disease and therefore an increased risk of the development of a TOA.
Endometriotic cyst
An ovarian endometrioma is a cyst that’s filled with the same fluid that’s in the lining of the uterus (endometrium). Sometimes they are called `chocolate cysts`. Endometriomas are cystic lesions that stem from the disease process of endometriosis. Endometriomas are most commonly found in ovaries. They are filled with dark brown endometrial fluid. Endometriosis is estimated to occur in roughly 6-10% of women.
Case presentation
A 36 years’ young lady presented with sudden onset of abdominal pain radiating to right iliac fossa that was associated with vomiting. The pain was localized. Previously she had similar episodes that she thought it was normal, and resolved usually with oral analgesics.
The patient has past history of seizure disorder (2013), last episode of seizure was in May 2023. She was on treatment with Tab. Dicorate Er 125 mg (Divalproex) She had a seasonal wheezing also. Later she was affected by viral encephalitis in 2016 and was ventilated and extubated during that period. During that time, she underwent tracheostomy surgery and later it was de-cannulated. Then she was treated well and she was on regular follow up.
She had no history of chest pain, loose stools, palpitations, hematuria or fever. She had no other bowel (or) urinary symptoms. The patient had no history of abdominal trauma. Her menarche occurred at age of 16 and her menstrual cycle was regular. On the 30th days of cycle dysmenorrhea present. She had no other gynecological symptoms.
On Examination
The patient was conscious and oriented. Her vital signs were Temp: 98.4°F, BP: 110/60mmhg, HR: 84 b/mts, RR: 22 b/mts, Spo2: 97% at RA. CVS: S1&S2 (+), RS: BAE(+) , P/A: soft, CNS: NFND.
An abdominal examination revealed tenderness present in right iliac fossa.
Her GRBS is 122mg/dl,
Blood investigations were done like CBC, Electrolytes, LFT, RFT, PT/INR, APTT, Serology, Ca125, AFP, and Blood grouping & typing. ECG & chest X-ray were also taken.
- Ca125: 56.20
- AFP: 4.15
ECG, Chest X-ray & all the basic blood investigations were normal. CECT abdomen and pelvis was done. It revealed enlarged cystic right ovary with thickened edematous pedicle with minimal free fluid and surrounding inflammatory changes in right side of pelvis. It was advised to consider right ovarian Torsion.
Management
Her pain score was 10. Initially the patient was treated with:
- Paracetamol 1gm IV
- Tramadol 50mg IV
- Emeset 4mg IV
- Pantocid 40mg IV
Fluid management was with IVF Isolyte M, two pints & IVF NS, one pints, which were given.
Onco surgeon saw the patient & assessment was done. Diagnostic laparoscopic+ bilateral ovarian cystectomy was planned based on pre-operative diagnosis of right ovarian cyst torsion/Turbo ovarian abscess/Endometriotic cyst.
Pre-operatively neurophysician opinion was obtained for known case of seizure disorder & surgery fitness had given for surgery & advised to withhold Tab. Dicorate ER 125 mg and to give Inj. Sodium valporate 200mg Q8th hourly
Patient was hemodynamically stable and procedure was done under general and epidural anaesthesia. (Laparoscopic bilateral ovarian cystectomy and peritoneal wash).
Operative notes
Findings
- Ruptured right ovarian endometriotic cyst of size 4×3cm with spillage of content in the left ovarian endometriotic cyst of size 3×3cm present.
- Right hydro salpinx/bulky uterus.
- Adhesions of uterus with rectum noted.
Procedure
- One 10mm camera port inserted
- 2-5mm working port inserted.
- Above findings are noted.
- Bilateral ovarian cystectomy done. Through wash given.
- Specimen retrieved through BERT bag (Sterile laproscopic tissue/specimen retrieval bag) & sent for histopathology for further evaluation.
- Port suture with `J` vicryl, skin clip.
Postoperatively gynecologist opinion was obtained. They assessed the patient, On their examination patient was conscious, oriented, febrile. Temp: 97.8°F, HR: 78 b/mins, RR: 20 b/mins, Spo2: 98% RA, BP: 110/70 mmhg, CVS: S1S2 (+), RS: NVBS (+), P/A: soft, wound & dressing intact. L/E: No P/V bleed.
After examination, they advised to give Inj. Leuprolide 3.75ml IM. Then they planned for Cabergoline regimen at the time of review. Patient was symptomatically better and were discharged with stable conditions.
Health Promotion
Prevention is better than cure. Common risk factors for ovarian torsion include ovarian mass, stromal edema, internal hemorrhage, hyper stimulation. Ovarian Torsion must be treated.
Nursing management
Hemodynamic monitoring
Our team aggressively managed this patient. We hourly monitored the patient by using non-invasive BP, pulse rate and quality, skin temperature and colour, papillary refill time, pulse oximeter and invasive when required. Whenever the patient had complaints they were managed immediately.
The patient had pain (pain score was 4) Temp: 97.6°F, PR: 94b/mts, RR: 22b/mts, Spo2: 97% in RA, BP: 110/80mmhg. Provided comfortable position (supine) & analgesics were given.
Intake and output monitoring
The patient had poor oral intake due to NPO status and pain. Periodically we monitored intake and output every 2 hrly to rule out dehydration.
We educated patient and their family members regarding more intake of fluids. Closely monitored the amount and colour of urine. Watched over patient health status for symptoms such as muscle cramping, lethargy, giddiness, etc and ruled out dehydration (fluid volume deficit).
Fluid management
Fluids were administered through IV at first for dehydration & NPO.
IVF NS/RL was given at 100ml per hr. After clearing the NPO, liquid diet was started; encouraged the patient to take more oral liquids like juices, tender coconut water, buttermilk, water. Then slowly oral liquids were changed to soft diet then IV Fuids were stopped, and adviced to take more orals.
Pain management
Patient had moderate pain at surgical site, the pain score was 5. Iinitially the patient was treated with analgesics like Inj. Tramadol 50mg IV and Inj. Emeset 4mg IV. Provided comfortable position and rest.
Nutritional support
For any patient to come out from their illness the nutrition part is very important. The nurse was focused on patient nutrition along with doctors and dietitians to avoid nutritional deficiency etc
Our team had taken the challenge and provided good nutrition with adequate calories, protein, fibre rich diet and supported with IV fluids when necessary.
Health education
Medication
Educated the patient and family members regarding taking medicine regularly and in correct time.
Abdominal (or) pelvic pain is common after surgery. Advised to take medicines properly as per doctor advice.
Diet
Constipation is common after surgery. So. we had advised to take more protein and fibre rich diet for reliving constipation as well as wound healing process.
Surgeon may recommend some stool softener medicine to take it in night time like Syp. Cremaffin plus 15 ml PO (Sodium picosulphate +liquid paraffin + milk of Megnesia).
Advice on Activity
- Avoid driving for 2-4 weeks (or) long if on pain medication.
- Walk as much as possible to prevent from compilation like blood clots.
- Avoid heavy lifting for some more weeks.
- To do deep breathing exercises daily sunlight exposure and do some exercises.
Wound care
Advised that she should be able to shower 72 hr after doing surgery. Advised the patient to wash gently on the surgical site after that dry it with soft cotton cloth.
To wear clean clothes and avoid wearing of tight inner wear and cloths to avoid compression on surgical site.
Note if any redness, swelling, warmth (or) abnormal discharge from surgical site as they may need immediate medical attention as soon as possible.
Psychological support
Our team gave emotional and psychological support to the patient and their family members. Then provided the best communication and coordination with other team members so patient and their family members were well satisfied and the patient’s health status was improved well and obtained positive outcomes.
Conclusion
Although ovarian torsion is not common, it is a medical emergency. Surgery will be necessary to untwist or remove the ovary. If ovarian torsion is suspected, timely intervention with diagnostic laparoscopy and surgery are indicated to preserve ovarian function and future fertility. A minimally invasive surgical approach is recommended with detorsion and preservation of the adnexal structures regardless of the appearance of the ovary.
Ms. Gracelin Jebamalar.G
Staff Nurse
Ms. Kalaiyarasi
Nursing Supervisor