Background: The estimated incidence of adnexal masses in pregnancy range from 2% to 10%, with the majority resolving spontaneously.¹ Ovarian torsion (OT) is a rare complication of pregnancy with most occurring in the first or second trimester.² Prompt diagnosis and intervention is required to prevent irreversible sequela such as ovarian necrosis, peritonitis, reduction in reproductive potential and may also threaten the pregnancy. Antepartum diagnosis of OT can be challenging as clinical, imaging and laboratory findings are often non-specific.

Case report: We illustrate a 28-year-old woman, G3P2 who presented with right sided abdominal pain at 17 weeks gestation with a monochorionic diamniotic twin pregnancy. Her previous obstetric history included a vaginal delivery and an elective caesarean section for breech presentation at term. Her antenatal care had otherwise been unremarkable. The pain was acute in onset and associated with nausea and vomiting. Her observations were stable and she was afebrile, preliminary blood investigations revealed normal inflammatory markers.  Clinical examination revealed tenderness in the right lower quadrant and no other signs of an acute abdomen. Pelvic ultrasound demonstrated an uncomplicated twin pregnancy and a right ovary containing a 4.5cm cyst with no definitive vascularity on colour Doppler suggestive of ovarian torsion. The patient clinically improved with expectant management and analgesia and was discharged after 2 days of observation. She represented the same day with worsening right sided pain, vomiting, low grade temperature and clinical features of an acute abdomen. The inflammatory markers were raised during readmission with CRP of 30 mg/L and WCC of 13.7 x10⁹/L (neutrophilia). An emergency exploratory laparoscopy took place after perioperative use of a tocolytic, which confirmed torsion of the right ovary and a 4cm ovarian cyst. The ovary was detorted and the cyst drained where fluid was sent for cytology. The patient made an uneventful postoperative recovery and discharged 2 days following surgery. She proceeded to have an uneventful pregnancy and delivered at term by caesarean section where the ovaries were found to be normal in appearance.

A video presentation of a laparoscopic detorsion and cyst drainage during second trimester of pregnancy will be demonstrated. A review of the existing literature of the available diagnostic work up, treatment options and the challenges faced in managing this gynaecological emergency in pregnancy will be discussed.