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CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 99-101

Twisted paraovarian cyst with pregnancy during treatment of infertility – Laparoscopic removal


1 Department of Obstetrics and Gynecology, Vardann Maternity Home, Mumbai, Maharashtra, India
2 Anaesthesiologist, Vardann Maternity Home, Mumbai, Maharashtra, India
3 Gynecologist, Paranjpe Maternity Home, Mumbai, Maharashtra, India

Date of Web Publication8-Dec-2015

Correspondence Address:
Sumit Paranjpe
Paranjpe Maternity Home, 28/b "Savla Sadan" Building, R. C. Marg, Chembur - 400 071, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2907.171214

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  Abstract 

Paraovarian cysts constitute approximately 10% of all adnexal masses. Here, we present a case of a 7-week pregnant woman with a paraovarian cyst. The cyst was approximately the size of a 24-week pregnancy. The patient came with acute abdominal pain due to torsion of the paraovarian cyst. The conception following clomiphene citrate (CC) was a part of the treatment of infertility. In this case, CC was started without any investigations. From this case, we would like to suggest that even before starting a simple treatment such as clomiphene for infertility, a baseline ultrasound is essential.

Keywords: Clomiphene induction, cyst, laparoscopic removal, paraovarian, torsion


How to cite this article:
Shah N, Shah V, Paranjpe S. Twisted paraovarian cyst with pregnancy during treatment of infertility – Laparoscopic removal. IVF Lite 2015;2:99-101

How to cite this URL:
Shah N, Shah V, Paranjpe S. Twisted paraovarian cyst with pregnancy during treatment of infertility – Laparoscopic removal. IVF Lite [serial online] 2015 [cited 2020 Jan 26];2:99-101. Available from: http://www.ivflite.org/text.asp?2015/2/3/99/171214


  Introduction Top


Clomiphene citrate (CC) is one of the first medications employed as an ovulation-inducing agent and enjoys widespread use by obstetrician/gynecologists and reproductive endocrinologist/infertility specialists.[1]

Clomiphene is often overused. Many well-controlled studies have demonstrated that pregnancy is most likely to occur during the first 3–6 ovulatory cycles of clomiphene and therapy beyond that time is not recommended. Yet, we still see women who have been on clomiphene for much longer times, sometimes without even a semen analysis.

Pregnant women have a greater risk of torsion of the adnexa than nonpregnant women (12–18% of ovarian torsion occurs during pregnancy). Women treated with fertility drugs who develop ovarian hyperstimulation syndrome have a greater risk of torsion with pregnancy than those who do not become pregnant.[2]

A prompt diagnosis and treatment of ovarian torsion helps the preservation of the fallopian tube, ovarian function, and the patient's fertility.[3]

Here is a rare case of twisted paraovarian cyst of 24 weeks size managed laparoscopically, with a pregnancy of 7 weeks.


  Case Report Top


A 22-year-old female presented to the hospital with acute abdomen along with 2 months of amenorrhea. On asking a detailed history, the patient was previously diagnosed as primary infertility elsewhere and was given CC for induction ovulation. The patient gave no history of bleeding or spotting per vaginum. On per abdominal examination, a soft cystic mass extending up to the umbilicus was felt.

Laboratory investigations including hemoglobin, total leukocyte count, differential count, and routine and microscopic examination of the urine were found to be normal. A urine pregnancy test was positive. Hence, an ultrasound was performed giving a differential diagnosis of right paraovarian/ovarian/adnexal cyst of about 20 cm with a live intrauterine pregnancy of 7 weeks.

Since it was an acute abdomen, an operative laparoscopy was performed. It was done under spinal anesthesia with a very low CO2 pressure of 10.

During laparoscopy, torsion of the right paraovarian cyst was seen with 3 twists [Figure 1] and [Figure 2]. The cyst was punctured and drained [Figure 3]. Moreover, a cystectomy was done. Both sides of ovaries and tubes were normal.
Figure 1: Twisted paraovarian cyst

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Figure 2: Pedicle with 3 twists seen

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Figure 3: Cyst seen after puncture and gravid uterus seen

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The procedure was completed, and the patient was put on progesterone supplements, and the pregnancy was allowed to continue.

Histopathology showed ciliated, columnar cells with underlying matrix and some inflammatory cells. Thus, confirming a paraovarian cyst.


  Discussion Top


Common side effects of CC include hot flashes, headache, abdominal bloating and pain, nausea and vomiting, mood changes, and breast tenderness. Visual symptoms of blurring, double vision, or seeing spots are seen in 1–2% of women and usually resolve when CC is stopped.

There is no mention of CC use related to paraovarian cysts.

It is generally accepted that the preferred imaging modality for the adnexa is ultrasound.[4],[5]

The prevalence of paratubal or paraovarian cysts in a normal population is not known due to inadequate data of these cysts in healthy women.[6]

Other paraovarian cystic lesions include cystadenoma and adenofibroma, lymphangioma, ependymoma, multicystic endosalpingiosis, which have been associated with tamoxifen therapy.[7]

In our day to day life, we see some people around us who are habituated to popping pills. However, this trend should be totally discouraged among doctors. Therefore, hence forward doctor should be encouraged to do at least a baseline sonography before just penning prescriptions of CC to women who are anxious for a child.

Being an uncommon surgical emergency with no definitive diagnostic signs, its diagnosis is often delayed, which may result in causation of irreversible damage to the fallopian tube and the ovary if involved. Surgeons should be aware of this condition so that an early diagnosis can be made.

In our case, the laparoscopy procedure was uneventful. The cyst was excised, and the pregnancy continued.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Barloon TJ, Brown BP, Abu-Yousef MM, Warnock NG. Paraovarian and paratubal cysts: Preoperative diagnosis using transabdominal and transvaginal sonography. J Clin Ultrasound 1996;24:117-22.  Back to cited text no. 1
    
2.
Regad J. Mechanism of Isolated fallopian tube torsion in a gravid uterus. Gynecol Obstet 1933;27:519-35.  Back to cited text no. 2
    
3.
Thakore SS, Chun MJ, Fitzpatrick K. Recurrent ovarian torsion due to paratubal cysts in an adolescent female. J Pediatr Adolesc Gynecol 2012;25:e85-7.  Back to cited text no. 3
    
4.
American College of Obstetricians and Gynecologists. ACOG practice bulletin. Management of adnexal masses. Obstet Gynecol 2007;110:201-14.  Back to cited text no. 4
[PUBMED]    
5.
Liu JH, Zanotti KM. Management of the adnexal mass. Obstet Gynecol 2011;117:1413-28.  Back to cited text no. 5
    
6.
Tailor A, Hacket E, Bourne T. Ultrasonography of the ovary. In: Anderson JC, editor. Gynecologic Endoscopy. London: Churchill Livingstone; 1999. p. 334-49.  Back to cited text no. 6
    
7.
McCluggage WG, Weir PE. Paraovarian cystic endosalpingiosis in association with tamoxifen therapy. J Clin Pathol 2000;53:161-2.  Back to cited text no. 7
    

 
  Authors Top

About the Author
Dr. Nitin Shah is a specialist in Endoscopic operations in the field of Obstetrics and Gynecology. He serves as an honorary consultant Endoscopic surgeon at various hospitals including Wadia hospital, Railway hospital, Umrao hospital and Tunga hospital. He completed his MS in 2006 from Seth GS Medical College and KEM Hospital. He holds a diploma in Gynaecological Endoscopy (from Germany) and is certified in IVF and Test Tube Baby procedures (from Israel). His research interests includes 3D Laparoscopic and Hysteroscopic surgeries. He has also authored a chapter on Rh Isoimmunization in the text book of high risk cases in Obstetrics.


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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