Ovarian cyst, torsion

Fernando L. Heinen MD*, Alfredo Camargo MD^#, Patricia Farias MD^#

*Pediatric Surgery, and ^#Imaging dept of Fetal Surgery Program Hospital Italiano de Buenos Aires, Argentina

This healthy G₁P₁ 29-year-old mother with uneventful gestation, has an ultrasound at 30 weeks. The examination demonstrates a single female fetus with a multilocular, 35 by 50 mm, pelvic cystic mass.

Initially there were 2 cystic structures one of them later regressed. Images 2 and 3 demonstrate a small amount of fetal ascitis, which later resolved. 

A follicular ovarian cyst was initially suspected and considered the most likely diagnosis. Teratoma and lymphangioma were also entertained as differential diagnosis. No other maternal or fetal abnormalities were found during the ultrasound monitoring of the pregnancy.

Postnatally the healthy, 3.300 g baby girl, presented with a similar cystic mass, measuring 35 mm in diameter, which was observed in several ultrasounds performed in a weekly basis.

Ultrasound at 50 days.

Against our counseling, the parents elected to watch and wait for spontaneous resolution of the cystic mass, despite signs of possible hemorrhage and torsion (low level of intracystic debris). Detailed explanations were given to the parents concerning the probable consequences to the remaining ovarian tissue adjacent to the cyst if torsion occurred. They refused treatment until 70 days of life as the baby remained healthy, thriving and totally asymptomatic. 

They had obtained medical information elsewhere and were anxious and reluctant to accept surgical management. At 70 days of life, as the mass remained unchanged, with similar ultrasound appearance, we decided to insist and emphasized the need for a proper diagnosis and videolaparoscopy was accepted by the family. 
Under general anesthesia a 5mm scope was inserted and a necrotic mass was observed. This mass was extremely mobile and fragile. Through a small Pfannenstiel suprapubic incision, the brown color cystic mass was confirmed to be a necrotic ovary. It was the left, and not the right ovary as it was expected pre- and postnatally. The tube was twisted 7 times and also appeared compromised. 

The left mass and tube were resected and send to pathology. 

The right ovary and tube were normal. The baby went home uneventfully; her parents were surprised she was quite and peaceful as never before (I assume she was in pain due to the torsion).
I wonder if we would have been able to resolve the torsion if we had operated on earlier, as soon as the "sonographical sign of complicated cyst were first observedâ€. I assume a follicular cyst as most probable diagnosis but pathology report is pending.