Drainage by Ovarian Incision for the Treatment of Massive Ovarian Edema Torsion During Pregnancy

Abstract

Massive ovarian edema (MOE) is a rare benign condition presenting as unilateral ovarian enlargement with stromal edema, and only a limited number of MOE cases during pregnancy have been reported. MOE is often complicated by ovarian torsion, which requires detorsion. Although the diagnosis of MOE can be made using ultrasound and magnetic resonance imaging, its rarity makes diagnosis difficult, usually leading to overtreatment. Preserving the ovary in the treatment of MOE torsion is essential, and consideration of oophoropexy after detorsion is often reported. However, fixing an enlarged ovary to the pelvic wall in the limited space of the pelvis is challenging. Herein, we present a case of MOE of the right ovary diagnosed at the fifth week of gestation after ovulation induced by clomiphene citrate. Torsion of the ovary occurred in the seventh week. We achieved preservation of the ovary through laparoscopic surgery with detorsion and drainage by making a small incision to the enlarged ovary, resulting in an immediate size reduction. There was no recurrence of torsion or MOE throughout the pregnancy, and the patient gave birth in the 39th week of gestation. This is the third reported case of MOE after ovulation using clomiphene citrate, and it highlights the effectiveness of treatment with detorsion and a small incision of the ovary via laparoscopic surgery in patients with MOE torsion during pregnancy.

Keywords: clomiphene citrate; laparoscopy; massive ovarian edema; ovarian torsion; ovulation induction; pregnancy.

Figure 1. Transvaginal ultrasound imaging and the time course of ovarian changes

A: Image of the preoperative ovary. Enlargement of the right ovary can be observed (white arrowhead), whereas the gestational sac is detected in the uterine cavity (yellow arrowhead). The right ovary measures 93x70 mm. B: Image of the preoperative ovary. Color Doppler imaging of the right ovary shows no abnormal blood flow. C: Image of the ovary at the one-week follow-up after discharge. The right ovary measures 37x24 mm. D: Image of the ovary at one month after delivery. The right ovary measures 23x17 mm.

Figure 2. Pelvic magnetic resonance imaging findings

A: Axial T2-weighted image. A high signal is observed in the stromal region of the right ovary. B: Axial T1-weighted image. No sign of bleeding or hematoma in the right ovary is evident.

Figure 3. Laparoscopic findings

A: Enlargement of the right ovary is observed with a smooth, white, and edematous surface undergoing 360° clockwise torsion (white arrowhead). B: Small incision for biopsy of the right ovary placed opposite from the ovarian vessels, with observable edematous stroma.

Figure 4. Histopathological findings

An increase of spindle-shaped stromal-like cells in the ovary is observed, accompanied by edematous changes in the stroma (blue arrowhead). No malignant findings are noted (low-power field; hematoxylin-eosin stain).