A rare cause of abdominal pain in early pregnancy

Abstract

twisted, necrotic left tube and ovary were found ( Figure 1). A laparoscopic left salpingo-oophorectomy was performed. The histology report showed extensive haemorrhage and necrosis of the left ovary and fallopian tube, but no evi dence of trophoblastic tissue to suggest ectopic pregnancy.Subsequently, a pelvic ultrasound scan showed a viable intrauterine pregnancy equivalent to eight weeks' gestation. She had vaginal progesterone support for the rest of the fi rst trimester. Her 20-week anomaly scan was normal and she gave birth to a healthy baby girl, at 39 weeks of gestation, by caesarean section for breech presentation. DiscussionTorsion of an ovary and fallopian tube is rare in pregnancy and poses a considerable diagnostic challenge. 1,2 The prevalence of this condition has been estimated at 1 in 1800, 3 but we believe this to be an overestimation.In the case reported here, the pregnancy was initially unrecognised because of a false-negative pregnancy test kit. False-negative qualitative urine pregnancy tests are well documented. 4-8 Qualitative point-of-care and home pregnancy tests both have limitations and are not 100 per cent sensitive in detecting pregnancy. In one study, 5 only 44 per cent of 18 brands gave a clearly positive result at serum beta-human chorionic gonadotrophin (β-hCG) levels of 100mIU/ml. In other words, 56 per cent were falsely negative. In a woman of childbearing age with abdominal pain, we therefore suggest that a negative qualitative urine pregnancy test should be confi rmed by quantitative serum β-hCG measurement.Laparoscopic salpingo-oophorectomy was performed because the tissues appeared necrotic and persistent fever suggested early sepsis. The necrosis was subsequently confi rmed histologically. However, successful detorsion of twisted adnexa has been described regardless of delay in diagnosis and the appearance of the adnexum. 1 A 33-year-old woman was referred to the urology team with a four-day history of left loin pain, syncope and vomiting. She had tachycardia (108 beats per minute), a mildly raised temperature (37.3°C) and tenderness in the left lumbar region and iliac fossa. Urine pregnancy test was negative, but a trace of haemolysed blood was found on ward urinalysis. An intravenous urogram showed no ureteric obstruction. A diagnosis of pyelonephritis was made.However, her pain failed to settle on antibiotics, and a gynaecological opinion was sought two days after admission. On questioning, her last menstrual period transpired to be three months before presentation. She was cardiovascularly stable, but examination revealed abdominal peritonism, a bulky uterus and cervical excitation. A repeat pregnancy test was positive. A clinical diagnosis of ectopic pregnancy was made.The authors present a case history of a pregnant woman with abdominal pain who was found to have torsion of an ovary and fallopian tube. This condition is rare in pregnancy and the case highlights the diagnostic challenges involved. Twisted adnexum Necrotic left tube Necrotic left ovary a b Figure 1. La...