23 year old primigravida presented to the antenatal clinic with 7 months amenorrhoea and pain abdomen and 3 episodes of vomitings, since one day. Her menstrual cycles were regular. She described the pain as sharp non-radiating type of pain in the right iliac fossa with sudden onset, with no relieving factors. She gave no history of vaginal bleeding or discharge. There was no history of diarrhoea, constipation, fever, urinary complaints or any recent illness. She conceived spontaneously. She had regular antenatal checkups. Her first & second trimesters were uneventful. No significant past medical and surgical history noted.
On examination, patient was conscious, coherent with pulse 82/min, blood pressure 130/80 mm of hg, temperature normal, cardiovascular and respiratory systems normal. Abdominal examination revealed fundal height corresponding to 30 weeks gestation. Uterus was irritable. There was a single fetus in longitudinal lie with breech presentation. Fetal heart rate was good & regular. There was severe tenderness in right iliac fossa. On vaginal examination, cervix was posterior, 50% effaced, 2 cm dilated, and breech presentation.
All her blood and urine investigations were within normal limits. Ultrasonography revealed a 10 × 5 cm single anechoic cystic lesion in right iliac fossa with single thin septation and no solid components. It also showed a single intrauterine live fetus in longitudinal lie with breech presentation of 30 wks gestational age. Estimated fetal weight-1629 gms, Amniotic fluid adequate, placental position posterior upper segment with grade 2 maturity. No evidence of free fluid in the abdomen.
MRI showed extended breech presentation of the fetus and a large hyper intense mass lesion on the right side of the abdomen, outside the uterus measuring 10.4 × 5.0 cms suggestive of right ovarian cyst. (Figure 1, 2)
With the provisional diagnosis of twisted ovarian cyst, emergency laparotomy was done under regional anaesthesia. A 10 × 5 cm right ovarian cyst was found to be twisted around its pedicle by 3 rotations. After untwisting, cystectomy was done by carefully enucleating the cyst and separating it from the capsule. The cyst was sent for histopathological examination. (Figure 3)
Patient recovered with an uneventful postoperative period and was discharged on 9th post operative day. Her histopathology report showed benign serous cystadenoma of the ovary. She was followed up, her pregnancy continued unremarkably and she delivered an alive female baby of birth weight 2.75 kg at term gestation by caesarean section.