CASE REPORT

Ruptured ectopic pregnancy with contralateral adnexal

torsion after spontaneous conception
Andrea J. DiLuigi, M.D., Donald B. Maier, M.D., and Claudio A. Benadiva, M.D.
The Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, University of
Connecticut Health Center, Farmington, Connecticut

Objective: To describe a case of ruptured ectopic pregnancy and contralateral adnexal torsion after spontaneous
conception.
Design: Case report.
Setting: Tertiary university medical center.
Patient(s): A 23-year-old multiparous female with severe bilateral pelvic pain and a positive pregnancy test.
Intervention(s): Operative laparoscopy with detorsion of left adnexa, drainage of left ovarian hemorrhagic corpus
luteum cyst, right salpingectomy, and dilation and curettage.
Main Outcome Measure(s): Laparoscopy revealed a 5 cm hemorrhagic corpus luteum cyst of the left ovary, torsion
of the left ovary and fallopian tube, and a ruptured right ampullary ectopic pregnancy.
Result(s): Normal perfusion of left ovary and fallopian tube after detorsion, resolution of left ovarian hemorrhagic
corpus luteum cyst, patent left fallopian tube with chromopertubation, and successful removal of ectopic
pregnancy.
Conclusion(s): This is a unique case of adnexal torsion and contralateral ectopic pregnancy occurring after
spontaneous conception. (Fertil Steril 2008;90:2007.e1–e3. 2008 by American Society for Reproductive Medicine.)
Key Words: Adnexal torsion, ectopic pregnancy, pelvic pain, Doppler sonography

CASE REPORT or other pelvic infections. She reported condom use for con-
Approval from the Institutional Review Board at the Univer- traception. Her obstetric history was significant for three
sity of Connecticut Health Center was obtained for this case prior spontaneous pregnancies resulting in term vaginal
report. A 23-year-old gravida 4 para 3 woman with no history deliveries, one of which was a term intrauterine fetal demise
of infertility presented to the emergency department at our of unknown cause. She had no medical problems, was not
hospital with symptoms of severe bilateral lower quadrant taking any medications, and had no prior surgeries. The
abdominal pain. The pain was described as dull and constant patient denied smoking or drug use. The patient was married,
with episodes of sharp intermittent superimposed pain. The and she and her husband stated that they did not desire future
patient reported mild intermittent pelvic pain which started fertility.
4 days earlier and acutely worsened on the evening of admis- On presentation, the patient appeared to be in moderate
sion. Her last normal menstrual period was approximately distress owing to pain but was alert and lucid. She was
4 weeks before presentation, and she had been having afebrile and normotensive and had a normal heart rate and
minimal vaginal bleeding intermittently for the 2 weeks rhythm. Physical examination revealed bilateral lower quad-
before admission. She reported nausea with one episode of rant tenderness and a palpable left lower quadrant mass.
emesis on the evening of admission. There was no rebound or guarding noted. Speculum exam re-
The patient had regular menstrual cycles occurring every vealed approximately 30 mL of blood in the posterior fornix
28–29 days and lasting approximately 5 days. Her history and a closed cervix without lesions. A gentle bimanual exam
was significant for a chlamydia cervicitis 7 years before revealed a small anteverted uterus, bilaterally tender adnexae,
admission. She had no history of pelvic inflammatory disease and a palpable left adnexal mass. Transvaginal pelvic ultra-
sound revealed a normal-appearing uterus with a homoge-
neous endometrial stripe measuring 1.2 cm, a moderate
Received August 8, 2007; revised and accepted January 14, 2008. amount of heterogeneous free fluid in the cul-de-sac, and
The authors have nothing to disclose. a complex left ovarian mass which crossed the midline and
Reprint requests: Andrea J. DiLuigi, M.D., The Center for Advanced Re- was adjacent to the right adnexa. The mass measured 7.1 
productive Services, University of Connecticut Health Center, 263
Farmington Avenue, Dowling South Building, Farmington, CT 4.7 cm and contained a 4.1  4.6 cm area with a homogeneous
06030-6224 (FAX: 1-860-679-3639; E-mail: diluigi@uchc.edu). hypoechoic internal signal. Doppler sonography revealed

0015-0282/08/$34.00 Fertility and Sterility Vol. 90, No. 5, November 2008 2007.e1
doi:10.1016/j.fertnstert.2008.01.053 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
bilateral arterial and venous ovarian blood flow. The right
FIGURE 1
ovary was normal in appearance and measured 3.3  2.1
cm. The patient’s hemoglobin and hematocrit were 9.8 g/ Laparoscopic view of pelvis. A ¼ torsed left ovary
dL and 28.8%, respectively. Her white blood cell count was and fallopian tube; B ¼ uterus; C ¼ right fallopian
10,200/mL with no left shift, b-hCG was 130 IU/L, and tube with ruptured ectopic pregnancy.
progesterone was 2.6 ng/mL.
Emergent laparoscopy was performed for suspected rup-
tured left-sided ectopic pregnancy (Fig. 1). Approximately
250 mL of blood and clots was noted in the cul-de-sac. A 7
 5 cm left adnexal mass was noted. This was the left ovary
and fallopian tube, which were ischemic, edematous, and
torsed two times about the axis of the infundibulopelvic
and uteroovarian ligaments. The left ovary and tube initially
appeared dusky and gray colored and were immediately de-
torsed with a blunt probe. The ovary and tube appeared to
rapidly regain normal perfusion, as evidenced by their pink
color within approximately 2 min. The left ovary was also
initially noted to have a 5  5 cm complex cyst which ap-
peared to be consistent with a hemorrhagic corpus luteum.
This cyst ruptured with manipulation of the left adnexa dur-
ing the process of detorsion, yielding dark serosanguinous
fluid. Irrigation was performed, and no active bleeding was DiLuigi. Ectopic pregnancy contralateral torsion. Fertil Steril 2008.
noted. Inspection of the right adnexa revealed an ampullary
ectopic pregnancy with evidence of rupture through the me-
dial antimesenteric border. There was active bleeding noted of ruptured ectopic pregnancy with contralateral adnexal
through the site of rupture as well as blood and clot protrud- torsion after spontaneous conception.
ing from the end of the fallopian tube. The fimbriated end of
DeCherney and Eichhorn (1) reported a case of a 31-year-
the tube appeared to be somewhat clubbed. The right ovary
old gravida 1 para 0 woman with a heterotopic pregnancy and
appeared normal. Right salpingectomy was performed, given
contralateral adnexal torsion. However, this case differed
the extensive irreparable tubal damage and the patient’s pre-
from the present case in that the patient had a history of dieth-
operatively expressed wish to have a damaged tube removed
ylstilbestrol exposure and infertility, conceived using
to reduce her risk of ectopic pregnancy in the future. Chromo-
controlled ovarian hyperstimulation and intrauterine insemi-
pertubation before right salpingectomy revealed a patent left
nation, and had a heterotopic pregnancy.
fallopian tube which was completely normal in appearance.
Dilation and curettage was also performed to exclude the Recognized risk factors for ovarian torsion include adnexal
rare possibility of a coexisting intrauterine pregnancy as masses, controlled ovarian hyperstimulation, and pregnancy.
well as endometrial pathology such as endometritis. In fact, 12%–18% of ovarian torsion cases occur during preg-
nancy (2). There appears to be a right-sided predominance to
The patient’s postoperative course was uncomplicated and
ovarian torsion, although the reason behind this is unclear.
she was discharged home on the first postoperative day. She
Two theories have been proposed in an attempt to explain
had no further episodes of pain. The patient was started on
this finding. One proposes that the left side is somewhat pro-
ferrous sulfate after surgery, and her anemia resolved. After
tected from torsion, because it has less mobility owing to the
extensive counseling regarding all available contraception
sigmoid colon. The second theory suggests that the right-
options, the patient opted to start oral contraceptive pills
sided predominance is due to the different venous drainage
and stated that she was considering undergoing permanent
systems of the two ovaries (3).
surgical sterilization. Pathology revealed an implantation
site and chorionic villi in the right fallopian tube as well as The preferred treatment for ovarian torsion is detorsion.
normal secretory endometrium. Given the fact that tubal Laparoscopy is the surgical approach of choice, because it
rupture had occurred, b-hCG levels were followed on an is the least invasive and provides excellent outcomes. If rapid
outpatient basis until they were at <5 IU/L to confirm tissue reperfusion occurs, salvage of the adnexa may be
complete resolution of the ectopic pregnancy. accomplished. A recent review revealed that ovarian function
was preserved in 88%–100% of reported cases after surgical
DISCUSSION detorsion was performed (4).
Adnexal torsion and ruptured ectopic pregnancy both repre- The most common sonographic finding associated with
sent gynecologic surgical emergencies. These events are rel- ovarian torsion is a pelvic mass (5), although this nonspecific
atively rare, and exceedingly rare when occurring in finding can be seen with other diagnoses, such as ectopic
combination. This represents the first known reported case pregnancy. Because the present patient had a left adnexal

2007.e2 DiLuigi et al. Ectopic pregnancy contralateral torsion Vol. 90, No. 5, November 2008
mass and free fluid in the cul-de-sac on transvaginal ultra- uterus. Although migration of embryos from uterus to tube
sound, as well as a positive b-hCG level, her preoperative does occur after in vitro fertilization and embryo transfer, it
diagnosis was ruptured left-sided ectopic pregnancy. On ul- is less likely to have occurred in this case of spontaneous
trasound, it was difficult to delineate the boundaries of the pregnancy.
large left adnexal mass, because it traversed the midline
This interesting case should serve as a reminder that
and was in close proximity to the right adnexa. This may
uncommon events may also occur in combination. Although
explain why the right-sided ectopic pregnancy was not
radiologic studies often facilitate diagnosis, they cannot be
visualized on ultrasound.
solely relied upon for accurate diagnosis. This case under-
Although Doppler sonography can be a useful diagnostic scores the importance of using clinical diagnostic skills in
modality, the present case underscores the relatively low sen- cases of surgical emergency.
sitivity of Doppler for diagnosis of ovarian torsion. In a recent
report by Pe~ na et al. (3), Doppler sonography correctly diag-
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