Twisted ovarian cyst is a gynecological emergency. This is a real case presentation on twisted ovarian cyst of a 14 year old girl child.

1. In the Name of Allah
Most Gracious, Most Merciful

2. Clinical Case Presentation
by
Dr. Mahmudul Hasan Monnaf

4. Get Acquaintance with our Case
Miss.RaziaKhatun,14Years,SchoolGirl
From: Shahzadpur, Sirajganj
Was in Ward-28, RMCH

5. Miss. Razia Khatun, 14 years old unmarried,
Muslim girl coming off a lower middle class
family hailing from Shaktipur, Shahzadpur,
Sirajganj got admitted into RMCH, Gynae Unit-
II on 03 July 2013 with the complaints of –
 A lump in the lower abdomen for one month.
 Lower abdominal pain for 3 days.
 Vomiting for once 3 days ago.

6. History of present illness:
Patient stated that, she was reasonably well a
month back. Then she noticed an abdominal lump
in the left iliac fossa. She suddenly developed pain
in the left lower abdomen 3 days back which was
severe, agonizing, continuous in nature. She also
complained single episode of vomiting 3 days
back. She got admitted into RMCH for better
management.

7. History of past illness:
She has no history of Tuberculosis, bronchial
asthma, heart disease, renal disease, DM,
pelvic operations etc.
Family History:
She has no family history of Hypertension,
diabetes, tuberculosis, carcinoma etc.
Personal History:
She is non alcoholic, non smoker.

8. Drug History:
Nothing significant.
Socio-economic History:
She came of a lower middle class family.
Immunization History:
Immunized according to EPI schedule.

9. Menstrual History:
Age at menarche - 13 years
MC - Regular (28 days cycle)
MP - 3-4 days
MF - Average
LMP - 17 June 2013

10. Physical Examination:
General Examination:
Appearance - Anxious
Body Built - Average
Weight - 36 Kg
Nutrition - Average
Co-operation - Co-operative
Anemia - Absent
Jaundice - Absent
Oedema - Absent
Cyanosis - Absent

11. General Examination contd.
Dehydration - Absent
Temp - Raised (slight)
Pulse - 96 b/min
BP - 110/70 mmHg
Respiration - 18/min
Heart - NAD
Lung - NAD
Lymph Node - Not Palpable
Thyroid - Not Enlarged

12. Systemic Examination:
Systemic examination reveals nothing
significant.
Local Examination:
Per-abdominal examination:
Inspection:
• Abdomen was scaphoid shaped with a
moderate sized lump in the left iliac fossa.
Flanks were flat.
• Overlying skin was normal in appearance.
• No engorged vein was seen.

13. Palpation:
• Local temperature was slightly raised,
tenderness present.
• The mass was about 20 17 cm in size, cystic
in consistency, surface was smooth, margins
were well defined, mobile in side to side
direction but restricted from above
downwards.

14. Percussion:
Dull over the lump and resonant over the flanks.
Auscultation:
Nothing significant

15. Pelvic Examination:
Bimanual Examination:
• A groove is felt between the uterus and the
mass.
• The uterus is separated from the mass.
• Movement of the mass per abdomen fails to
move the cervix.
• The mass was palpable through anterior fornix.

16. Provisional Diagnosis
?
Twisted Ovarian Cyst

17. Investigations:
Haematological Investigations:
Hb% - 11.39 gm/dl, 71%
ESR - 42 mm in 1st hour
WBC- 7,700/cumm

18. Differential Count:
 Neutrophil - 65%
 Lymphocyte - 28%
 Monocyte - 04%
 Eosinophil - 03%
Biochemical Analysis:
 RBS – 85 mg/dl, 4.72 mmol/L
 Serum Creatinine - 0.65 mg/dl, 57.46
µmol/L

19. Urine Analysis:
Physical
 Color - Straw
 Appearance - Clear
 Sediment - Nil
Chemical
 Reaction - Acidic
 Albumin - Nil
 Sugar - Nil
Microscopic
 Epithelial cell - 3-5/ HPF
 Pus cell - 2-4/ HPF
 RBC - Nil

20. USG of Whole abdomen

21. USG Findings:
None of the ovaries are visualized. A large
cystic mass measuring about 12 10 cm is
found in pelvic cavity along the midline. A
thick septum is seen within the cyst. Outline
of the cyst is mildly irregular but well defined.
The cyst appears to be an ovarian cyst.
Impression: Suggestive of Ovarian Cystic
Neoplasm.

22. Salient Feature:
Miss. Razia Khatun, 14 years old unmarried, Muslim
girl coming off a lower middle class family hailing
from Shaktipur, Shahzadpur, Sirajganj got admitted
into RMCH, Gynae Unit- II on 03 July 2013 with the
complaints of Lower abdominal pain for 3 days. She
also complained of a lump in the lower abdomen for
one month and vomiting for once 3 days ago.
On general examination she is anxious, temperature is
slightly raised, not anemic, not icteric.
Systemic examinations reveal nothing significant.

23. Abdominal examination revealed a lump in the left
iliac fossa, about 20 17 cm in size, cystic in
consistency, surface was smooth, margins were well
defined, mobile in side to side direction but restricted
from above downwards.
On bimanual examination, lump felt through the
anterior fornix was separated from the uterus and the
uterus was of normal size. Movement of the lump fails
to move the cervix.
Investigations specially USG of whole abdomen
creates impression for Ovarian Cystic Neoplasm. She
is now admitted into RMCH for appropriate
treatment.

24. Diagnosis
?
Twisted Ovarian Cyst

25. Management:
General Management:
Diet: Normal
Tab. Ciprofloxacin 500 mg
1 tab 12 hourly
 Tab. Tiemonium Methyl Sulphate 50 mg
1 tab 8 hourly
 Tab. Omeprazole 20 mg
1 tab 12 hourly before meal
 Tab. Ondansetron 8 mg
1 tab 8 hourly
 Inj. Nalbuphine Hydrochloride INN 20 mg
1 amp IM stat and SOS (with inj. vergon)

26. Definitive Treatment (Laparotomy)
On 08 July 2013 at 10:00 AM
Name of Operation: Left Sided
Oophorectomy with Preservation of Right
Ovary
Surgeon and Anesthetist: Doctors of the
Gynae Unit-II
Anesthesia: SAB

27. With all aseptic precautions abdomen was opened
by Pfannenstiel incision. After opening the
peritoneal cavity there found left sided twisted
huge (about 20*17 cm) ovarian cyst. Fluid is
sucked out by giving Purse-string suture. The fluid
was haemorrhagic and somehow straw-berry
colored. Tumor stalk is clamped, incised and
secured. Then left sided oophorectomy along with
conservation of right ovary and both fallopian tube
were done. After proper peritoneal toileting and
having a drain tube inside abdomen was closed
layer by layer. Resected ovarian cyst was sent for
histo-pathological examination.
Findings on Laparotomy

28. Follow-up:
Her post operative days were uneventful. On 8th
POD (16 July 2013) stiches were off and patient
got the discharge with advice.

30. Questions are always
welcome!!
But I Can’t Guarantee for satisfactory answer

31. Tab. Acical-M
(Calcium & Minerals)
Pivacain-D
(Bupivacaine Hcl.+Dextrose)
Cap. Xeldrin
(Omeprazole)
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