Massive Ovarian Edema in Pregnancy

İncim Bezircioğlu, Levent Hiçyılmaz, Ergun Öziz, Demet Etit, Ali Baloğlu

Background: Massive ovarian edema is a very rare condition characterized by a tumorlike enlargement of the ovary. The ultrasound findings have been reported as a solid tumorlike mass or as a solid mass containing a cystic component

Case: Our 30 years old case presented with acute abdomen syndrome in 13th week of gestation. The color doppler sonographic evaluation revealed right ovary as a solid mass, 90*50 mm in diameter with increased vascularity and increased ovarian arterial blood flow. A right salpingo-oopherectomy was performed by exploratory laparotomy. As a result of histopathologic examination, massive ovarian edema was diagnosed.

Conclusion: The sonographic appereance is nonspecific and the definitive diagnosis requires histological examination. The consideration of this rare entity is important to prevent incorrect treatment.

Fikret Gökhan Göynümer, MD.
Göztepe Education and Research Hospital , Gynecology and Obsterics Clinic, Istanbul

Massive Ovarian Edema (MOE) is a pathology similar to ovarian tumors which is formed by interstitial fluid retention in the ovarian stroma. It is a rare disease. In its’ etiopathogenesis recurrent semi-ovarian torsions are considered to be responsible.1
It is mostly reported in young age group like 6 to 33 years but some cases are also presented in menapause age group. 2,3
Conservative treatment is essential in younger age group to preserve the ovarian functions. It is diffucult to diagnose preoperatively. Specific Ultrasonography and Magnetic Resonance signs has not been defined adequately.
In our case the signs of scanning and the relation between ovulation induction is presented and our aim was to contribute to data in the literature.

A 30 years old female patient G1P0 with severe abdominal pain, nausea, vomiting and vaginal bleeding has admitted to our clinic in emergency conditions. She had a 13 week old pregnancy according to her last menstrual period which was a result of clomiphene citrate ovulation induction. She had a regular antenatal follow-up and her routine control was performed 10 days previously.
In her physical exam a mass with regular contour which could not be differentiated from the pregnant uterus in right abdominal quadrant was palpated. There was a significant defence in the lower quadrants. In her pelvic exam a small amount of blood was oozing from the cervical os and the uterus which is consistent with 13 week old pregnancy was soft and right to the uterus a painful, large, soft mass was also palpated.
In the abdominal ultrasonography 13 week + 5 days old single, live fetus and a retroplacental 36x14 mm hematoma was seen. In the right adnexial location near to the pregnant uterus a solid mass of 90x50 mm was observed. With the color Doppler scanning an increase in vascularity in right ovarian mass (figure 1) and an increase in right ovarian arterial flow was seen. RI values were 0.60. There was free fluid in Douglas pouch.
A laparotomy was planned because of acute abdomen. Infraumblical median incision was performed. In exploration the uterus was consistent with the week of pregnancy. A serous free fluid about 20 ml was observed. A specimen was taken for cytologic exam. In the right ovary there was a dark red colored semitorsioned mass of 90x60x30 mm volume. As it was performed under emergency conditions there was not a possibility to do frozen section. A right oopherectomy was performed. After the bleeding control the surgery was ended.
In the microscopic evaluation of the cytologic specimen; a few amount of lymphocytes, mesothelial cell groups in reactive characterization on bleeding erythrocyte background was observed.
In pathological exam right ovary was found to be macroscopically 90x60x50 mm, there was a surface bleeding which was bright dark red in color and solid. In microscopic evaluation on edematic stroma there were microcystic structures and the vascular regions showing erythrocyte extravasation with dilated lymphatics (figure 2). Massive ovarian edema diagnosis was made by the histyopathologic signs.
In the postoperative period the patient’s vaginal bleeding stopped and had no pain. In the ultrasonographic follow-up retroplacental hematoma was not seen. On the postoperative 7th day she was discharged. There was no problem with her antenatal follow-up. Her pregnancy is carried out and now it is 37 week old.

We have found that the number of single, twin, triplet, and quadruplet births was 54914, 559, 20 and 2, respectively, out of all deliveries registered in our clinic for a five-years period. Three of multiple gestations had major fetal anomaly while both babies had the same anomaly only in one case. In our series with a total number of 247 cases (0.44%) with anomaly, the distribution of major congenital anomalies by years is shown in Table 1. The anomaly incidence ranging from 0.4 to 0.5 % in the first four years decreased to the border of 0.26 % in 2004 (p <0.05).

An analysis on the distribution of congenital anomalies by system and region showed that the most frequent anomalies were of the central nervous system (Table 2), which were followed by non-immune hydrops fetalis and multiple anomalies.

The prognosis of congenital anomalies is shown in Table 3. Fiftynine (74.68%) of the anomaly cases were lost during the antenatal period while 20 of them (25.32%) died during the early postnatal period. The mortality rate was found 31.99% in anomaly cases.

In the etiology of massive ovarian edema recurrent semi-torsion of ovarian pedicule is thought to be responsible . While with the torsion venous and lymphatic flow is disrupted, but the arterial flow persists, this condition may lead to this consequence. However, in half of the cases during the surgery torsion can be seen2. In our case there were signs of semi-torsion.
15% of the cases are bilateral, 85% unilateral and 75% located in the right ovary. The pressure is higher in the right because right ovarian vein directly drains into vena cava. It is mostly seen in right ovary because of the pressure differences in ovarian veins4. It also developed in the right ovary in our case.
The cases admit to the hospital with acute pain secondary to the torsion 5,6. Our case admitted to the hospital with acute abdomen.
It is difficult to make a definitive diagnosis of massive ovarian edema cases preoperatively. The published cases are evaluated by conventional ultrasonography, color Doppler sonography and magnetic resonance imaging (MRI). The sonographic signs are different, mostly solid tumor-like mass appearance has been defined.
It is found to be more hypoechoic than myometrium and contains peripherally located cystic components and these are the ultrasonographic features defined in the literature. 3,7,8 However there is no case which has a MOE diagnosis only by ultrasonography.
Characteristic Doppler features have not been defined for these cases. When there is complete torsion it is expected that ovarian blood flow is stopped and with Doppler sonography there should be no vascularization. However the signs can be different according to the level of effected vascular system from torsion because ovaries get blood from two different supplies. The first sign of torsion is the absence of venous blood flow, during this period arterial flow can be shown as highly resistant. Doppler sonography signs can be minimal in incomplete or intermittent torsion. 9,10
Güvenal et al 11 presented a MOE case with a normal blood flow in Doppler sonography. In our case Doppler sonography revealed an increase in vascularity in ovarian mass and an increase in ovarian artery flow . It is noted that there was highly resistant flow samples in ovarian artery and ovarian parenchyma. These signs indicate that there was no complete torsion .
In published cases of MOE, in MRI findings it is defined in T1 weighted images heterogenous low intensity and in T2 weighted images homogenous high intensity.8 When the evaluation of ultrasonography and MRI is combined it is thought that preoperative diagnosis rate will be increased.12
As our case was managed under emergency conditions MRI evaluation could not be done.
In the literature polycystic ovary syndrome and infertility together with MOE is published.13,14
Ovulation induction in infertility treatment causes increased ovarian volume and predispose to torsion.
Patty et al has published a case of massive ovarian mass which is a result of ovulation induction with clomiphene citrate, however in this case pregnancy was not achieved.15 In our case pregnancy was achieved after ovulation induction with clomiphene citrate and the case occurred during pregnancy. There are two more published cases of massive ovarian edema in pregnancy 8,16 and our case is the third.
As a conclusion, massive ovarian edema is a rare benign pathology seen in young age patients. In a few amount of published case, it was possible to preserve ovarian functions with conservative treatment 17,18 with the diagnosis of preoperatively or intraoperatively. As it could be seen in young age group and infertile patients, during ovulation induction it should be also taken into consideration. Scanning signs are nonspecific and has not been defined adequately. In our case we aimed to contribute to literature about this subject presenting the relation between scanning signs and ovulation induction.

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11. Guvenal T, Cetin A, Tasyurt A. Unilateral massive ovarian edema in a woman with polycystic ovaries. Eur J Obstet Gynecol Reprod Biol 2001;99:129-30.

12. Umesaki N, Tanaka T, Miyama M, Nishimura S, Kawamura N, Ogita S. Successful preoperative diagnosis of massive ovarian edema aided by comparative imaging study using magnetic resonance and ultrasound. Eur J Obstet Gynecol and Reprod Biol 2000;89:97-9.

13. Güvenal T, Çetin A,Taşyurt A. Unilateral massive ovarian edema in a women with polycystic ovaries. Eur J Obstet Gynecol and Reprod Biol 2001;99:129-30.

14. Sageshima M, Masuda H, Kawamura K, Shozawa T. Massive ovarian edema associated with polycystic ovary. Acta Pathol Jpn 1990;40:73-8.

15. Patty JR, Galle PC, McRae MA. Massive ovarian edema in a woman receiving clomiphene citrate. A case report. J Reprod Med 1993;38:475-9.

16. Lambert B, Lessard M. Massive ovarian edema in a twin pregnancy. Can J Surg 1987;30: 40-1.

17. Kocak M, Caliskan E, Haberal A. Laparoscopic conservation of the ovaries in cases with massive ovarian edema. Gynecol Obstet Invest 2002;53:129-32.

18. Hubbell GP, Punch MR, Elkins TE, Abrams GD. Conservative management of bilateral massive edema of the ovary. A case report. J Reprod Med 1993;38:61-4.