Prediction of Adnexal Torsion by Ultrasound

in Women with Acute Abdominal Pain

“Is There Yet Place for Improvement?”

Ron Bardin
Helen Schneider Hospital for Women
Rabin Medical Center
Petach Tikva, ISRAEL

February 2018
The sonographic signs of adnexal torsion
whirlpool
 background

• Ovarian torsion is the a common gynecologic surgical

emergency

• Prevalence rates of 2.7% to 3%

• Early diagnosis is important to prevent loss of the adnexa

 background

• The accuracy remains controversial

• Correct diagnosis before surgery in only 23% to 84%

of cases

• The preoperative diagnosis of adnexal torsion

remains a challenge
 Fertility and Sterility
2009

• Seventy-eight women laparoscopy for suspected OT

• The preoperative diagnosis of OT was confirmed in only 36

(46.1%) of the patients

Despite 20 years of research, the accuracy of the

preoperative diagnosis of OT remains low.
 J Ultrasound Med
2011

• Included 63 women who had suspected ovarian torsion on

sonography and subsequently underwent laparoscopy
In the setting of a specialized ultrasound unit,
• Sonography had diagnostic accuracy
sonographic of 74.6%
diagnosis of for ovarian
torsion torsion had high accuracy compared with
ovarian
previous reports
• Abnormal ovarian blood flow and the presence of free fluid
were the most diagnostically accurate isolated sonographic
signs
 Archives of Gynecology and Obstetrics 2018

• Association of clinical, laboratory and ultrasound findings with the

surgical diagnosis of adnexal torsion in a retrospective cohort of
women operated for suspected torsion

• Adnexal torsion was surgically diagnosed in 111/199 (55.8%) cases

• Multivariate logistic regression analysis:

Presence of free pelvic fluid
Ovarian edema
Benign cystic teratoma
Location of the ultrasound pathology on the right side
were positively associated with adnexal torsion
ROC
 JUM 2017

• Investigate the role of ultrasound in the preoperative diagnosis

of adnexal torsion

• 195 female patients with clinically suspected adnexal torsion

111 us diagnosis of torsion / 91 confirmed op

84 R/O of torsion by US / correct in 66 women

sensitivity was 0.84

specificity was 0.77
positive predictive value 0.82
 Aim of the study

To assess the accuracy of ultrasound diagnosis

for adnexal torsion and investigate the factors
which influence its accuracy
 Methods

Surgical Diagnosis of
Adnexal Torsion

Condition Condition
positive negative

Test True positive False positive Positive predictive

Sonographic positive value
Diagnosis of
False
Adnexal Torsion True negative Negative predictive
Test negative negative
value

Sensitivity Specificity Accuracy

 Results

Surgical Diagnosis of
Adnexal Torsion
Condition Condition
positive negative
Positive predictive
value (Precision)
Test True positive False positive
Sonographic positive n=228 n=52 81.4%
Diagnosis of
N=280
Adnexal Torsion
False Negative predictive
Test True negative
negative value
negative NA
n=42 NA
Sensitivity
Specificity Accuracy
84.4% NA NA
n=270
 Results
another version……legitimate?

Surgical Diagnosis of
Adnexal Torsion

Condition Condition
positive negative

Test True positive False positive Positive

Positive predictive value
Test
positive n=228 n=52 (Precision)
(Precision) 81.4%

Sonographic Diagnosis
of Adnexal Torsion True negative Negative
False negative
Test negative
n=42 predictive value
n=103 / 335 71.3% / 88.9%
Sensitivity Specificity Accuracy
Sensitivity 84.4%
84.4% 66.4% / 86.6% 77.9% / 85.7%
 JUM 2017

• Investigate the role of ultrasound in the preoperative diagnosis

of adnexal torsion

• 195 female patients with clinically suspected adnexal torsion

The
diagnoses of the true negative cases included ectopic
pregnancy (46 of 66), ovarian cyst rupture (13 of 66),
ovarian tumor (6 of 66), and tubal mesosalpinx cyst (1 of 66)
 Results

Demographic and Clinical Characteristics of the cohort,

divided by subgroups
True Positive False Negative False Positive P value
(n = 228) (n = 42) (n = 52)

Body Mass Index, Kg/m2 23.3 ± 4.2 24.7 ± 5.8 24.9 ± 5.4 0.030

Pregnancy: 73 (32.0%) 9 (21.4%) 3 (5.8%) 0.0004

1st Trimester, ≤13+6 weeks 51 (22.4%) 6 (14.3%) 1 (1.9%)
 Results
Pre-Operative Sonographic Features and Findings of the cohort,
divided by subgroups
True Positive False Negative False Positive P value
(n = 228) (n = 42) (n = 52)
Ultrasound Operator:
Expert Sonographer 166 (72.8%) 31 (73.8%) 38 (73.1%) 0.991
OB/GYN Attending 62 (27.2%) 11 (26.2%) 14 (26.9%)

Edematous Ovary 149 (65.4%) 2 (4.7%) 26 (50.0%) <0.0001

Echogenic Ovary 28 (12.3%) 5 (11.9%) 5 (9.6%) 0.865
Absent Flow by Doppler 91 (39.9%) 7 (16.7%) 24 (46.1%) 0.006
Whirlpool Sign 58 (25.4%) 0 9 (17.3%) 0.0007
Enlarged Ovary (≥4cm) 221 (92.5%) 37 (88.1%) 43 (82.7%) 0.0002
Ovarian Cyst 127 (55.7%) 35 (83.3%) 27 (51.9%) 0.0007
 Results
Sensitivity and Positive predictive values of individual Pre-Operative
Sonographic Features
Sensitivity Positive Predictive value
Edematous Ovary
Echogenic Ovary
Absent Flow by Doppler
Whirlpool Sign 100% (0.92-1.00)
Enlarged Ovary (≥4cm)
Ovarian Cyst
Edematous Tube 92.5% (0.72-0.99)
Free Pelvic Fluid )
 Results

Contribution of a repeat sonographic assessment, divided by

subgroups
True Positive False False Positive
(n = 228) Negative (n = 52)
(n = 42)
1st Positive 31 3 6
Ultrasound Negative 45 16 14
2nd Positive 76 -- 20
Ultrasound Negative -- 19 --
Positive 76 19 --
Laparoscopy
Negative -- -- 20
 Results
Pre-Operative Sonographic Features and Findings of the cohort,
divided by sonographer’s experience
Expert Sonographer Ob-Gyn P value
(n = 235) Attending
(n = 87)
Edematous Ovary
Echogenic Ovary
Absent Flow by Doppler 206 (87.6%) 54 (62.1%) <0.0001
Whirlpool Sign 78 (33.2%) 11 (12.6%) 0.003
Enlarged Ovary 226 (96.2%) 76 (90.8%) 0.015
Edematous Tube
Fluid in Douglas
Sensitivity 84.2% (0.78-0.89) 84.9% (0.74-0.92)
Positive predictive values 81.3% (0.75-0.86) 81.5% (0.71-0.89)
Data presented as n (%)
 conclusions

• Ultrasound is highly sensitive with high PPV in

the diagnosis of adnexal torsion

• Upgrading the diagnosis of adnexal torsion is

possible only by a team work approach
Noga Pearl
Reuven Mashiach
Ram Eitan
Anon Wiznitzer
Israel Meizner
Eran Hadar