This video is Laparoscopic management of Torted Ovarian Dermoid Cyst in Pregnant Patient. Dermoid cyst (Mature cystic teratoma), the most common type of primordial germ cell ovarian tumors is usually benign and asymptomatic. It can be malignant in 5% of cases. The incidence of torsion in pregnant patients with ovarian cyst persisting during pregnancy is approximately 15%. Benign dermoid cysts/teratomas are the most frequent ovarian tumors, with an incidence ranging from 5% to 25% of all ovarian neoplasms [3]. They are of germ cell origin and composed of multiple types of tissue. Torsion of the cystic contents and ovary may occur in them, thus leading to vascular infarction and necrosis. Torsion of the pedicle has been reported to be the most frequent complication, occurring in 16.1% of cases [3]. Traditional risk factors for ovarian torsion are increased ovarian size, ovarian tumors, ovarian hyperstimulation, and pregnancy.

Ovarian dermoid cysts, also known as mature cystic teratomas, are common benign ovarian tumors that contain tissues from multiple germ layers, such as hair, sebaceous material, and sometimes bone or teeth. While generally asymptomatic, they can pose significant risks during pregnancy, particularly when torsion occurs. Ovarian torsion is a surgical emergency that requires prompt diagnosis and management to preserve maternal health and, when possible, fetal viability.

Epidemiology

Ovarian dermoid cysts account for approximately 10–20% of all ovarian neoplasms and are most frequently diagnosed in women of reproductive age. In pregnancy, the incidence of ovarian torsion is estimated at 1 in 5,000 pregnancies, with dermoid cysts being a common predisposing factor due to their solid and cystic nature and potential for mobility.

Pathophysiology
Torsion occurs when the ovary twists around its vascular pedicle, leading to venous and lymphatic obstruction. Initially, arterial blood flow may persist, but progressive torsion results in ischemia, necrosis, and severe abdominal pain. In pregnant patients, the enlarging uterus can alter the normal anatomical position of the ovary, increasing the risk of torsion.

Clinical Presentation
Symptoms of a torted ovarian dermoid cyst in pregnancy include:

• Sudden-onset, severe unilateral lower abdominal or pelvic pain

• Nausea and vomiting

• Adnexal tenderness on examination

• Occasionally, a palpable adnexal mass

• Signs of peritoneal irritation if necrosis or rupture occurs

Because pregnancy can mask some symptoms or mimic other conditions such as appendicitis or placental complications, diagnosis can be challenging.

Diagnosis

• Ultrasound: The first-line imaging modality. A torted dermoid may show a heterogeneous mass with echogenic components (fat, hair), free fluid, and absence or reduction of Doppler blood flow in the ovary.

• MRI: Useful when ultrasound findings are inconclusive or in the second and third trimesters when the uterus limits ultrasound visualization. MRI is safe in pregnancy and provides excellent soft tissue characterization.

• Laboratory tests: Generally nonspecific; mild leukocytosis may be present. Tumor markers (e.g., CA-125) are not reliable during pregnancy.

Management
Surgical intervention is the treatment of choice and should not be delayed due to pregnancy:

• Timing:

  • First trimester: Surgery is riskier for miscarriage but may be necessary if torsion occurs.

  • Second trimester (optimal window, 14–20 weeks): Lower risk of miscarriage and preterm labor.

  • Third trimester: Surgery is technically challenging due to the enlarged uterus; conservative management is sometimes considered if symptoms are mild and the patient is stable.

• Approach:

  • Laparoscopy: Preferred in hemodynamically stable patients and for gestational age <24 weeks. Minimally invasive, reduced postoperative pain, faster recovery.

  • Laparotomy: May be required in advanced gestation, large cysts, or necrotic ovaries.

• Procedure:

  • Detorsion of the ovary if viable

  • Cystectomy for dermoid cyst removal

  • Oophorectomy if the ovary is necrotic

  • Preservation of fertility whenever possible

Complications
If untreated, torsion can lead to:

• Ovarian necrosis

• Infection or peritonitis

• Preterm labor

• Maternal hemodynamic instability

Prognosis
With timely surgical intervention, maternal outcomes are excellent, and pregnancy can often continue to term without adverse effects. Preservation of ovarian function is possible in most cases if the ovary is not necrotic. Recurrence of dermoid cysts is rare but can occur.

Conclusion
Torted ovarian dermoid cysts during pregnancy are rare but serious emergencies requiring rapid diagnosis and surgical management. Ultrasound remains the mainstay for detection, while laparoscopy is increasingly preferred for intervention during the second trimester. Multidisciplinary care involving obstetricians and gynecologic surgeons ensures optimal outcomes for both mother and fetus. Awareness of this condition is crucial for timely recognition and prevention of severe maternal and fetal complications.