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In what it says is world first, Hadassah medical team saves fetus’s twisted ovaries

In a procedure Hadassah Medical Center in Jerusalem is calling the first case of its kind in the world, doctors saved both ovaries of a premature fetus by delivering her in an emergency cesarean section and performing surgery on her just half an hour after birth.

The hospital published details of the case Monday, though it occurred in February. When the mother went in for an ultrasound that month, in her 35th week of pregnancy, the scan revealed huge cysts on both of the fetus’s ovaries. The cysts were causing ovarian torsion, or twisting — a serious condition that, if not treated immediately, leads to the death of the organs.

“Ovarian torsion is seen in some women and teenage girls. It is extremely rare in fetuses, and even rarer for both ovaries of a fetus to be affected,” said Dr. Shay Porat, director of the obstetrics and gynecology ultrasound service at Hadassah.

While fetal ovarian torsion is rare, according to a case report in the peer-reviewed Journal of Diagnostic Medical Sonography, ovarian cysts in late-second and early third-trimester fetuses and neonates is not uncommon due to maternal hormonal stimulation of the fetal ovary. The article states that most of these cysts resolve on their own by the age of 12 weeks. However, cysts can be complicated and require timely diagnosis and intervention.

Ovarian torsion occurs in approximately 6 per 100,000 women and is more common among females of childbearing age. However, prepubescent girls and post-menopausal women can also experience the painful condition.

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Ovarian torsion is often (but not solely) caused by one or more cysts on the ovary, whose weight causes the ovary to twist on its longitudinal axis. This cuts off the blood vessels that nourish the organ, thus depriving it of oxygen. When this happens, the ovary dies, damaging fertility and the hormonal production needed for female health.

Illustrative: A 3D illustration of a fetus in the womb (magicmine via iStock by Getty Images)

The sudden symptoms of a twisted ovary — severe lower abdominal pain, nausea, and vomiting — can be preceded by cramping for days or weeks. The only treatment for ovarian torsion is urgent surgery to remove the cyst (if present) and untwist the ovary. This can be done either by laparoscopy or laparotomy.

“Normally, you don’t see a fetus’s ovaries in a regular scan, but the ovaries in this fetus were so large due to the cysts that they took up much of the abdomen and were impossible to miss. They were each almost 4 centimeters (1.6 inches) in size,” Porat said.

He explained that in almost all cases where an ovarian cyst or ovarian torsion is detected in a fetus, it is only in one ovary.

“There is controversy about what to do, but most of us do nothing because even if the ovary is twisted, then most likely you have already missed the train [in terms of saving it]. Also, you still have the other ovary as a backup. So, in such a case we usually don’t intervene and deliver the baby early,” Porat said.

In the case of the baby treated in February, both ovaries were affected, making it not only extremely rare, but also more worrisome. When Porat, using a special ultrasound feature, detected that there was still blood flow in both ovaries, time became of the essence.

Hadassah Ein Kerem Hospital in Jerusalem on August 17, 2021. (Yonatan Sindel/Flash90)

“We still had something to save. If we continued to wait and monitor the baby, the situation could have taken a turn for the worse from moment to moment, and we would have missed our window of opportunity,” Porat said.

According to Porat, an induced vaginal birth was also not a safe option, so the baby was delivered by emergency C-section and taken immediately for surgery.

“The neonate was only 35 weeks, so there were calculated risks involved. Of course, the decision was not only ours. The parents agreed for us to go ahead,” he said.

The pediatric surgeon, Dr. Dan Arbel, opted for a mini-laparotomy, making a small incision in the baby’s abdomen.

“Through this incision, he managed to to to get the ovaries, untwist them,  and drain the cysts,” Porat said.

According to Porat, there is nothing in the published medical literature on the surgical treatment of a newborn baby with simultaneous bilateral ovarian torsion. The only other case he knows of was shared in an Israeli medical forum, and it dealt with a fetus showing the condition on a scan at 39 weeks gestation. There was no sign of blood flow to the ovaries, but the baby was delivered by emergency C-section and operated on immediately in the hopes that the ovaries were still alive and could be saved.

“Unfortunately, the ovaries were dead. It was absolutely no one’s fault. It just happened like this,” Porat said.

Fortunately for the baby born at Hadassah and her parents, the story ended differently. Now six months old, she has had some follow-up checks at the hospital, and, by all indications, she should grow up with healthy ovaries.