New Insight in Recurrent Ovarian Torsion Managements’’ In A 12 Years Old Girl with Simple Cyst in Polycystic Ovary

Ovarian torsion is a rare but significant cause of acute abdominal pain in women. Commonly, patients present with the sudden onset of severe lower abdominal pain with progressive quality over hours. This condition is usually accompanied by decreased blood return from ovaries which leads to swelling and congestion of them. Abdominopelvic ultrasonography with color Doppler analysis is the first choice to diagnosis and estimating impairment of blood flow in ovaries. Quick diagnosis is required to protect the ovaries from necrosis and save the normal function. In our case ,the treatment we performed after three time of recurrent ovarian torsion surgery ,was to wait


Introduction
Ovarian torsion is a condition caused by the complete or partial rotation of the ovary around the supporting ligaments which in most cases leads to impaired ovarian blood supply by compressing of the ovarian circulation. This disorder is a medical emergency and one of the most common causes of gynecological surgery which can involve women of all ages, even fetuses and infants. However, according to studies, women between the ages of 20_50 are the most affected [1,2]. Despite of the diversity in clinical manifestations of ovarian torsion, the classic presentation of this disorder include: moderate to severe acute onset of pelvic pain which is often accompanied by nausea and vomiting, and in some cases fever [3,4]. According to reports, torsion is more common in the right ovary probably due to the longer infandibulopelvic ligament on the right side and the protection effect of the sigmoid intestine on the left side of the body which prevents the left ovary from moving and twisting [5]. After taking a complete history of the patient and clinical examination and performing basic laboratory tests, ultrasound is performed as the first line of diagnosis of ovarian torsion by para-clinic which can determine the morphology, size, density and vascular flow of and guarding, normal limits in vital signs based on her age. The laboratory investigations showed count elevated white blood cells up to 16.400 mm3. Other basic biochemical test results' such as platelets count, hemoglobin rate, Urine analysis, renal function, serum electrolytes all were normal. The pregnancy blood test was negative. An abdominopelvic ultrasound scan revealed a left echogenic ovary with two cysts (33.38 mm and 37.29 mm), with dimension in 88.56.63 mm and volume as 160 cc but dimension and echogenicity of right ovary were normal. The patient was prepared for surgery by ovarian torsion as primary diagnosis so Pfannenstiel incision laparoscopic detorsion of left ovary was performed.
After stabilizing the patient, she was discharged from the hospital but two months later was registered to the clinic again

Discussion
The incidence of ovarian and adnexal torsion is unknown.
Ovarian torsion can affect women of all ages, it can even occur in fetuses and Infants. However, the most commonly reported cases of ovarian torsion are the women in reproductive ages and sexually active who are between 20-50 years old [2]. Ovarian torsion can occur completely or partially, and according to studies, mostly on the right side. The longer utero ovarian ligament and the lack of a protective structure on the right side, such as the sigmoid colon which prevents ovarian motility on the left side, have been cited as possible causes in the articles [5]. The main risk factor for ovarian torsion is cystic or neoplastic mass. As a result, it significantly increases the risk of twisting in lower risk group, such as pre-monarchal girl ages [6,7]. Some data suggest that pregnancy, ovarian stimulation, tubal ligation, enlarged ovaries in polycystic ovary syndrome and history of abdominal surgery are associated with an increased risk of ovarian torsion, but the degree of these risks is uncertain [2,8]. Although, patients with torsion shows different clinical manifestations, but the most presentation of torsion include: abdominal pain, nausea, vomiting and nonmenstrual bleeding in rare cases [3,4]. Early diagnosis is very important to prevent severe consequences of torsion and preserve the function of ovaries and fallopian tubes [6]. For the approach to patient after taking the medical history and performing clinical examinations, basic laboratory tests are requested for the patient.
In most scientific resources pelvic ultrasound is the first line choice of imaging study for patients which are suspected for ovarian torsion [9]. The most likely ultrasound findings in a patient with to preservation ovarian function [10,11]. Another study was dysfunctional tissue, after detorsion and fixation surgery, with medical treatment and follow-up of the patient for the several months ,the ovarian tissue became pink with normal function .in our case on last ultrasound examination AFC were observed. Therefore , that in same cases ,before performing aggressive treatment such as oophorectomy ,after detorsion surgical procedure ,with anticipatory care planning and follow-up the patient ,give a chance to the damaged ovary to heal and tissue repair. this performance gives patients of reproductive ages, the opportunity to preserve their ovaries and fertility abilities to live perfectly normal.