Venous Thromboembolism and Ovarian Torsion-detorsion in Pregnancy: a Case Report and Systematic Review of the Literature 

Venous Thromboembolism and Ovarian Torsion-detorsion in Pregnancy: a Case Report and Systematic Review of the Literature  | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Case report Venous Thromboembolism and Ovarian Torsion-detorsion in Pregnancy: a Case Report and Systematic Review of the Literature Peng Zhao, Ying Zhao, Quan Zhang, Zhu Zhou, Jianhong Zhou, Fei Ruan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-114658/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The safety of adnexal detorsion in pregnant women is debatable as the hypercoagulable state during pregnancy intensifies the risk of thromboembolism. The diagnosis and treatment is challenging because its rarity and complexity due to the foetal health. Here we presented a rare case of venous thromboembolism (VTE) after ovarian detorsion during early pregnancy and conducted a review of the literature. VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. The diagnosis depends mainly on the clinical manifestation, D-dimer level and imaging tests such as compression ultrasonography and computed tomography pulmonary angiogram. Low-molecular-weight heparin remains the drug of choice for both prophylactic measurement and therapeutic strategy. With prompt diagnosis and immediate treatment, VTE after ovarian torsion-detorsion is usually uneventful. Obstetrics & Gynecology Adnexal torsion Ovarian torsion Detorsion Venous thromboembolism Pulmonary embolism Low molecular weight heparin Figures Figure 1 Introduction Ovarian torsion during pregnancy, although fairly uncommon, is a well-recognized gynaecological emergency. It has been assumed that venous thromboembolism (VTE), being the leading cause of maternal death, was associated with ovarian torsion-detorsion. In order to avoid the release of emboli from the thrombotic vessels in the twisted adnexa, salpingo-oophorectomy without unwinding the adnexa was once the preferred surgical strategy [ 1 ]. However, in recent years, researchers have been advocating adnexal detorsion in place of salpingo-oophorectomy with the claim that infarcted adnexa were rarely attributed to VTE [ 2 – 5 ]. As a result, adnexal detorsion has now taken over as the mainstay of treatment for adnexal torsion to preserve ovarian function in young women. Even so, the safety of adnexal detorsion in pregnant women is still debatable as the hypercoagulable state during pregnancy intensifies the risk of thromboembolism. Consequently, we presented a case report of VTE after ovarian detorsion in pregnancy and conducted a systematic review of the literature. Case Report A 28-year-old women, gravida 1, para 0, in the 7th week of gestation was admitted to our hospital, complaining of lower abdominal pain and vomiting. Bimanual examination showed a pelvic mass and a point of tenderness in the right lower abdominal quadrant. Laboratory results revealed that the white blood cell count, C-reactive protein, hepatic enzymes and urine analysis were within normal ranges. Transvaginal ultrasound showed one intrauterine gestational sac with a viable embryo. The left adnexa were normal whereas the right ovary was enlarged, measuring 8.5*7.3*5.3 cm and a 6.9*5.8*4.8 ovarian cyst could be appreciated with an absence of vascular flow. The kidneys, pancreases, gall bladder and appendix showed no signs of abnormalities. In view of the above-mentioned findings, an explorative laparotomy was performed and an ischemic oedematous ovary was noted, containing a haemorrhagic corpus luteum cyst, around two thirds of which was dark bluish in colour and twisted for 1080 degree. Detorsion of the twisted adnexa was done and re-colouration of the adnexa was noted during the observation period. Therefore, ovarian cystectomy was performed. The post-operative pathology report described a corpus luteum cyst. The necessary measures to prevent thrombosis were taken. For instance, early ambulation and anti-embolism stockings were encouraged. Nevertheless, on the third post-operative day, the patient complained of calf pain in her right leg. Palpation of the affected limb showed Neuhof's sign positive. Ultrasonography revealed an extensive thrombosis within the deep veins of her right leg. An elevated D-dimer of 2.4 mg/l was noted. The patient commenced on low weight molecular heparin (LWMH, Nadropin calcium) 4100 IU twice daily subcutaneously for 14 days. By the 10th day of treatment, the level of D-dimer dropped to 0.55 mg/l. Moreover, the follow-up ultrasonography performed at her 3 months review showed that the deep vein thrombosis in her right leg had completely disappeared. The patient eventually delivered a healthy infant at 39 weeks of gestation. Prophylactic administration of low-molecular-weight heparin (LMWH) was initiated after the delivery and the postpartum ultrasound examinations showed no signs of any further venous thrombosis. Discussion One may argue that the current study is a case of ovarian torsion simultaneously with an event of VTE; however, we believe there is no need to debate as it is virtually impossible to confirm the relationship between ovarian torsion and VTE. The clinical significance of this study is to remind physicians that 1) VTE could occur after ovarian detorsion during pregnancy; 2) Early ambulation and anti-embolism stockings may not prevent VTE and therefore 3) the epidemiology, diagnosis and treatment regimens should be reviewed due to its rarity and complexity regarding to foetal health during pregnancy. Current research status About 10–22% of adnexal torsion occurred during pregnancy [ 6 , 7 ]. It is more likely to occur between the 10th week and the 17th week of gestation with an ovarian mass larger than 4 cm in diameter [ 8 ]. The venous thromboembolism risk was reported to be 0.03% in pregnant women, which is increased by 5 folds as compared to non-pregnant women [ 9 , 10 ]. The above-mentioned data were mainly focused on the population of pregnant women. In addition to that, to the best of our knowledge, the subgroup of pregnancies with VTE after ovarian torsion-detorsion has seldom been evaluated. A comprehensive search was performed in Embase and PubMed. The search strategies were designed using controlled vocabulary and plain language without language restrictions (Supplementary material). As a result, there has been only one case of VTE and three cases of pulmonary embolism (PE) in patients with adnexal torsion in the literature across the globe. Three of four cases received adnexal resection without detorsion and all of the three cases were complicated with PE. One of four cases received cystectomy with detorsion and developed postoperative DVT. However, none of the cases occurred during pregnancy [Table 1 ]. Therefore, we are the first to present a case of an ovarian torsion in a pregnant woman which has been complicated with VTE after the surgical intervention with ovarian detorsion. Table 1 Reports of venous thromboembolism after adnexal torsion Author, year age Pregnant/non-pregnant Torsion site Surgery Thromboembolic event Jauch,1922(15) 19 non-pregnant Fallopian tube Salpingectomy without detorsion Pulmonary embolism McGovern,1999(11) 38 non-pregnant Fallopian tube Salpingectomy without detorsion Pulmonary embolism McGovern,1999(11) 16 non-pregnant Left ovarian torsion Detorsion + Cystectomy deep vein thrombosis (right iliac vein) McGovern,1999(11) 44 non-pregnant Right adnexal torsion Right salpingo-oophorectomy without detorsion Pulmonary embolism Epidemiology In order to evaluate the epidemiological characteristics of pregnancies with post-detorsion VTE, we reviewed all of the medical records of our hospital from September 1991 to September 2019. Consequently, there were totally 256086 deliveries, out of which 260 cases had adnexal torsion and 17 cases had isolated fallopian tube torsion, amounting to an incidence of 0.11% and 0.007%, respectively. Of the 260 cases, 223 had ovarian tumour and 1 case developed VTE after the surgical detorsion, giving an incidence of 0.38% (Fig. 1 flow diagram). Evaluation and diagnosis The diagnosis of VTE after ovarian torsion-detorsion during pregnancy mainly depends on the clinical symptoms, physical examination and imaging tests. Patients with deep vein thrombosis (DVT) may present with calf pain, swelling and tenderness in the leg and a positive Neuhof's sign. On the other hand, those who develop iliac vein thrombosis may complain of inguinal, pelvic, or abdominal pain, and experience swelling of the entire leg. Pregnant women with a high suspicion of DVT should undergo a D-dimer test and compression ultrasonography (CUS). If the initial CUS is negative, repeat CUS must be performed when there is a high index of suspicion. In comparison with DVT, PE is more challenging to diagnose as the clinical presentation may be non-specific. One should be cautious of PE when the patient complains of weakness and faintness, which is usually considered as the normal recovery process after the surgical detorsion and is therefore neglected. Some may experience tachycardia and tachypnea [ 11 ]. Under such circumstances, a computed tomography pulmonary angiogram (CTPA) is highly recommended [ 12 ]. CUS should be performed after the confirmation of PE as DVT and PE are usually associated. In our study, the patient presented with calf pain and soreness of the lower limb and the diagnosis was established with an elevated D-dimer level and CUS. We did not perform further test for PE as the patients showed no clinical signs of any respiratory or cardiovascular diseases. Treatment The prophylactic measurements after surgical detorsion during pregnancy are early ambulation, anti-embolism stockings and intermittent pneumatic compression devices. It should be noted that the prophylactic measurements may not be able to prevent VTE. As in our case, VTE occurred although early ambulation and anti-embolism stockings were applied. Unfractionated heparin (UFH) and LMWH are both safe during pregnancy as neither will cross the placenta. However, administration of anticoagulants need careful considerations as heavy bleeding has been reported in 1.98% of pregnancies [ 13 ]. In clinical practice, LMWH is the drug of choice for it is relatively easy to use and doses not require tedious monitoring. Guideline from the Royal College of Obstetricians and Gynaecologists [ 14 ] suggests that thromboprophylactic doses for antenatal LMWH should be based on weight with the most frequently used LMWH being Enoxaparin, Dalteparin and Tinzaparin. LMWH is recommended in therapeutic doses once daily or twice daily in the management of acute VTE in pregnancy. Nevertheless, for pregnant women with PE or severe VTE, LMWH should be initiated with therapeutic doses twice daily [ 12 ]. In the current study, we started the treatment with therapeutic doses twice daily, and the complete resolution of emboli occurred in two weeks. Conclusion In conclusion, VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. The thrombotic events, compromising of DVT and PE, are life-threatening conditions and their diagnosis depends mainly on the clinical manifestation, D-dimer and imaging tests such as CUS and CTPA. LMWH remains the drug of choice for both prophylactic measurement and therapeutic strategy. With prompt diagnosis and immediate treatment, VTE after ovarian torsion-detorsion is usually uneventful. Abbreviations LWMH low weight molecular heparin; UFH:Unfractionated heparin; VTE:Venous thromboembolism; PE:Pulmonary embolism; DVT:Deep vein thrombosis; CUS:compression ultrasonography; CTPA:Computed tomography pulmonary angiogram ; Declarations Authors’ contributions Study design: Peng Zhao, Jianhong Zhou, Fei Ruan; Literature search: Peng Zhao, Ying Zhao; Acquisition of data: Quan Zhang, Zhu Zhou; Data Synthesis and analysis: Ying Zhao, Quan Zhang, Zhu Zhou; Drafting of the manuscript: Peng Zhao, Ying Zhao, Quan Zhang, Zhu Zhou; Peng Zhao, Jianhong Zhou and Fei Ruan critically revised the manuscript for critical content. Funding Information None Availability of data and materials Not applicable Ethics approval and consent to participate This study was approved by the ethics committee of Women’s Hospital, Zhejiang University School of Medicine. Consent for publication Written informed consent for publication was obtained from the patient. Conflict of Interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Author details Department of Obstetrics, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China; 2. Department of Obstetrics and Genecology, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China; 3. Department of Genecology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China. References Hibbard LT: Adnexal torsion . AM J OBSTET GYNECOL 1985, 152 (4):456-461. Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S: Long-term follow-up of the twisted ischemic adnexa managed by detorsion . FERTIL STERIL 1993, 60 (6):976-979. Zweizig S, Perron J, Grubb D, Mishell DJ: Conservative management of adnexal torsion . AM J OBSTET GYNECOL 1993, 168 (6 Pt 1):1791-1795. Taskin O, Birincioglu M, Aydin A, Buhur A, Burak F, Yilmaz I, Wheeler JM: The effects of twisted ischaemic adnexa managed by detorsion on ovarian viability and histology: an ischaemia-reperfusion rodent model . HUM REPROD 1998, 13 (1O):2823-2827. Hasiakos D, Papakonstantinou K, Kontoravdis A, Gogas L, Aravantinos L, Vitoratos N: Adnexal torsion during pregnancy: report of four cases and review of the literature . J Obstet Gynaecol Res 2008, 34 (4 Pt 2):683-687. Huang C, Hong MK, Ding DC: A review of ovary torsion . Ci Ji Yi Xue Za Zhi 2017, 29 (3):143-147. Seo SK, Lee JB, Lee I, Yun J, Yun BH, Jung YS, Chon SJ: Clinical and pathological comparisons of adnexal torsion between pregnant and non-pregnant women . J Obstet Gynaecol Res 2019, 45 (9):1899-1905. Robertson JJ, Long B, Koyfman A: Myths in the Evaluation and Management of Ovarian Torsion . J EMERG MED 2017, 52 (4):449-456. Friedman AM, Ananth CV, Prendergast E, Chauhan SP, D'Alton ME, Wright JD: Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations . AM J OBSTET GYNECOL 2015, 212 (2):221. Greer IA: Thrombosis in pregnancy: updates in diagnosis and management . Hematology Am Soc Hematol Educ Program 2012, 2012 :203-207. McGovern PG, Noah R, Koenigsberg R, Little AB: Adnexal torsion and pulmonary embolism: case report and review of the literature . OBSTET GYNECOL SURV 1999, 54 (9):601-608. McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, Muller P, Tran H, Walters BN, Young L: Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period . Aust N Z J Obstet Gynaecol 2012, 52 (1):14-22. Greer IA, Nelson-Piercy C: Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy . BLOOD 2005, 106 (2):401-407. Gynaecologists RCOO (ed.): Green-Top Guideline No. 37b. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. : London: Royal College of Obstetricians and Gynaecologists; 2015. Jauch FJ. Acute torsion of a hydrosalpinx . Br Med J 1922,2:83-84. Supplementary Files Supplementarymaterial.Searchstrategy.doc Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-114658","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case report","associatedPublications":[],"authors":[{"id":5229410,"identity":"4e5d861c-e0da-4dc3-8d71-57f68e119664","order_by":0,"name":"Peng Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYDACCSjNxt588MEHBjYQ24A4Lfw8x5INZ5CkRXKGj5k0D4SNX4v87OaHjwsq7thtuMFgIG3zhy+xgb15mwRDzR2cWhjnHDM2nnHmWfKG2w0Jxjk8bIkNPMfKJBiOPcOphVkiwUyat+1wssGdAweScySAWiRyzCQYGw7j1MImkf5NmvcfUMuNxIbDFgZALfJv8GvhAZopzdtw2E5yRjJjM0MCyBYe/FokJHKKjWccO5wADGRmxp4DbMZtPGnFFgnHcGuRn5G+8XFBzWF7Nvb+7z9+/Dkm289+eOONDzW4tYCDAIgTGyDsY5DITMCrAaLFHsquIaB2FIyCUTAKRiIAANDaVIsfo+vVAAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang University School of Medicine Women's Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Peng","middleName":"","lastName":"Zhao","suffix":""},{"id":5229411,"identity":"394656e4-d9b5-4c97-960a-20e321c145d3","order_by":1,"name":"Ying Zhao","email":"","orcid":"","institution":"Zhejiang University School of Medicine the Forth affiliated hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Zhao","suffix":""},{"id":5229412,"identity":"a07e2f18-098c-460b-980f-fe777344f868","order_by":2,"name":"Quan Zhang","email":"","orcid":"","institution":"Zhejiang university school of medicine the forth affiliated hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Quan","middleName":"","lastName":"Zhang","suffix":""},{"id":5229413,"identity":"ee56268d-39f8-46cd-97a4-ae5161f9d96c","order_by":3,"name":"Zhu Zhou","email":"","orcid":"","institution":"Zhejiang university school of medicine the forth affiliated hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhu","middleName":"","lastName":"Zhou","suffix":""},{"id":5229414,"identity":"e89c49c8-9247-43ad-a49c-c00c4889db6e","order_by":4,"name":"Jianhong Zhou","email":"","orcid":"","institution":"Zhejiang University School of Medicine Women's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jianhong","middleName":"","lastName":"Zhou","suffix":""},{"id":5229415,"identity":"0d7a2fba-9a35-49d8-9dc5-0ed373a76fb3","order_by":5,"name":"Fei Ruan","email":"","orcid":"","institution":"Zhejiang University School of Medicine Women's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Ruan","suffix":""}],"badges":[],"createdAt":"2020-11-23 23:54:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-114658/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-114658/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":3922656,"identity":"839cb91e-618e-46a8-a91f-e623a402ee50","added_by":"auto","created_at":"2020-12-01 16:39:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47599,"visible":true,"origin":"","legend":"Flow diagram","description":"","filename":"Fig1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-114658/v1/9c48d67053fcd18264315a67.JPG"},{"id":13620920,"identity":"2e9a6a92-47c2-4935-a7ac-2a111ff64c68","added_by":"auto","created_at":"2021-09-17 07:07:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":531846,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-114658/v1/6c843605-66a9-4f30-aaec-b67e6a9bc064.pdf"},{"id":3922657,"identity":"81d51f61-b912-4c7e-b9e8-49f4e7f22244","added_by":"auto","created_at":"2020-12-01 16:39:50","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12288,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.Searchstrategy.doc","url":"https://assets-eu.researchsquare.com/files/rs-114658/v1/5c902e0254c1bd681f784b55.doc"}],"financialInterests":"","formattedTitle":"\u003cp\u003eVenous Thromboembolism and Ovarian Torsion-detorsion in Pregnancy: a Case Report and Systematic Review of the Literature\u0026nbsp;\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eOvarian torsion during pregnancy, although fairly uncommon, is a well-recognized gynaecological emergency. It has been assumed that venous thromboembolism (VTE), being the leading cause of maternal death, was associated with ovarian torsion-detorsion. In order to avoid the release of emboli from the thrombotic vessels in the twisted adnexa, salpingo-oophorectomy without unwinding the adnexa was once the preferred surgical strategy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, in recent years, researchers have been advocating adnexal detorsion in place of salpingo-oophorectomy with the claim that infarcted adnexa were rarely attributed to VTE [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As a result, adnexal detorsion has now taken over as the mainstay of treatment for adnexal torsion to preserve ovarian function in young women. Even so, the safety of adnexal detorsion in pregnant women is still debatable as the hypercoagulable state during pregnancy intensifies the risk of thromboembolism. Consequently, we presented a case report of VTE after ovarian detorsion in pregnancy and conducted a systematic review of the literature.\u003c/p\u003e "},{"header":"Case Report","content":" \u003cp\u003eA 28-year-old women, gravida 1, para 0, in the 7th week of gestation was admitted to our hospital, complaining of lower abdominal pain and vomiting. Bimanual examination showed a pelvic mass and a point of tenderness in the right lower abdominal quadrant. Laboratory results revealed that the white blood cell count, C-reactive protein, hepatic enzymes and urine analysis were within normal ranges. Transvaginal ultrasound showed one intrauterine gestational sac with a viable embryo. The left adnexa were normal whereas the right ovary was enlarged, measuring 8.5*7.3*5.3\u0026nbsp;cm and a 6.9*5.8*4.8 ovarian cyst could be appreciated with an absence of vascular flow. The kidneys, pancreases, gall bladder and appendix showed no signs of abnormalities. In view of the above-mentioned findings, an explorative laparotomy was performed and an ischemic oedematous ovary was noted, containing a haemorrhagic corpus luteum cyst, around two thirds of which was dark bluish in colour and twisted for 1080 degree.\u003c/p\u003e \u003cp\u003eDetorsion of the twisted adnexa was done and re-colouration of the adnexa was noted during the observation period. Therefore, ovarian cystectomy was performed. The post-operative pathology report described a corpus luteum cyst. The necessary measures to prevent thrombosis were taken. For instance, early ambulation and anti-embolism stockings were encouraged. Nevertheless, on the third post-operative day, the patient complained of calf pain in her right leg. Palpation of the affected limb showed Neuhof's sign positive. Ultrasonography revealed an extensive thrombosis within the deep veins of her right leg. An elevated D-dimer of 2.4\u0026nbsp;mg/l was noted. The patient commenced on low weight molecular heparin (LWMH, Nadropin calcium) 4100\u0026nbsp;IU twice daily subcutaneously for 14 days. By the 10th day of treatment, the level of D-dimer dropped to 0.55\u0026nbsp;mg/l. Moreover, the follow-up ultrasonography performed at her 3 months review showed that the deep vein thrombosis in her right leg had completely disappeared. The patient eventually delivered a healthy infant at 39 weeks of gestation. Prophylactic administration of low-molecular-weight heparin (LMWH) was initiated after the delivery and the postpartum ultrasound examinations showed no signs of any further venous thrombosis.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eOne may argue that the current study is a case of ovarian torsion simultaneously with an event of VTE; however, we believe there is no need to debate as it is virtually impossible to confirm the relationship between ovarian torsion and VTE. The clinical significance of this study is to remind physicians that 1) VTE could occur after ovarian detorsion during pregnancy; 2) Early ambulation and anti-embolism stockings may not prevent VTE and therefore 3) the epidemiology, diagnosis and treatment regimens should be reviewed due to its rarity and complexity regarding to foetal health during pregnancy.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCurrent research status\u003c/h2\u003e \u003cp\u003eAbout 10\u0026ndash;22% of adnexal torsion occurred during pregnancy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It is more likely to occur between the 10th week and the 17th week of gestation with an ovarian mass larger than 4\u0026nbsp;cm in diameter [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The venous thromboembolism risk was reported to be 0.03% in pregnant women, which is increased by 5 folds as compared to non-pregnant women [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The above-mentioned data were mainly focused on the population of pregnant women. In addition to that, to the best of our knowledge, the subgroup of pregnancies with VTE after ovarian torsion-detorsion has seldom been evaluated. A comprehensive search was performed in Embase and PubMed. The search strategies were designed using controlled vocabulary and plain language without language restrictions (Supplementary material). As a result, there has been only one case of VTE and three cases of pulmonary embolism (PE) in patients with adnexal torsion in the literature across the globe. Three of four cases received adnexal resection without detorsion and all of the three cases were complicated with PE. One of four cases received cystectomy with detorsion and developed postoperative DVT. However, none of the cases occurred during pregnancy [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. Therefore, we are the first to present a case of an ovarian torsion in a pregnant woman which has been complicated with VTE after the surgical intervention with ovarian detorsion.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReports of venous thromboembolism after adnexal torsion\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePregnant/non-pregnant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTorsion site\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThromboembolic event\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJauch,1922(15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-pregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFallopian tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSalpingectomy without detorsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcGovern,1999(11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-pregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFallopian tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSalpingectomy without detorsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcGovern,1999(11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-pregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLeft ovarian torsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDetorsion\u0026thinsp;+\u0026thinsp;Cystectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003edeep vein thrombosis (right iliac vein)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcGovern,1999(11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enon-pregnant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight adnexal torsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRight salpingo-oophorectomy\u003c/p\u003e \u003cp\u003ewithout detorsion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eEpidemiology\u003c/h2\u003e \u003cp\u003eIn order to evaluate the epidemiological characteristics of pregnancies with post-detorsion VTE, we reviewed all of the medical records of our hospital from September 1991 to September 2019. Consequently, there were totally 256086 deliveries, out of which 260 cases had adnexal torsion and 17 cases had isolated fallopian tube torsion, amounting to an incidence of 0.11% and 0.007%, respectively. Of the 260 cases, 223 had ovarian tumour and 1 case developed VTE after the surgical detorsion, giving an incidence of 0.38% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e flow diagram).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eEvaluation and diagnosis\u003c/h2\u003e \u003cp\u003eThe diagnosis of VTE after ovarian torsion-detorsion during pregnancy mainly depends on the clinical symptoms, physical examination and imaging tests. Patients with deep vein thrombosis (DVT) may present with calf pain, swelling and tenderness in the leg and a positive Neuhof's sign. On the other hand, those who develop iliac vein thrombosis may complain of inguinal, pelvic, or abdominal pain, and experience swelling of the entire leg. Pregnant women with a high suspicion of DVT should undergo a D-dimer test and compression ultrasonography (CUS). If the initial CUS is negative, repeat CUS must be performed when there is a high index of suspicion. In comparison with DVT, PE is more challenging to diagnose as the clinical presentation may be non-specific. One should be cautious of PE when the patient complains of weakness and faintness, which is usually considered as the normal recovery process after the surgical detorsion and is therefore neglected. Some may experience tachycardia and tachypnea [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Under such circumstances, a computed tomography pulmonary angiogram (CTPA) is highly recommended [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. CUS should be performed after the confirmation of PE as DVT and PE are usually associated. In our study, the patient presented with calf pain and soreness of the lower limb and the diagnosis was established with an elevated D-dimer level and CUS. We did not perform further test for PE as the patients showed no clinical signs of any respiratory or cardiovascular diseases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eTreatment\u003c/h2\u003e \u003cp\u003eThe prophylactic measurements after surgical detorsion during pregnancy are early ambulation, anti-embolism stockings and intermittent pneumatic compression devices. It should be noted that the prophylactic measurements may not be able to prevent VTE. As in our case, VTE occurred although early ambulation and anti-embolism stockings were applied. Unfractionated heparin (UFH) and LMWH are both safe during pregnancy as neither will cross the placenta. However, administration of anticoagulants need careful considerations as heavy bleeding has been reported in 1.98% of pregnancies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In clinical practice, LMWH is the drug of choice for it is relatively easy to use and doses not require tedious monitoring. Guideline from the Royal College of Obstetricians and Gynaecologists [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] suggests that thromboprophylactic doses for antenatal LMWH should be based on weight with the most frequently used LMWH being Enoxaparin, Dalteparin and Tinzaparin. LMWH is recommended in therapeutic doses once daily or twice daily in the management of acute VTE in pregnancy. Nevertheless, for pregnant women with PE or severe VTE, LMWH should be initiated with therapeutic doses twice daily [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the current study, we started the treatment with therapeutic doses twice daily, and the complete resolution of emboli occurred in two weeks.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Conclusion","content":" \u003cp\u003eIn conclusion, VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. The thrombotic events, compromising of DVT and PE, are life-threatening conditions and their diagnosis depends mainly on the clinical manifestation, D-dimer and imaging tests such as CUS and CTPA. LMWH remains the drug of choice for both prophylactic measurement and therapeutic strategy. With prompt diagnosis and immediate treatment, VTE after ovarian torsion-detorsion is usually uneventful.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLWMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow weight molecular heparin; UFH:Unfractionated heparin; VTE:Venous thromboembolism; PE:Pulmonary embolism; DVT:Deep vein thrombosis; CUS:compression ultrasonography; CTPA:Computed tomography pulmonary angiogram ;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design: Peng Zhao, Jianhong Zhou, Fei Ruan; Literature search: Peng Zhao, Ying Zhao; Acquisition of data: Quan Zhang, Zhu Zhou; Data Synthesis and analysis: Ying Zhao, Quan Zhang, Zhu Zhou; Drafting of the manuscript: Peng Zhao, Ying Zhao, Quan Zhang, Zhu Zhou; Peng Zhao, Jianhong Zhou and Fei Ruan critically revised the manuscript for critical content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of Women\u0026rsquo;s Hospital, Zhejiang University School of Medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr /\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eDepartment of Obstetrics, Women\u0026rsquo;s Hospital, Zhejiang University School of Medicine, Hangzhou, China; 2. Department of Obstetrics and Genecology, the Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China; 3. Department of Genecology, Women\u0026rsquo;s Hospital, Zhejiang University School of Medicine, Hangzhou, China.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHibbard LT: \u003cstrong\u003eAdnexal torsion\u003c/strong\u003e. \u003cem\u003eAM J OBSTET GYNECOL\u003c/em\u003e 1985, \u003cstrong\u003e152\u003c/strong\u003e(4):456-461.\u003c/li\u003e\n\u003cli\u003eOelsner G, Bider D, Goldenberg M, Admon D, Mashiach S: \u003cstrong\u003eLong-term follow-up of the twisted ischemic adnexa managed by detorsion\u003c/strong\u003e. \u003cem\u003eFERTIL STERIL\u003c/em\u003e 1993, \u003cstrong\u003e60\u003c/strong\u003e(6):976-979.\u003c/li\u003e\n\u003cli\u003eZweizig S, Perron J, Grubb D, Mishell DJ: \u003cstrong\u003eConservative management of adnexal torsion\u003c/strong\u003e. \u003cem\u003eAM J OBSTET GYNECOL\u003c/em\u003e 1993, \u003cstrong\u003e168\u003c/strong\u003e(6 Pt 1):1791-1795.\u003c/li\u003e\n\u003cli\u003eTaskin O, Birincioglu M, Aydin A, Buhur A, Burak F, Yilmaz I, Wheeler JM: \u003cstrong\u003eThe effects of twisted ischaemic adnexa managed by detorsion on ovarian viability and histology: an ischaemia-reperfusion rodent model\u003c/strong\u003e. \u003cem\u003eHUM REPROD\u003c/em\u003e 1998, \u003cstrong\u003e13\u003c/strong\u003e(1O):2823-2827.\u003c/li\u003e\n\u003cli\u003eHasiakos D, Papakonstantinou K, Kontoravdis A, Gogas L, Aravantinos L, Vitoratos N: \u003cstrong\u003eAdnexal torsion during pregnancy: report of four cases and review of the literature\u003c/strong\u003e. \u003cem\u003eJ Obstet Gynaecol Res\u003c/em\u003e 2008, \u003cstrong\u003e34\u003c/strong\u003e(4 Pt 2):683-687.\u003c/li\u003e\n\u003cli\u003eHuang C, Hong MK, Ding DC: \u003cstrong\u003eA review of ovary torsion\u003c/strong\u003e. \u003cem\u003eCi Ji Yi Xue Za Zhi\u003c/em\u003e 2017, \u003cstrong\u003e29\u003c/strong\u003e(3):143-147.\u003c/li\u003e\n\u003cli\u003eSeo SK, Lee JB, Lee I, Yun J, Yun BH, Jung YS, Chon SJ: \u003cstrong\u003eClinical and pathological comparisons of adnexal torsion between pregnant and non-pregnant women\u003c/strong\u003e. \u003cem\u003eJ Obstet Gynaecol Res\u003c/em\u003e 2019, \u003cstrong\u003e45\u003c/strong\u003e(9):1899-1905.\u003c/li\u003e\n\u003cli\u003eRobertson JJ, Long B, Koyfman A: \u003cstrong\u003eMyths in the Evaluation and Management of Ovarian Torsion\u003c/strong\u003e. \u003cem\u003eJ EMERG MED\u003c/em\u003e 2017, \u003cstrong\u003e52\u003c/strong\u003e(4):449-456.\u003c/li\u003e\n\u003cli\u003eFriedman AM, Ananth CV, Prendergast E, Chauhan SP, D'Alton ME, Wright JD: \u003cstrong\u003eThromboembolism incidence and prophylaxis during vaginal delivery hospitalizations\u003c/strong\u003e. \u003cem\u003eAM J OBSTET GYNECOL\u003c/em\u003e 2015, \u003cstrong\u003e212\u003c/strong\u003e(2):221.\u003c/li\u003e\n\u003cli\u003eGreer IA: \u003cstrong\u003eThrombosis in pregnancy: updates in diagnosis and management\u003c/strong\u003e. \u003cem\u003eHematology Am Soc Hematol Educ Program\u003c/em\u003e 2012, \u003cstrong\u003e2012\u003c/strong\u003e:203-207.\u003c/li\u003e\n\u003cli\u003eMcGovern PG, Noah R, Koenigsberg R, Little AB: \u003cstrong\u003eAdnexal torsion and pulmonary embolism: case report and review of the literature\u003c/strong\u003e. \u003cem\u003eOBSTET GYNECOL SURV\u003c/em\u003e 1999, \u003cstrong\u003e54\u003c/strong\u003e(9):601-608.\u003c/li\u003e\n\u003cli\u003eMcLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, Muller P, Tran H, Walters BN, Young L: \u003cstrong\u003eRecommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period\u003c/strong\u003e. \u003cem\u003eAust N Z J Obstet Gynaecol\u003c/em\u003e 2012, \u003cstrong\u003e52\u003c/strong\u003e(1):14-22.\u003c/li\u003e\n\u003cli\u003eGreer IA, Nelson-Piercy C: \u003cstrong\u003eLow-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy\u003c/strong\u003e. \u003cem\u003eBLOOD\u003c/em\u003e 2005, \u003cstrong\u003e106\u003c/strong\u003e(2):401-407.\u003c/li\u003e\n\u003cli\u003eGynaecologists RCOO (ed.): \u003cstrong\u003eGreen-Top Guideline No. 37b. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium.\u003c/strong\u003e: London: Royal College of Obstetricians and Gynaecologists; 2015.\u003c/li\u003e\n\u003cli\u003eJauch FJ. \u003cstrong\u003eAcute torsion of a hydrosalpinx\u003c/strong\u003e. Br Med J 1922,2:83-84.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adnexal torsion, Ovarian torsion, Detorsion, Venous thromboembolism, Pulmonary embolism, Low molecular weight heparin","lastPublishedDoi":"10.21203/rs.3.rs-114658/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-114658/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe safety of adnexal detorsion in pregnant women is debatable as the hypercoagulable state during pregnancy intensifies the risk of thromboembolism. The diagnosis and treatment is challenging because its rarity and complexity due to the foetal health. Here we presented a rare case of venous thromboembolism (VTE) after ovarian detorsion during early pregnancy and conducted a review of the literature. VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. The diagnosis depends mainly on the clinical manifestation, D-dimer level and imaging tests such as compression ultrasonography and computed tomography pulmonary angiogram. Low-molecular-weight heparin remains the drug of choice for both prophylactic measurement and therapeutic strategy. With prompt diagnosis and immediate treatment, VTE after ovarian torsion-detorsion is usually uneventful.\u003c/p\u003e","manuscriptTitle":"Venous Thromboembolism and Ovarian Torsion-detorsion in Pregnancy: a Case Report and Systematic Review of the Literature\u0026nbsp;","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-01 16:39:48","doi":"10.21203/rs.3.rs-114658/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf366ac9-e8e8-404c-9176-beafccc5d6cf","owner":[],"postedDate":"December 1st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":1232388,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2021-01-14T23:55:22+00:00","versionOfRecord":[],"versionCreatedAt":"2020-12-01 16:39:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-114658","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-114658","identity":"rs-114658","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}