Ovarian preservation in a pregnant woman with a leaking dermoid cyst and ovarian torsion: a case study and review of diagnostic and therapeutic challenges

The patient is a 27-year-old primigravida with a gestational age of 18 weeks and 6 days, based on a nuchal translucency (NT) scan. She presented with abdominal pain, nausea, and loss of appetite for 2 days. The pain was localized to the right lower quadrant without radiation, and its intensity increased over a period of 2 days. She had no urinary symptoms, with normal urination and bowel movements. The patient had no significant past medical, surgical, or family history except for a 6-cm dermoid cyst in the right ovary observed in pre-pregnancy ultrasounds. On examination, she was afebrile, with a pulse rate of 96 bpm and a blood pressure of 110/80 mmHg. Her tilt test was negative. Abdominal examination revealed tenderness in the right lower quadrant without rebound tenderness. Laboratory results showed hemoglobin of 11.8 g/dL and a white blood cell (WBC) count of 11 000/mm 3 . An abdominal and pelvic ultrasound revealed a live fetus at 18–19 weeks of gestation and a 10-cm dermoid cyst in the right ovary. Early-stage appendicitis was also suspected, with findings of a non-compressible bowel loop (7.8 mm) and mild inflammatory changes near the cyst. Although there were no definitive imaging signs of acute appendicitis, clinical concerns remained. The patient underwent a laparotomy due to abdominal pain, during which a Pfannenstiel incision was made. Upon entering the abdomen, the right ovary was found to be completely twisted around the mesovarium, with a small tear in the dermoid cyst and leakage of its contents. The ovary appeared congested but showed no necrosis and regained its normal color after detorsion, allowing preservation. The appendix was firmly adherent to the cyst at the site of torsion. The ovary was detorsed, the cyst excised (cystectomy), and the ovary placed in warm saline to aid recovery. The procedure was completed successfully, preserving the right ovary (Fig. 1 ). Due to acute inflammatory changes consistent with early appendicitis, an appendectomy was also performed by a general surgeon. Histopathological analysis confirmed a mature cystic teratoma of the ovary and acute appendicitis. Postoperatively, vaginal progesterone suppositories were prescribed for 1 week to reduce the risk of miscarriage. Follow-up ultrasounds showed no signs of threatened miscarriage, and the patient was discharged in stable condition. She continued receiving regular prenatal care until 39 weeks of gestation and ultimately had an uncomplicated vaginal delivery. The case has been reported in line with the 2025 SCARE criteria [ 18 ] . Figure 1. (A) Appendix. (B) Ovary with dermoid cyst after Ovarian detorsion. (A) Appendix. (B) Ovary with dermoid cyst after Ovarian detorsion.

Dermoid cysts, also known as mature cystic teratomas, are the most common benign ovarian tumors in women of reproductive age, accounting for 10–25% of all ovarian neoplasms [ 1 ] . The highest prevalence is in women of age 20–40 years [ 2 ] , and 10–15% of patients have bilateral involvement [ 3 ] . They are slow-growing tumors arising from totipotent germ cells and composed of tissues from all three embryonic layers, including skin, fat, teeth, hair, nails, bone, nerves, and muscles [ 4 , 5 ] . HIGHLIGHTS Dermoid cysts are common in reproductive-age women, with a 0.3% incidence during pregnancy. They pose risks such as torsion, rupture, and peritonitis, which can endanger maternal and fetal health. Diagnosing ovarian torsion during pregnancy is complex due to overlapping symptoms with appendicitis and other abdominal conditions. Laparoscopic surgery is preferred in early pregnancy for its minimal invasiveness, while laparotomy is necessary in advanced pregnancy or when cysts are large, as seen in this case. A team of obstetricians, gynecologists, and general surgeons play a crucial role in diagnosis, surgical intervention, and postoperative care, ensuring the best outcome for both mother and baby. HIGHLIGHTS Dermoid cysts are common in reproductive-age women, with a 0.3% incidence during pregnancy. They pose risks such as torsion, rupture, and peritonitis, which can endanger maternal and fetal health. Diagnosing ovarian torsion during pregnancy is complex due to overlapping symptoms with appendicitis and other abdominal conditions. Laparoscopic surgery is preferred in early pregnancy for its minimal invasiveness, while laparotomy is necessary in advanced pregnancy or when cysts are large, as seen in this case. A team of obstetricians, gynecologists, and general surgeons play a crucial role in diagnosis, surgical intervention, and postoperative care, ensuring the best outcome for both mother and baby. Small dermoid cysts are usually asymptomatic and often discovered accidentally during routine imaging, such as pelvic ultrasounds or CT scans [ 6 ] . Typical radiologic features include a cystic mass with fat-fluid levels, echogenic shadowing, and a “Rokitansky nodule” or a dermoid plug [ 7 , 8 ] . As these cysts grow, they can cause symptoms like abdominal discomfort, bloating, pelvic pressure, and digestive disturbances [ 9 ] . Though complications such as torsion and rupture are uncommon, they can be severe, leading to conditions like peritonitis or bowel obstruction from leaking cyst contents [ 10 , 11 ] . Surgical removal is generally recommended once the cyst exceeds 5–6 cm in size, primarily to reduce the heightened risk of torsion and the small but clinically important risk of malignant transformation, which has been reported in approximately 1–2% of cases, most commonly into squamous cell carcinoma [ 12 ] . For women in their reproductive years and adolescents, managing dermoid cysts demands careful clinical consideration, especially when surgery is involved, since it can cause fertility implications. Surgical excision of the cyst could lead to the removal of healthy ovarian tissue, which may reduce the ovarian reserve or increase the risk of pelvic adhesions, potentially affecting future fertility [ 12 , 13 ] . Approximately 0.3% of pregnancies involve dermoid cysts, most often detected in the second trimester [ 14 ] . The growth of dermoid cysts during pregnancy, caused by hormonal changes and mechanical pressure from the enlarging uterus, can lead to an increased risk of complications such as ovarian torsion, cyst rupture, or infection, making careful monitoring and timely intervention essential [ 15 , 16 ] . Ovarian torsion is an uncommon but important condition, accounting for about 3% of all gynecologic emergencies [ 17 ] . Pregnancy itself is a recognized risk factor, with ovarian torsion reported in approximately 1–2% of all pregnancies. Despite this, the diagnosis is often delayed or missed due to its nonspecific clinical presentation [ 15 ] . Since a complicated ovarian dermoid cyst can be life-threatening for both mother and fetus due to ovarian torsion or rupture of cysts, and it can also be misdiagnosed as other conditions such as appendiceal abscess, retroverted uterus, pelvic kidney, or ectopic pregnancy, consistent follow-up and careful monitoring are essential [ 15 ] . The diagnosis and management of complicated dermoid cysts during pregnancy pose significant challenges for obstetricians and gynecologists, as these conditions can lead to severe complications such as peritonitis, ovarian torsion, or preterm labor. Surgical approaches like detorsion and cystectomy are critical for preserving ovarian function and future fertility, but delayed or inappropriate management can result in unnecessary oophorectomy and reduced ovarian reserve. Effective clinical decision-making requires balancing the risks of intervention with the safety of the pregnancy to ensure optimal outcomes. This report presents a unique case of a leaking dermoid cyst with torsion during pregnancy, highlighting the diagnostic and therapeutic challenges to ensure both immediate and long-term reproductive health. The case has been reported in line with the 2025 SCARE criteria [ 18 ] .

In this study, we report a unique and complex case of a pregnant patient at 18 weeks of gestation who presented with acute abdominal pain due to a leaking dermoid cyst with ovarian torsion. The successful preservation of ovarian function and an uncomplicated pregnancy in this case highlight the importance of early detection, diagnosis, and management. Comparing this case with other cases of complicated dermoid cysts in pregnant patients, summarized in Table 1 , provides valuable insights into the varied risk factors and management options for symptomatic dermoid cysts during pregnancy. Table 1 Summary of case reports on dermoid cysts complications during pregnancy: clinical presentations, management, and outcomes. Case Age (years) Gestational age at the time of diagnosis Gestational age at the time of procedure Complications of the patient Size of cyst Localization of cyst Prognosis of pregnancy Type of intervention Author/ year 1 38 7 w 16 w + 2 d Diagnosed during routine evaluations in pregnancy 7 cm Right ovary Without complication Single-port laparoscopic ovarian cystectomy Misawa, 2023 [ 19 ] 2 40 5 w 17 w Diagnosed during routine evaluations in pregnancy 6 cm Left ovary Without complication Single-port laparoscopic ovarian cystectomy Misawa, 2023 [ 19 ] 3 29 7 w 15 w + 3 d Diagnosed during routine evaluations in pregnancy 7 cm Left ovary Without complication Single-port laparoscopic ovarian cystectomy Misawa, 2023 [ 19 ] 4 35 1 month after NVD 1 month after NVD Rupture & peritonitis 16 cm Both ovaries Previous NVD Laparoscopic left cystectomy and right oophorectomy Bužinskienė, 2020 [ 20 ] 5 22 The first trimester of pregnancy 19 w + 5 d Right ovarian torsion 7.7 cm Right ovary Without complication Multi-port laparoscopic oophorectomy Osto, 2021 [ 21 ] 6 23 14 w 14 w Right ovarian torsion 14 cm Right ovary Without complication Laparotomy and oophorectomy After untwisting it Dhobale, 2023 [ 15 ] 7 32 5 w 37 w + 1 d Left ovarian torsion 6.9 cm Left ovary Without complication Laparotomy and left oophorectomy Agrawal, 2024 [ 22 ] 8 26 16 w 16 w Left ovarian torsion 7 cm Left ovary Without complication laparoscopic left cystectomy Abu-Musa, 2001 [ 23 ] 9 33 40 w 40 w Autoamputation of the ovary in the cul-de-sac 8 cm Cul-de-sac Uneventful cesarian section Laparotomy Remove of cyst, autoamputated ovary during c/s Peitsidou, 2009 [ 24 ] 10 26 31 w 31 w Torsion and lipogranulomatosis peritonitis due to spilled cyst contents 8 cm Pouch of Douglas Without complication, NVD at 40 w Laparoscopic Cystectomy Roman, 2005 [ 25 ] 11 31 26 w 26 w + 3 d Prior 7-cm dermoid cyst (5 years ago); recent scan: 2-cm simple cyst 9.8 cm Cul-de-sac Spontaneous NVD at 39 + 1 weeks Diagnostic laparoscopy with pelvic irrigation and peritoneal fluid sampling Fernandes, 2024 [ 26 ] 12 27 23 w 23 w Adnexal torsion on a dermoid cyst was made 4 cm Right ovary Term NVD Cystectomy via laparotomy Essebbagh, 2025 [ 27 ] d, days; NVD, natural vaginal delivery; w, weeks. This table presents a review of case reports on dermoid cysts in pregnant women, highlighting surgical approaches and pregnancy outcomes. Interventions ranged from single-port laparoscopy for smaller, uncomplicated cysts to laparotomy and oophorectomy for larger or symptomatic masses. The cyst sizes ranged from 6 to 16 cm, with some requiring emergency intervention due to torsion or rupture, while others were managed electively after incidental detection. Despite complications such as torsion, rupture, or lipogranulomatosis, the majority of pregnancies resulted in healthy maternal and fetal outcomes. The findings underscore the importance of individualized surgical planning to optimize results. Summary of case reports on dermoid cysts complications during pregnancy: clinical presentations, management, and outcomes. d, days; NVD, natural vaginal delivery; w, weeks. This table presents a review of case reports on dermoid cysts in pregnant women, highlighting surgical approaches and pregnancy outcomes. Interventions ranged from single-port laparoscopy for smaller, uncomplicated cysts to laparotomy and oophorectomy for larger or symptomatic masses. The cyst sizes ranged from 6 to 16 cm, with some requiring emergency intervention due to torsion or rupture, while others were managed electively after incidental detection. Despite complications such as torsion, rupture, or lipogranulomatosis, the majority of pregnancies resulted in healthy maternal and fetal outcomes. The findings underscore the importance of individualized surgical planning to optimize results. About 0.3% of all pregnant women have a dermoid cyst, usually diagnosed between the gestational ages of 18 and 28 weeks [ 14 ] . Managing dermoid cysts during pregnancy is particularly challenging for clinicians, as these cysts can lead to serious complications like torsion, rupture, and peritonitis, which threaten both maternal and fetal health [ 28 ] . In non-pregnant women, adnexal torsion accounts for up to 3% of emergency presentations with acute abdominal pain [ 17 ] . Pregnancy itself increases the risk of torsion, particularly in the first and early second trimesters, with a peak incidence between 6 and 14 weeks of gestation, when rapid uterine growth displaces adnexal structures [ 29 ] . The clinical presentation of torsion typically includes acute pelvic pain, nausea, vomiting, and occasionally fever or vaginal bleeding. However, these symptoms overlap significantly with other acute abdominal pathologies, most notably appendicitis [ 30 , 31 ] . Risk factors include pregnancy, fertility treatments, and the presence of ovarian cysts or masses [ 31 , 32 ] . In non-pregnant patients, the time between symptom onset and hospital referral is often longer, leading to delayed detection of ovarian masses before pregnancy [ 33 ] . However, in pregnant women presenting with acute abdominal pain and a history of an ovarian mass, torsion must remain a critical differential diagnosis, even if imaging findings are inconclusive [ 21 ] . This diagnostic overlap is particularly important in pregnancy, where appendicitis is the most common non-obstetric surgical emergency, with an incidence ranging from 1 in 500 to 1 in 2000 pregnancies [ 34 ] . While the coexistence of appendicitis with gynecologic pathology has been reported in approximately 4.6% of appendicitis cases [ 17 ] , true simultaneous presentation of acute appendicitis with adnexal torsion, particularly torsion of a dermoid cyst, remains extraordinary, with only a handful of cases documented in the literature [ 17 ] . In our case, the pre-pregnancy diagnosis of a dermoid cyst, combined with acute abdominal symptoms and physical examination findings, led to an emergent laparotomy to prevent severe complications. Hormonal changes and mechanical stress during pregnancy can make asymptomatic dermoid cysts symptomatic. Although the overall prognosis is favorable for symptomatic dermoid cysts during pregnancy, with timely intervention, choosing the best management approach depends on several factors, such as gestational age, cyst size, symptom severity, and the presence of complications [ 21 ] . In this case, the patient presented with progressive right lower quadrant pain, nausea, and anorexia (classic signs of ovarian torsion). Similar presentations are seen in torsion cases summarized in Table 1 (Cases 4–8 and 10), whereas other cysts (Cases 1–3) were detected incidentally during routine evaluations. Risk factors for developing symptoms during pregnancy, like cyst size, mobility, and long pedicles, are critical [ 15 ] , such as the 10-cm cyst in our patient or the 16-cm cyst in Case 4. Evaluating acute abdominal pain in pregnancy is complex and challenging due to altered anatomy caused by the gravid uterus, which creates a broad differential diagnosis, including conditions like preterm labor, placental abruption, appendicitis, renal colic, and ectopic pregnancy [ 35 ] . In the present case, appendicitis was initially suspected due to imaging findings and later confirmed to be related to cyst adhesions. Additionally, the incidence of right-sided ovarian torsion is more common, as observed in Case 5, Case 6, and the present case, which can be attributed to the anatomy of the pelvis and the stabilizing effect of the sigmoid colon on the left side, which limits the mobility of the left ovary and reduces its risk of torsion [ 36 , 37 ] . Considering this pattern helps clinicians accurately diagnose and manage acute abdominal pain during pregnancy. Managing dermoid cysts during pregnancy requires careful consideration to balance ovarian function preservation, maternal-fetal safety, and the prevention of severe complications. Conservative observation is typically preferred for small, asymptomatic cysts to maintain fertility, but emergencies like twisted or ruptured cysts require immediate surgery [ 38 , 39 ] , which may lead to more invasive procedures, including oophorectomy, if the ovarian damage is irreversible, as seen in cases 6 and 7, which were managed by radical oophorectomy. When surgical intervention is necessary, the decision between laparoscopy and laparotomy depends on several factors. Laparoscopy is the preferred approach, especially in early pregnancy, because of its reduced postoperative pain, shorter hospital stays, and lower risks of adverse fetal outcomes, such as premature birth or stillbirth [ 40 ] . However, in cases of advanced gestation or large cysts, laparotomy often provides better access and visualization and is preferred when there is limited expertise in laparoscopic surgery [ 38 ] . Cyst size is a critical factor affecting the choice of treatment. Most dermoid cysts are discovered incidentally during routine evaluations, with sizes ranging from 6 cm to 16 cm. Larger cysts, particularly those exceeding 5 cm, are at a higher risk of torsion and rupture [ 41 ] , as shown in Table 1 . Smaller cysts (≤7 cm) are often managed laparoscopically, even in cases of torsion, as demonstrated in Cases 5 and 8. In contrast, larger cysts or those with severe complications, such as rupture (Case 4), typically require laparotomy. The 10-cm cyst in the present case underwent an immediate cystectomy, in line with studies recommending surgical intervention and cystectomy for cysts over 10 cm due to the increased risk of complications [ 42 ] . For cysts measuring 6–10 cm, management decisions are guided by cyst complexity and patient symptoms, ranging from conservative observation with serial imaging [using ultrasound or magnetic resonance imaging (MRI)] to prophylactic surgery [ 43 ] . Moreover, characteristics such as complexity, multi-nucleation, septation, papillary excrescences, and solid components are suggested as indications for resection [ 43 ] . As stated earlier, gestational age also influences treatment decisions; as demonstrated in the present case, the emergent presentation and a gravid uterus at 18 weeks necessitated laparotomy to ensure proper visualization and safe cyst removal. Similarly, Cases 7 and 9 show how advanced gestational age and anatomical limitations often prevent the use of minimally invasive techniques, making laparotomy the preferred approach for safe management. Prophylactic surgery for masses measuring between 6 and 10 cm is recommended to prevent complications. If elective surgery is chosen, it is typically performed laparoscopically between 16 and 28 weeks of gestation [ 44 ] . Cystectomy with detorsion is usually the most recommended approach in cases of ovarian torsion, even if the ovaries are ischemic. However, if the ovarian damage is irreversible, salpingo-oophorectomy may be performed [ 45 ] . The decision requires careful consideration of surgical risks and maternal outcomes, involving a multidisciplinary team to ensure optimal care [ 22 ] . Taken together, our comparisons with previously reported cases demonstrate several important patterns: smaller cysts identified earlier in pregnancy are more often managed laparoscopically with successful preservation; larger cysts or those presenting later in gestation typically require laparotomy, with oophorectomy performed when necrosis is evident. The patient in the present case, however, presented at 18 weeks with a large (10 cm) leaking dermoid cyst complicated by torsion and appendiceal adhesion, yet ovarian function was successfully preserved following detorsion and cystectomy with concurrent appendectomy. This outcome highlights that even in complex presentations, careful intraoperative assessment can allow for fertility-preserving management and safe maternal–fetal outcomes. Our case, therefore, adds to the limited body of evidence supporting ovarian preservation in pregnancy, even under challenging circumstances.

The diagnosis and management of dermoid cysts during pregnancy are challenging due to the diverse clinical presentations and diagnostic difficulties. Managing symptomatic dermoid cysts during pregnancy depends on factors such as cyst size, gestational age, and the surgeon's expertise. Laparoscopy is often preferred in early pregnancy, but laparotomy may be necessary for larger cysts or advanced gestation. A multidisciplinary approach is essential to ensure an accurate diagnosis and optimal maternal-fetal outcomes.