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gyn.ovarian-torsion.v1PRODUCTION
gyn.ovarian-torsion.v1

Ovarian / adnexal torsion (time-critical surgical emergency)

obstetricsacuteadultpediatric
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Time-critical surgical emergency — every hour of torsion reduces ovarian salvage; do NOT defer surgery if clinical suspicion high despite normal Doppler (ACOG CO 783, 2019)

Inputs
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Advance rule
Set
Advance when

torsion suspected (ACOG CO 783, 2019)

Patient inputs (12)

Pediatric / adolescent / reproductive-age / postmenopausal — different probabilities + management (ACOG CO 783, 2019; NASPAG 2020)

70%+ have N/V — presence raises suspicion (ACOG CO 783, 2019)

Ovarian hyperstimulation + pregnancy = elevated risk (ACOG CO 783, 2019)

Sudden onset + severe unilateral + colicky / persistent (ACOG CO 783, 2019)

Always pregnancy-test reproductive-age females; pregnancy + adnexal mass = increased torsion risk + ectopic ddx (ACOG CO 783, 2019)

Leukocytosis nonspecific; baseline for surgery (ACOG CO 783, 2019)

Definitive imaging; absence of arterial flow specific but presence does NOT rule out torsion (ACOG CO 783, 2019; ACR Appropriateness Criteria)

Hemodynamic check; usually stable but possible peritonitic deterioration (ACOG CO 783, 2019)

Tachycardia from pain + possible necrosis (ACOG CO 783, 2019)

Fever suggests necrosis or alternative dx (PID, appendicitis — ACOG CO 783, 2019)

When ultrasound non-diagnostic; CT shows enlarged ovary, twisted vascular pedicle (whirlpool — ACR Appropriateness Criteria)

Prior torsion = high recurrence risk; previous oophoropexy (ACOG CO 783, 2019)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningperitonitic_findings_or_instability — ACOG 2019
    Rebound, guarding, hypotension, tachycardia, or fever (ACOG CO 783, 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbilateral_torsion_simultaneous — ACOG 2019 / NASPAG 2020
    Simultaneous bilateral adnexal torsion — rare but with severe fertility consequence; pediatric and IVF / OHSS populations at higher relative risk (ACOG CO 783, 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_clinical_suspicion_normal_doppler — ACOG 2019
    Sudden severe unilateral pelvic pain + N/V + adnexal mass on US even with preserved Doppler flow (ACOG CO 783, 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_torsion — ACOG 2019
    Pediatric or adolescent female with sudden severe unilateral pelvic pain +/- adnexal mass (NASPAG 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_torsion — ACOG 2019
    Pregnant patient with suspected torsion (esp. first trimester or after IVF — ACOG CO 783, 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_torsion — ACOG 2019
    Second or third torsion event in same patient (ACOG CO 783, 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_malignancy — ACOG 2019
    Adnexal mass with imaging features suggesting malignancy (solid components, papillary projections, ascites) or postmenopausal patient (ACOG CO 783, 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereovarian_hyperstimulation_syndrome_overlap — ACOG 2019
    Recent IVF / ovulation induction with bilateral enlarged ovaries and torsion features (ACOG CO 783, 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredelayed_or_after_confirmation — Oelsner 2003 / ACOG 2019
    > 6 hours from confirmed torsion diagnosis (imaging or clinical) to OR — ovary salvage rate drops to < 30 % beyond 24 h despite still-recommended detorsion attempt (Oelsner Hum Reprod 2003; Bouguizane 2003; Anders 2005)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Ovarian torsion — perioperative supportive care + surgical pathway (ACOG CO 783, 2019)
axis: ovarian_torsion_perioperativestep 1 - Tier 1 — Pre-operative resuscitation + analgesia + antiemetics
Selected step "Tier 1 — Pre-operative resuscitation + analgesia + antiemetics" — Suspected torsion + clinical decision to operate (ACOG CO 783, 2019)
  • Lactated Ringer solution
    first line
    IV_crystalloid
    500-1000 mL IV bolus, then maintenance • IV • continuous
    triggers: preoperative_NPO, pain_or_volume_loss
    Pre-op resuscitation + maintenance; balanced crystalloid preferred (ACOG CO 783, 2019)
    rxcui 9863
  • ondansetron
    first line
    serotonin_5HT3_antagonist
    4 mg IV • IV • q8h PRN
    triggers: nausea_vomiting
    Symptom control; non-sedating (ACOG CO 783, 2019)
    rxcui 26225
  • morphine
    first line
    opioid
    0.1 mg/kg IV (typical 4-10 mg adult) • IV • q3-4h PRN
    triggers: severe_pain
    Severe acute pain; titrate to effect (ACOG CO 783, 2019)
    rxcui 7052
  • fentanyl
    add on
    opioid
    25-100 mcg IV • IV • q5-15 min PRN
    triggers: hemodynamic_lability, shorter_half_life_needed
    Short-acting, less histamine release; preferred in unstable patients (ACOG CO 783, 2019)
    rxcui 4337
  • ketorolac
    add on
    NSAID
    15-30 mg IV • IV • q6h PRN, max 5 days
    triggers: adjunct_analgesia_no_renal_impairment_no_bleeding_risk
    Multimodal analgesia; avoid in renal impairment, bleeding risk, suspected pregnancy (ACOG CO 783, 2019)
    rxcui 35827
  • acetaminophen
    add on
    analgesic
    1 g IV/PO • IV/PO • q6h, max 4 g/day
    triggers: multimodal_analgesia
    Opioid-sparing; safe in pregnancy (ACOG CO 783, 2019)
    rxcui 161

outpatient playbook — drug actions (5)

  1. 1. acetaminophen
    rxcui 161
    650-1000 mg PO q6h PRN (max 3 g/day) • PO • q6h PRN
    trigger: Post-op pain at 1-2 week visit if ongoing (NICE multimodal analgesia)
    Multimodal opioid-sparing analgesia (ACOG CO 783, 2019)
  2. 2. ibuprofen
    rxcui 5640
    400-600 mg PO q6h PRN (max 2.4 g/day) • PO • q6h PRN
    trigger: Post-op pain — no renal impairment, no bleeding risk, not pregnant
    Effective laparoscopy post-op adjunct (ACOG CO 783, 2019)
  3. 3. LARC OR combined OC OR barrier
    Per provider preference; LARC (copper IUD or LNG-IUS) acceptable; combined OC if no contraindications • PO / IUD • continuous
    trigger: Reproductive-plan-aligned contraception (no fertility-preservation barrier post-detorsion if ovary preserved) (ACOG CO 783, 2019)
    Reproductive autonomy + cycle regulation
  4. 4. estradiol or hormonal replacement (if early menopause from oophorectomy in young patient)
    Per endocrine / REI consult • PO / transdermal • continuous
    trigger: Premature ovarian insufficiency post-bilateral-oophorectomy or post-unilateral with poor remaining-ovary reserve (NASPAG 2020)
    Symptomatic + bone-health management for early menopause
  5. 5. oral iron (if post-op anemia)
    rxcui 90176
    Ferrous sulfate 325 mg PO daily • PO • daily
    trigger: Post-op anemia (Hgb < 11 g/dL) at 1-2 week visit (ACOG CO 783, 2019)
    Iron repletion for post-bleed anemia recovery

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden severe unilateral pelvic / lower abdominal pain (ACOG CO 783, 2019); Pelvic pain with nausea and vomiting (mimics ovarian torsion — ACOG CO 783, 2019); TVUS: enlarged ovary >5 cm, decreased / absent Doppler flow, whirlpool sign, ovarian edema (ACR Appropriateness Criteria).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Ovarian / adnexal torsion (time-critical surgical emergency)** (gyn.ovarian-torsion.v1).
Phenotype framing: Ovarian torsion vs hemorrhagic ovarian cyst rupture vs ectopic pregnancy vs PID / TOA vs appendicitis vs ureteral stone vs endometriosis flare; in children consider intussusception, Meckel diverticulum, testicular torsion (always exam males — NASPAG 2020; ACOG CO 783, 2019)
Scope: Time-critical surgical emergency — every hour of torsion reduces ovarian salvage; do NOT defer surgery if clinical suspicion high despite normal Doppler (ACOG CO 783, 2019)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Ovarian torsion — perioperative supportive care + surgical pathway (ACOG CO 783, 2019)** — step "Tier 1 — Pre-operative resuscitation + analgesia + antiemetics".
1. Lactated Ringer solution 500-1000 mL IV bolus, then maintenance IV continuous (IV_crystalloid, first line) — Pre-op resuscitation + maintenance; balanced crystalloid preferred (ACOG CO 783, 2019)
2. ondansetron 4 mg IV IV q8h PRN (serotonin_5HT3_antagonist, first line) — Symptom control; non-sedating (ACOG CO 783, 2019)
3. morphine 0.1 mg/kg IV (typical 4-10 mg adult) IV q3-4h PRN (opioid, first line) — Severe acute pain; titrate to effect (ACOG CO 783, 2019)
4. fentanyl 25-100 mcg IV IV q5-15 min PRN (opioid, add on) — Short-acting, less histamine release; preferred in unstable patients (ACOG CO 783, 2019)
5. ketorolac 15-30 mg IV IV q6h PRN, max 5 days (NSAID, add on) — Multimodal analgesia; avoid in renal impairment, bleeding risk, suspected pregnancy (ACOG CO 783, 2019)
6. acetaminophen 1 g IV/PO IV/PO q6h, max 4 g/day (analgesic, add on) — Opioid-sparing; safe in pregnancy (ACOG CO 783, 2019)

Setting playbook (outpatient) — Post-detorsion gynecology follow-up: ovarian function assessment, fertility counseling, contraception OR fertility-preservation discussion, oophoropexy consideration if recurrent torsion or large adnexal mass remaining, psychosocial recovery + future-pregnancy anxiety, pelvic ultrasound at 3 months if ovary preserved, future-pregnancy counseling (early TVUS at next pregnancy — recurrence on contralateral ovary risk) (ACOG CO 783 2019; NASPAG 2020; ACOG PB 234 2021)
7. acetaminophen 650-1000 mg PO q6h PRN (max 3 g/day) PO q6h PRN — Post-op pain at 1-2 week visit if ongoing (NICE multimodal analgesia) (Multimodal opioid-sparing analgesia (ACOG CO 783, 2019))
8. ibuprofen 400-600 mg PO q6h PRN (max 2.4 g/day) PO q6h PRN — Post-op pain — no renal impairment, no bleeding risk, not pregnant (Effective laparoscopy post-op adjunct (ACOG CO 783, 2019))
9. LARC OR combined OC OR barrier Per provider preference; LARC (copper IUD or LNG-IUS) acceptable; combined OC if no contraindications PO / IUD continuous — Reproductive-plan-aligned contraception (no fertility-preservation barrier post-detorsion if ovary preserved) (ACOG CO 783, 2019) (Reproductive autonomy + cycle regulation)
10. estradiol or hormonal replacement (if early menopause from oophorectomy in young patient) Per endocrine / REI consult PO / transdermal continuous — Premature ovarian insufficiency post-bilateral-oophorectomy or post-unilateral with poor remaining-ovary reserve (NASPAG 2020) (Symptomatic + bone-health management for early menopause)
11. oral iron (if post-op anemia) Ferrous sulfate 325 mg PO daily PO daily — Post-op anemia (Hgb < 11 g/dL) at 1-2 week visit (ACOG CO 783, 2019) (Iron repletion for post-bleed anemia recovery)

Non-pharmacologic actions:
- Strict return precautions in writing — sudden severe new pelvic pain, vomiting, syncope, fever → ED immediately for recurrent torsion or other emergency (ACOG CO 783, 2019)
- Pelvic rest 1-2 weeks post-op — no intercourse / pelvic exam / strenuous activity until cleared (ACOG CO 783, 2019)
- Fertility-preservation referral if oophorectomy required at index OR + premenopausal status + interest (NASPAG 2020)
- Oophoropexy decision — joint discussion at 6-week visit if recurrent torsion history OR large adnexal mass remaining OR pediatric normal-ovary torsion (ACOG CO 783 2019; NASPAG 2020)
- Future-pregnancy counseling — early TVUS at next pregnancy; recurrence on contralateral ovary risk; torsion-recognition symptoms during pregnancy (ACOG CO 783 2019; Pansky 2006)
- Psychosocial support — pediatric / adolescent patients + post-IVF patients have heightened distress; offer counseling resources (NASPAG 2020)
- Patient education — recognise recurrence symptoms; emphasise importance of completing 3-month pelvic ultrasound to document ovarian viability (ACOG CO 783, 2019)

AVOID / contraindication checks:
- NSAIDs_avoid_in_pregnancy_third_trimester (ACOG CO 783, 2019)
- NSAIDs_avoid_in_renal_impairment (ACOG CO 783, 2019)
- Opioid_dosing_lower_in_pediatric_and_elderly (NASPAG 2020)
- Antibiotics_only_if_infection_suspected_not_routine_torsion (ACOG CO 783, 2019)
- No_anticoagulation_until_hemostasis_confirmed_post_op (ACOG CO 783, 2019)

Monitoring

Regimen monitoring:
- preop vitals and pain q15 30 min (ACOG CO 783, 2019)
- intraop anesthesia continuous (ACOG CO 783, 2019)
- postop vitals q1h then q4h (ACOG CO 783, 2019)
- pain score q4h (ACOG CO 783, 2019)
- tolerance of diet (ACOG CO 783, 2019)
- ambulation postop day 0 (ACOG CO 783, 2019)
- wound check (ACOG CO 783, 2019)
- postop 2 week outpatient visit (ACOG CO 783, 2019)

Setting (outpatient) monitoring:
- 1-2 week post-op visit — wound check, pain, return to activity (ACOG CO 783, 2019)
- 6-week post-op visit — psychosocial screen, contraception adherence, oophoropexy decision, fertility plan, pathology review confirmation (ACOG CO 783 2019; NASPAG 2020)
- 3-month pelvic ultrasound if ovary preserved — viability + perfusion + follicular activity (ACOG CO 783, 2019)
- FSH + estradiol at 3 months if symptomatic + ovary-preservation concern (ACOG CO 783, 2019)
- Annual gynecology follow-up if cyst pathology benign + symptomatic recovery complete (ACOG PB 234, 2021)
- Future-pregnancy early TVUS at 6-8 wk gestation in any next pregnancy — recurrence-on-contralateral-ovary risk (Pansky 2006)

Follow-up plan: Outpatient gyn 1-2 wk; pathology review; reproductive counselling; recurrence-prevention discussion (oophoropexy decision — ACOG CO 783, 2019); contraception counselling if pregnancy not desired
- Close-out criterion: pathology and outpatient plan documented (ACOG CO 783, 2019)

Monitoring phase: Post-op pain, bleeding, tolerating diet, ambulation; pelvic exam at 1-2 wk; pathology review of any cystectomy specimen; counsel on recurrence (~10-20% risk in patients without oophoropexy or with persistent risk factor — ACOG CO 783, 2019)

Disposition

Current setting: outpatient — Post-detorsion gynecology follow-up: ovarian function assessment, fertility counseling, contraception OR fertility-preservation discussion, oophoropexy consideration if recurrent torsion or large adnexal mass remaining, psychosocial recovery + future-pregnancy anxiety, pelvic ultrasound at 3 months if ovary preserved, future-pregnancy counseling (early TVUS at next pregnancy — recurrence on contralateral ovary risk) (ACOG CO 783 2019; NASPAG 2020; ACOG PB 234 2021)

Disposition criteria:
- Continue outpatient gynecology follow-up through 3-month pelvic ultrasound + ovarian function assessment if ovary preserved (ACOG CO 783, 2019)
- Discharge from gynecology to primary care once pathology benign + symptomatic recovery + ovarian function confirmed + contraception or fertility plan in place + psychosocial recovery confirmed (ACOG CO 783, 2019; NASPAG 2020)
- Continue annual gynecology follow-up if recurrent-torsion history, oophoropexy performed, fertility-preservation considerations, or postmenopausal complex pathology (ACOG PB 234, 2021)

Escalation triggers (move to higher acuity):
- New severe pelvic pain, vomiting, syncope → ED for recurrent torsion evaluation (ACOG CO 783, 2019)
- Pathology returns malignancy — refer gyn-onc; staging + adjuvant per histology (ACOG PB 234, 2021)
- Pelvic ultrasound at 3 months shows non-viable ovary OR persistent mass — gynecology re-evaluation; consider re-imaging with MRI (ACOG CO 783, 2019)
- Premature ovarian insufficiency markers (FSH > 25 mIU/mL on 2 occasions + amenorrhea / vasomotor symptoms) — refer REI / endocrinology for hormone replacement + fertility counseling (NASPAG 2020)
- Recurrent torsion at any time — return to gynecology for oophoropexy consideration (ACOG CO 783, 2019)
- Persistent psychosocial distress at 6-week or 3-month visit — referral to counseling / mental-health support (NASPAG 2020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Rebound, guarding, hypotension, tachycardia, or fever (ACOG CO 783, 2019)
- [LIFE_THREATENING] Simultaneous bilateral adnexal torsion — rare but with severe fertility consequence; pediatric and IVF / OHSS populations at higher relative risk (ACOG CO 783, 2019)
- [SEVERE] Sudden severe unilateral pelvic pain + N/V + adnexal mass on US even with preserved Doppler flow (ACOG CO 783, 2019)

Citations

- ACOG Committee Opinion 783 (2019, reaff 2023) — Adnexal torsion in adolescents and reproductive-age women + ACOG Practice Bulletin 234 (2021) — Management of Adnexal Masses + ACR Appropriateness Criteria — Acute Pelvic Pain in the Reproductive Age Group (most recent revision) + NASPAG 2020 + AAP pediatric ovary-preservation consensus + Oelsner Hum Reprod 2003 + Bouguizane 2003 + Anders Arch Pediatr Adolesc Med 2005 + Vijayaraghavan J Ultrasound Med 2004 (whirlpool sign) + SOGC Ovarian Torsion CPG (verify) [PMID:14645177](https://pubmed.ncbi.nlm.nih.gov/14645177/)
- Cited evidence (PMID 14593299) [PMID:14593299](https://pubmed.ncbi.nlm.nih.gov/14593299/)
- Cited evidence (PMID 15939851) [PMID:15939851](https://pubmed.ncbi.nlm.nih.gov/15939851/)
- Cited evidence (PMID 15557307) [PMID:15557307](https://pubmed.ncbi.nlm.nih.gov/15557307/)

Last reconciled with current guidelines: 2026-05-14.
References
  • ACOG Committee Opinion 783 (2019, reaff 2023) — Adnexal torsion in adolescents and reproductive-age women + ACOG Practice Bulletin 234 (2021) — Management of Adnexal Masses + ACR Appropriateness Criteria — Acute Pelvic Pain in the Reproductive Age Group (most recent revision) + NASPAG 2020 + AAP pediatric ovary-preservation consensus + Oelsner Hum Reprod 2003 + Bouguizane 2003 + Anders Arch Pediatr Adolesc Med 2005 + Vijayaraghavan J Ultrasound Med 2004 (whirlpool sign) + SOGC Ovarian Torsion CPG (verify) — PMID:14645177
  • Cited evidence (PMID 14593299) — PMID:14593299
  • Cited evidence (PMID 15939851) — PMID:15939851
  • Cited evidence (PMID 15557307) — PMID:15557307