A case report of severe hypothyroidism in pregnancy complicated by ovarian torsion: The role of medical treatment

There is a paucity of literature on the physiologic effects of hypothyroidism on ovarian tissue. Although ovarian enlargement and torsion secondary to hypothyroidism has been reported in non-pregnant patients, this phenomenon has not yet been described in pregnancy. We report the first case of this complication occurring in a pregnant patient. A 27-year-old gravida 3 para 2 presented at 29 3/7 weeks of gestation with acute onset of abdominal pain. Evaluation revealed severe maternal hypothyroidism [thyroid stimulating hormone (TSH) 213 μIU/mL and free thyroxine (FT4) 0.15 ng/dL] and bilaterally enlarged multicystic ovaries undergoing unilateral ovarian torsion. The consensus after a multidisciplinary meeting was that the ovarian enlargement was expected to reduce once the hypothyroidism was adequately treated. After urgent release of the ovarian torsion without cystectomy via maternal laparotomy, prompt thyroid hormone replacement using a combination of intravenous and oral levothyroxine resulted in a maternal euthyroid state. Concordantly, both ovaries demonstrated significant reduction in size within 3 weeks of initiating levothyroxine therapy, and normalization in appearance by 7 weeks postpartum. The patient did not experience recurrent abdominal pain after the initial surgical intervention. Both the patient and infant were doing well 12 months after delivery. Severe hypothyroidism is a rare, but potentially reversible cause of multicystic ovaries. Under such unique circumstances, ovarian preservation without cystectomy or oophorectomy is possible.