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Recurrence of Ovarian Torsion After Bilateral Synchronous Torsion and Oophoropexy: A Case Report and Review of the Literature
e30
Poster Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e27ee48
in 38 cases (53%). Staging was performed in 19 surgeries, with 16 done by pediatric surgeons. Appendectomy was performed in 17 cases, with pediatric surgery performing 15 of these (88%). Immature teratomas were present in 6 cases (8.3%) ages 5-20 years. All were laparotomies and in 5 tumor markers were obtained and staging performed. Alpha-fetoprotein, drawn in all 5, was elevated, ranging 25-390 ng/mL. Immature teratomas had an average greatest diameter of 15.4 cm (range 12 to 25.5 cm). Conclusions: Pediatric surgeons were more likely to perform laparotomy and oophorectomy as compared to general gynecologists and gynecology oncologists. Although there is minimal information regarding incidence of immature teratomas in children and adolescents, our percentage was higher than expected based on previous studies. Movement toward standardized imaging, tumor marker assessment and ovarian sparing surgery when appropriate should be done to benefit children and adolescents' recovery and future fertility.
8. Perinatal Ovarian Cysts: Ultrasonographic Finding and Consequence Gyun Ho Jeon MD 1, Jun Woo Ahn MD 2, Hyun Jin Roh MD 2, Sung Hoon Kim MD 3, Hee Dong Chae MD 3, Chung-Hoon Kim MD 3, Byung Moon Kang MD 3 1 Department of Obstetrics and Gynecology, Inje University, College of Medicine, Haeundae Paik Hospital, Busan, Korea 2 Department of Obstetrics and Gynecology, University of Ulsan, College of Medicine, Ulsan University Hospital, Ulsan, Korea 3 Department of Obstetrics and Gynecology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
Background: Although ovarian cysts in fetus and newborns are rare, the detection has increased with the extended use of ultrasonography. However, there is still controversy regarding the best treatment of these perinatal ovarian cyst. The aim of this study is to analyze the clinical outcome of perinatal ovarian cyst in relation to their ultrasonographic finding. Methods: 39 ovarian cysts were diagnosed in 33 fetuses and 6 infants, and followed with ultrasonograms until spontaneous or surgical resolution. The cases were divided into two groups on the basis of whether subsequent complications had developed or not (complicated cysts vs. non-complicated cysts) during their postnatal follow-up period. The size and characteristics of ovarian cysts at the initial ultrasonogram were analyzed in these two groups. The institutional review board of Asan Medical Center approved this study. Results: 25 cases (64.1%) were simple and 14 (35.9%) were complex at first scan. Mean maximum diameter of ovarian cyst was 4.8 1.6 cm. During their postnatal follow-up, 25 cases (64.1%) resolved spontaneously or after laparoscopic or ultrasound guided cyst aspiration. Fourteen cases (35.9%) were undergone operations in a clinical suspicion of complications such as torsion, rupture, hemorrhage, infarct or necrosis. However, only 7 cases were confirmed as complicated cysts, of which one was revealed as Table 1 The outcomes of perinatal ovarian cysts according to the mean size and characteristics at the initial ultrasonogram (USG) Non e complicated (n¼32) Mean size* (cm) Spontaneous Simple cystz (n¼25) regression Regression after aspiration Operation z Complex cyst Spontaneous (n¼14) regression Regression after aspiration Operation * y z x
6
4.5 1.5 23 (92.0%)
Complicated (n¼7) 6.1 1.6 2 (8.0%)
10 9 6
9 (64.3%)
3 5
Mean maximal diameter at initial USG Mann-Whitney U test, Characteristics at initial USG Fisher's exact test OR:6.389;95% CI (1.044-39.112)
P
0.012y 0.045x
a immature teratoma. The mean size of complicated cysts at first scan was significantly larger than non-complicated cysts (6.1 1.6 cm vs. 4.5 1.5 cm, P ¼ 0.012) and the complex characteristics at the initial diagnosis had a increased chance of developing subsequent complications (odds ratio, 6.389; 95% CI, 1.044-39.112; P ¼ 0.045). Conclusions: The majority of perinatal ovarian cysts can be primarily managed with observation or minimal surgical intervention. However, larger size and complex characteristics of the perinatal ovarian cysts at the initial ultrasonogram had a significant higher risk of subsequent complications in our study. This finding could be a useful basis in counseling about the prognosis and management of the perinatal ovarian cysts.
9. A Clinical Predictive Model for the Early Diagnosis of Adnexal Torsion in Children Cynthia Abraham MD 1, Heather Appelbaum MD 1, Jeanne Choi-Rosen MD 2 1 Department of Obstetrics and Gynecology, The Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York 2 Department of Radiology, The Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York
Introduction: Adnexal torsion accounts for 2.7% of all cases of children with acute abdominal pain. When adnexal torsion is undiagnosed, blood supply is compromised and may eventually lead to tissue necrosis and compromise to future fertility. Thus, early recognition and prompt management is critical in order to reduce morbidity and increase the chances of ovarian salvage. Historically, the diagnosis of ovarian torsion has been presumptive with definitive diagnosis dependant on laparoscopy. Because the clinical presentation of ovarian torsion is nonspecific and can easily be confused with other causes of acute abdominal pain, the preoperative diagnosis is very challenging and often leads to delay in diagnosis. The purpose of this study was to create a model that would aid in differentiating adnexal torsion from other sources of acute abdominal pain in children and adolescents in order to facilitate prompt management of this condition. Methods: This study was an IRB-approved retrospective chart review of 40 patients from 2 months to 18 years of age at a single institution who had adnexal torsion confirmed at time of surgery. Children under the age of 2 years were excluded because of incompatible data. Thirty-five charts were examined for data including age, symptoms, physical findings, laboratory tests, imaging studies, operative procedures and menarchal status. Sensitivities for presence of specific symptoms, physical findings, laboratory values and radiographic indicators were determined and subsequently assigned a diagnostic weight for the purpose of creating a scoring system. Results: Several factors were found to be suggestive of adnexal torsion: abdominal tenderness on physical exam (sensitivity 90%), intermittent nature of pain (sensitivity 83%), presence of adnexal mass (sensitivity 81%), size of adnexal mass (sensitivity 76%), heterogeneity of the ovarian parenchyma (sensitivity 73%), pain score greater than 6 (sensitivity 70%), presence of nausea and vomiting (sensitivity 64%), and asymmetrical ovarian enlargement. Other factors less suggestive of adnexal torsion included the presence of peritoneal signs (sensitivity 24%), radiating pain (sensitivity 31%), a palpable mass (sensitivity 7%), fever (sensitivity 12%), and leukocytosis (sensitivity 19%). Median age at the time of presentation was 13.0 years. 85% of patients were postmenarchal and 15% were premenarchal. A point score for predicting adnexal torsion was constructed based on these findings. Conclusions: This study demonstrates that a simple diagnostic scoring system based on both clinical and imaging parameters can aid in the diagnosis of adnexal torsion in children. A clinical scoring system for the assessment of adnexal torsion may facilitate preoperative diagnosis and more accurately indicate which patients will benefit from surgical intervention.
5 (35.7%)
10. Recurrence of Ovarian Torsion After Bilateral Synchronous Torsion and Oophoropexy: A Case Report and Review of the Literature Michelle Yates MD, Aimee Brecht-Doscher MD Department of Obstetrics and Gynecology, Ventura County Medical Center, Ventura, CA
Poster Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e27ee48
Background: In children and adolescents, ovarian torsion occurs 27.5% of the time in otherwise normal ovaries. Bilateral asynchronous torsion is reported in 11% of torsions with normal ovaries. Ovarian conservation and prophylactic oophoropexy are proposed to decrease the risk of ovarian failure. However, the optimal timing and technique for oophoropexy remains unclear. Case: We report a case of a 13 year old who presented with bilateral synchronous torsion. She underwent unilateral oophorectomy and oophoropexy of the contralateral ovary by plication of the utero-ovarian ligament. 9 months later she had recurrence of abdominal pain. After a delay of diagnosis for 5 days, she was diagnosed with recurrent ovarian torsion. She was treated laparoscopically with an untwisting of the ovary and ovarian conservation. The prior oophoropexy was clearly visible. However, the patient had no return of ovarian function. Comments: This case is remarkable for the presentation of synchronous torsion in normal ovaries and subsequent recurrent torsion after oophoropexy. This is one of few case reports of torsion after oophoropexy. This case reinforces the importance of continued education of primary providers on the signs, symptoms and ultrasound findings of ovarian torsion, and the importance of increased suspicion in patients with a prior torsion even after oophoropexy. It also demonstrates the importance of continued education of gynecologists and surgeons on the consideration for ovarian conservation in cases of torsion and the need for further research in effective methods and timing for oophoropexy.
e31
Fig. 1. Ultrasound documenting simple cyst.Ă
11. Massive Hydronephrosis from Ureteropelvic Junction Obstruction Masquerading as a Paratubal Cyst in an 11-Year-Old Girl Mariel A. Focseneanu MD , Diane F. Merritt MD Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Washington University School of Medicine, St. Louis, Missouri
Background: The differential diagnosis of a cystic pelvic mass in an adolescent girl is broad, and includes gastrointestinal, urologic, and gynecologic conditions. Some of the more commonly seen entities include an ovarian cyst, paratubal or paraovarian cyst, hydrosalpinx, peritoneal inclusion cyst, hydronephrosis, mesenteric or omental cyst, and enteric duplication cyst. Case: A premenarchal 11-year-old girl presented to the emergency room of an outside hospital due to abdominal pain and heavy vaginal bleeding. A transabdominal ultrasound of her pelvis was performed. On this ultrasound, the uterus appeared normal with an endometrial thickness of 3 mm. The right ovary measured 2.2 cm in diameter and contained 2 tiny follicles. The left ovary measured 2.3 cm in diameter and abutting the lateral side of the left ovary was a large mass with an appearance compatible with a large cyst measuring 16.7 x 11.9 cm in diameter. The patient was subsequently referred to us for evaluation. She had Tanner 4 breast development and a non-tender abdominal mass palpable up to the level of the umbilicus. It was determined that the bleeding was due to the onset of her first menses, and the cyst was likely paratubal since it appeared simple and distinct from the ovaries. Management options were discussed with the family, who elected to have repeat imaging rather than proceed directly to surgical removal. Serum tumor markers also were performed, including inhibin, BHCG, estradiol, AFP, and CA-125; these were all normal. Six days after the initial scan, a repeat ultrasound was performed at our institution to evaluate for any possible resolution or changes of this mass. The uterus and right ovary appeared normal. The left ovary was not visible on this examination. A large cystic mass was seen arising from the left adnexa, which was described as having a small septum in the superior aspect of the mass. It appeared to have enlarged, now measuring 17.7 x 13.6 cm. The cyst wall appeared smooth and there was no blood flow to the mass. At this point, the decision was made to proceed with an exploratory laparotomy for a presumed ovarian/paratubal cystectomy. The patient was found to have a massively dilated and displaced left kidney due to an ureteropelvic junction obstruction. Corrective surgery in the form of a dismembered pyeloplasty was done and the patient had a benign post-operative course. Comments: Pediatricians and gynecologists alike should be aware of the possibility that a cystic pelvic mass in an adolescent girl may not always be € llerian origin. Additional imaging (i.e. CT or MRI) may be of ovarian or mu
Fig. 2. Pfannenstiel incision demonstrating a portion of the massively dilated kidney and ureter (arrow).
helpful in distinguishing the origin of the cystic pelvic mass. Urinary tract obstruction is often silent; an incidental finding of hydronephrosis on ultrasound may be the first clue of the possibility of UPJ obstruction as the underlying diagnosis.
12. Precocious Puberty and Impending Ovarian Failure Associated With Neurologic Impairment in a Young Girl Sara E. Barton MD, Laurie E. Cohen MD Brigham and Women's Hospital, Boston, MA and Children's Hospital Boston, Boston, MA
Background: Precocious puberty is associated with CNS abnormalities. In addition, in girls with primary ovarian failure, gonadotropins can be elevated throughout early childhood. This case describes the clinical and laboratory findings in a young girl with co-existent precocious puberty and impending ovarian failure. Case: A 2 years 11 month old girl with a medical history significant for congenital hypotonia, global developmental delay, moderate sensineural hearing loss, and a complex cardiac malformation presented with vaginal bleeding. She carried no unifying underlying diagnosis, but prior extensive workup favored a metabolic disorder. Karyotype was 46 XX with a normal microarray. MRI showed patchy white matter disease and ventriculomegaly without evidence of intracranial mass. Her initial vaginal bleeding occurred at age 19 months, lasting 5 days. She was evaluated by pediatric gynecology who noted no abnormalities on physical exam, no pubic hair, and intact hymen. Pelvic ultrasound was ordered, and labs were performed: estradiol 45 pg/mL, FSH 16.79 IU/L, free T4 0.76 ng/dL (normal range 1.00-2.10) and TSH 4.520 uU/mL (normal range 0.700-5.70). She was then lost to follow-up.
Poster Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e27ee48
in 38 cases (53%). Staging was performed in 19 surgeries, with 16 done by pediatric surgeons. Appendectomy was performed in 17 cases, with pediatric surgery performing 15 of these (88%). Immature teratomas were present in 6 cases (8.3%) ages 5-20 years. All were laparotomies and in 5 tumor markers were obtained and staging performed. Alpha-fetoprotein, drawn in all 5, was elevated, ranging 25-390 ng/mL. Immature teratomas had an average greatest diameter of 15.4 cm (range 12 to 25.5 cm). Conclusions: Pediatric surgeons were more likely to perform laparotomy and oophorectomy as compared to general gynecologists and gynecology oncologists. Although there is minimal information regarding incidence of immature teratomas in children and adolescents, our percentage was higher than expected based on previous studies. Movement toward standardized imaging, tumor marker assessment and ovarian sparing surgery when appropriate should be done to benefit children and adolescents' recovery and future fertility.
8. Perinatal Ovarian Cysts: Ultrasonographic Finding and Consequence Gyun Ho Jeon MD 1, Jun Woo Ahn MD 2, Hyun Jin Roh MD 2, Sung Hoon Kim MD 3, Hee Dong Chae MD 3, Chung-Hoon Kim MD 3, Byung Moon Kang MD 3 1 Department of Obstetrics and Gynecology, Inje University, College of Medicine, Haeundae Paik Hospital, Busan, Korea 2 Department of Obstetrics and Gynecology, University of Ulsan, College of Medicine, Ulsan University Hospital, Ulsan, Korea 3 Department of Obstetrics and Gynecology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
Background: Although ovarian cysts in fetus and newborns are rare, the detection has increased with the extended use of ultrasonography. However, there is still controversy regarding the best treatment of these perinatal ovarian cyst. The aim of this study is to analyze the clinical outcome of perinatal ovarian cyst in relation to their ultrasonographic finding. Methods: 39 ovarian cysts were diagnosed in 33 fetuses and 6 infants, and followed with ultrasonograms until spontaneous or surgical resolution. The cases were divided into two groups on the basis of whether subsequent complications had developed or not (complicated cysts vs. non-complicated cysts) during their postnatal follow-up period. The size and characteristics of ovarian cysts at the initial ultrasonogram were analyzed in these two groups. The institutional review board of Asan Medical Center approved this study. Results: 25 cases (64.1%) were simple and 14 (35.9%) were complex at first scan. Mean maximum diameter of ovarian cyst was 4.8 1.6 cm. During their postnatal follow-up, 25 cases (64.1%) resolved spontaneously or after laparoscopic or ultrasound guided cyst aspiration. Fourteen cases (35.9%) were undergone operations in a clinical suspicion of complications such as torsion, rupture, hemorrhage, infarct or necrosis. However, only 7 cases were confirmed as complicated cysts, of which one was revealed as Table 1 The outcomes of perinatal ovarian cysts according to the mean size and characteristics at the initial ultrasonogram (USG) Non e complicated (n¼32) Mean size* (cm) Spontaneous Simple cystz (n¼25) regression Regression after aspiration Operation z Complex cyst Spontaneous (n¼14) regression Regression after aspiration Operation * y z x
6
4.5 1.5 23 (92.0%)
Complicated (n¼7) 6.1 1.6 2 (8.0%)
10 9 6
9 (64.3%)
3 5
Mean maximal diameter at initial USG Mann-Whitney U test, Characteristics at initial USG Fisher's exact test OR:6.389;95% CI (1.044-39.112)
P
0.012y 0.045x
a immature teratoma. The mean size of complicated cysts at first scan was significantly larger than non-complicated cysts (6.1 1.6 cm vs. 4.5 1.5 cm, P ¼ 0.012) and the complex characteristics at the initial diagnosis had a increased chance of developing subsequent complications (odds ratio, 6.389; 95% CI, 1.044-39.112; P ¼ 0.045). Conclusions: The majority of perinatal ovarian cysts can be primarily managed with observation or minimal surgical intervention. However, larger size and complex characteristics of the perinatal ovarian cysts at the initial ultrasonogram had a significant higher risk of subsequent complications in our study. This finding could be a useful basis in counseling about the prognosis and management of the perinatal ovarian cysts.
9. A Clinical Predictive Model for the Early Diagnosis of Adnexal Torsion in Children Cynthia Abraham MD 1, Heather Appelbaum MD 1, Jeanne Choi-Rosen MD 2 1 Department of Obstetrics and Gynecology, The Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York 2 Department of Radiology, The Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York
Introduction: Adnexal torsion accounts for 2.7% of all cases of children with acute abdominal pain. When adnexal torsion is undiagnosed, blood supply is compromised and may eventually lead to tissue necrosis and compromise to future fertility. Thus, early recognition and prompt management is critical in order to reduce morbidity and increase the chances of ovarian salvage. Historically, the diagnosis of ovarian torsion has been presumptive with definitive diagnosis dependant on laparoscopy. Because the clinical presentation of ovarian torsion is nonspecific and can easily be confused with other causes of acute abdominal pain, the preoperative diagnosis is very challenging and often leads to delay in diagnosis. The purpose of this study was to create a model that would aid in differentiating adnexal torsion from other sources of acute abdominal pain in children and adolescents in order to facilitate prompt management of this condition. Methods: This study was an IRB-approved retrospective chart review of 40 patients from 2 months to 18 years of age at a single institution who had adnexal torsion confirmed at time of surgery. Children under the age of 2 years were excluded because of incompatible data. Thirty-five charts were examined for data including age, symptoms, physical findings, laboratory tests, imaging studies, operative procedures and menarchal status. Sensitivities for presence of specific symptoms, physical findings, laboratory values and radiographic indicators were determined and subsequently assigned a diagnostic weight for the purpose of creating a scoring system. Results: Several factors were found to be suggestive of adnexal torsion: abdominal tenderness on physical exam (sensitivity 90%), intermittent nature of pain (sensitivity 83%), presence of adnexal mass (sensitivity 81%), size of adnexal mass (sensitivity 76%), heterogeneity of the ovarian parenchyma (sensitivity 73%), pain score greater than 6 (sensitivity 70%), presence of nausea and vomiting (sensitivity 64%), and asymmetrical ovarian enlargement. Other factors less suggestive of adnexal torsion included the presence of peritoneal signs (sensitivity 24%), radiating pain (sensitivity 31%), a palpable mass (sensitivity 7%), fever (sensitivity 12%), and leukocytosis (sensitivity 19%). Median age at the time of presentation was 13.0 years. 85% of patients were postmenarchal and 15% were premenarchal. A point score for predicting adnexal torsion was constructed based on these findings. Conclusions: This study demonstrates that a simple diagnostic scoring system based on both clinical and imaging parameters can aid in the diagnosis of adnexal torsion in children. A clinical scoring system for the assessment of adnexal torsion may facilitate preoperative diagnosis and more accurately indicate which patients will benefit from surgical intervention.
5 (35.7%)
10. Recurrence of Ovarian Torsion After Bilateral Synchronous Torsion and Oophoropexy: A Case Report and Review of the Literature Michelle Yates MD, Aimee Brecht-Doscher MD Department of Obstetrics and Gynecology, Ventura County Medical Center, Ventura, CA
Poster Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e27ee48
Background: In children and adolescents, ovarian torsion occurs 27.5% of the time in otherwise normal ovaries. Bilateral asynchronous torsion is reported in 11% of torsions with normal ovaries. Ovarian conservation and prophylactic oophoropexy are proposed to decrease the risk of ovarian failure. However, the optimal timing and technique for oophoropexy remains unclear. Case: We report a case of a 13 year old who presented with bilateral synchronous torsion. She underwent unilateral oophorectomy and oophoropexy of the contralateral ovary by plication of the utero-ovarian ligament. 9 months later she had recurrence of abdominal pain. After a delay of diagnosis for 5 days, she was diagnosed with recurrent ovarian torsion. She was treated laparoscopically with an untwisting of the ovary and ovarian conservation. The prior oophoropexy was clearly visible. However, the patient had no return of ovarian function. Comments: This case is remarkable for the presentation of synchronous torsion in normal ovaries and subsequent recurrent torsion after oophoropexy. This is one of few case reports of torsion after oophoropexy. This case reinforces the importance of continued education of primary providers on the signs, symptoms and ultrasound findings of ovarian torsion, and the importance of increased suspicion in patients with a prior torsion even after oophoropexy. It also demonstrates the importance of continued education of gynecologists and surgeons on the consideration for ovarian conservation in cases of torsion and the need for further research in effective methods and timing for oophoropexy.
e31
Fig. 1. Ultrasound documenting simple cyst.Ă
11. Massive Hydronephrosis from Ureteropelvic Junction Obstruction Masquerading as a Paratubal Cyst in an 11-Year-Old Girl Mariel A. Focseneanu MD , Diane F. Merritt MD Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Washington University School of Medicine, St. Louis, Missouri
Background: The differential diagnosis of a cystic pelvic mass in an adolescent girl is broad, and includes gastrointestinal, urologic, and gynecologic conditions. Some of the more commonly seen entities include an ovarian cyst, paratubal or paraovarian cyst, hydrosalpinx, peritoneal inclusion cyst, hydronephrosis, mesenteric or omental cyst, and enteric duplication cyst. Case: A premenarchal 11-year-old girl presented to the emergency room of an outside hospital due to abdominal pain and heavy vaginal bleeding. A transabdominal ultrasound of her pelvis was performed. On this ultrasound, the uterus appeared normal with an endometrial thickness of 3 mm. The right ovary measured 2.2 cm in diameter and contained 2 tiny follicles. The left ovary measured 2.3 cm in diameter and abutting the lateral side of the left ovary was a large mass with an appearance compatible with a large cyst measuring 16.7 x 11.9 cm in diameter. The patient was subsequently referred to us for evaluation. She had Tanner 4 breast development and a non-tender abdominal mass palpable up to the level of the umbilicus. It was determined that the bleeding was due to the onset of her first menses, and the cyst was likely paratubal since it appeared simple and distinct from the ovaries. Management options were discussed with the family, who elected to have repeat imaging rather than proceed directly to surgical removal. Serum tumor markers also were performed, including inhibin, BHCG, estradiol, AFP, and CA-125; these were all normal. Six days after the initial scan, a repeat ultrasound was performed at our institution to evaluate for any possible resolution or changes of this mass. The uterus and right ovary appeared normal. The left ovary was not visible on this examination. A large cystic mass was seen arising from the left adnexa, which was described as having a small septum in the superior aspect of the mass. It appeared to have enlarged, now measuring 17.7 x 13.6 cm. The cyst wall appeared smooth and there was no blood flow to the mass. At this point, the decision was made to proceed with an exploratory laparotomy for a presumed ovarian/paratubal cystectomy. The patient was found to have a massively dilated and displaced left kidney due to an ureteropelvic junction obstruction. Corrective surgery in the form of a dismembered pyeloplasty was done and the patient had a benign post-operative course. Comments: Pediatricians and gynecologists alike should be aware of the possibility that a cystic pelvic mass in an adolescent girl may not always be € llerian origin. Additional imaging (i.e. CT or MRI) may be of ovarian or mu
Fig. 2. Pfannenstiel incision demonstrating a portion of the massively dilated kidney and ureter (arrow).
helpful in distinguishing the origin of the cystic pelvic mass. Urinary tract obstruction is often silent; an incidental finding of hydronephrosis on ultrasound may be the first clue of the possibility of UPJ obstruction as the underlying diagnosis.
12. Precocious Puberty and Impending Ovarian Failure Associated With Neurologic Impairment in a Young Girl Sara E. Barton MD, Laurie E. Cohen MD Brigham and Women's Hospital, Boston, MA and Children's Hospital Boston, Boston, MA
Background: Precocious puberty is associated with CNS abnormalities. In addition, in girls with primary ovarian failure, gonadotropins can be elevated throughout early childhood. This case describes the clinical and laboratory findings in a young girl with co-existent precocious puberty and impending ovarian failure. Case: A 2 years 11 month old girl with a medical history significant for congenital hypotonia, global developmental delay, moderate sensineural hearing loss, and a complex cardiac malformation presented with vaginal bleeding. She carried no unifying underlying diagnosis, but prior extensive workup favored a metabolic disorder. Karyotype was 46 XX with a normal microarray. MRI showed patchy white matter disease and ventriculomegaly without evidence of intracranial mass. Her initial vaginal bleeding occurred at age 19 months, lasting 5 days. She was evaluated by pediatric gynecology who noted no abnormalities on physical exam, no pubic hair, and intact hymen. Pelvic ultrasound was ordered, and labs were performed: estradiol 45 pg/mL, FSH 16.79 IU/L, free T4 0.76 ng/dL (normal range 1.00-2.10) and TSH 4.520 uU/mL (normal range 0.700-5.70). She was then lost to follow-up.