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1. A Rare Case Of Huge Ovarian Cyst In Second Trimester. By Dr. S. Sahitya 3 rd yr OG PG

2. Case Summary:

3. COURSE DURING HER ADMISSION: Per abdominal examination revealed a distended abdomen. On palpation, the abdomen was soft and non-tender. Deep palpation revealed 20 weeks sized uterus. A huge mass of 18 cm × 15 × 10 cm was felt occupying the right hypochondrium, epigastrium, and the right lumbar region, with a smooth surface, cystic consistency. The lower pole of the mass could be reached, and the mass was non-tender. Tumor markers were done. CA – 125 -13 (0-35units/ml) CEA – 6.52 (0-2.5ng/ml) AFP – 31.19. (0-40ng/ml)

4. MRI ABDOMEN AND PELVIS: Showed a large well defined Abdomino -pelvic cystic lesion measuring 10.1*17*15cm with multiple thin internal septations arising from right adnexa and extending to right sub – hepatic space. No evidence of solid components. Right ovary not separately visualized. Left ovary appears normal.

5. DECISION TO OPERATE: Exploratory laparotomy with right salpingo-ophorectomy with omental biopsy and peritoneal cytology was planned. Inj. Proluton depot (hydroxyprogesterone) 500 mg IM stat was given a day before surgery.

6. INTRA – OP: Midline incision made. Peritoneum entered. Peritoneal aspirate sent for cytology. Right adnexal cyst of size 18*16*12cms was identified and exteriorized.

7. CONTD: Right Salphingo – oophorectomy was done. Infra – colic omentectomy done.

8. HISTOPATHOLGY: Benign mucinous cystadenoma Fibrocollagenous cyst wall lined by single layer of mucinous columnar epithelial cells. There is no stratification or atypia .

9. CASE DISCUSSION:

10. GENERAL POINTS: The prevalence of adnexal masses in pregnant women is 0.19-6.0%. More than 90% of these are less than 5 cm in size and are spontaneously absorbed before 16th weeks of gestation. However, a rapidly enlarging ovarian tumor during pregnancy is rare and should raise the suspicion for malignancy. In our Institution : 3 cases (only those which are operated in 1 st and 2 nd trimester). One torsion ovary was operated at 9weeks. Remaining two were operated in 2 nd trimester at 14weeks and 24weeks .

11. DIFFERENTIAL DIAGNOSIS:

12. ARE TUMOR MARKERS USEFUL? Ca–125 is a glycoprotein that increases in ovarian carcinoma, endometriosis, uterine fibroids, pelvic inflammation, menstruation and pregnancy. Particularly during 1st and 3rd trimester, increased amounts of Ca– 125 are produced from amnion and decidua. This marker is of importance when it is greater than 100IU/ml, while its main use is disease progression. CEA level is higher during 3rd trimester.

13. IOTA SIMPLE RULES: Rule 1: If one or more M features are present in absence of B feature, mass is classified as malignant. Rule 2: If one or more B features are present in absence of M feature, mass is classified as benign. Rule 3: If both M features and B features are present, or if no B or M features are present, result is inconclusive and second stage test is recommended.

14. MANAGEMENT: Management is dependent on the size and nature of the cyst as well as any patient symptoms. Generally surgery is avoided during pregnancy. If ovarian torsion is suspected , then the patient requires surgery. The torsion rate of adnexal masses during pregnancy is about 10–15%. The majority of ovarian torsion during pregnancy occurs at 8–16 weeks of gestation, during which the uterus grows faster.

15. CONTD: Patients having asymptomatic cysts of size 5–10 cm are reviewed after 16 weeks of pregnancy by ultrasonography. For asymptomatic cysts of size >10 cm, because of risk of torsion, malignancy, and labour obstruction, surgical removal is advised. Surgery in first trimester, can increase the risk of miscarriage and loss of luteal function. The recommendation to perform surgery is during the second trimester rather than the third trimester is primarily mechanical. The risk of preterm labour may be lower when surgery is performed during the second trimester than compared in the third trimester.

16. SURGICAL APPROACH: LAPAROTOMY Safer. Less anesthesia side effects. Minimal uterine manipulation. LAPAROSCOPY

17. IF MALIGNANT? Very very rare.  Most frequently reported are the non-epithelial tumours (germ-cell and sex-cord) followed by epithelial ovarian cancers. For early stage ovarian cancer, stage I and II, pregnancy preserving treatment may be considered. Removal of the adnexa and surgical staging by cytology, peritoneal biopsies, omentectomy and appendectomy in mucinous tumours. For high-grade stage I and any stage II disease, standard adjuvant chemotherapy (carboplatin-paclitaxel) can be considered after 14weeks of gestation. 

18. CONTD: For advanced stage III and IV, a dnexectomy/biopsy during pregnancy is aimed for, followed by completion of surgery after delivery. When the patient wants to proceed the pregnancy, neoadjuvant chemotherapy (carboplatin and paclitaxel) until fetal maturity and complete cytoreductive surgery after delivery is recommended.

19. REFERENCES: de Haan J, Verheecke M, Amant F. Management of ovarian cysts and cancer in pregnancy. Facts Views Vis Obgyn . 2015;7(1):25-31. PMID: 25897369; PMCID: PMC4402440. Kamalimanesh , Batool, Reza Jafarzadeh Esfehani , and Jila Agah . "Papillary serous cystadenoma of ovary: A huge ovarian cyst complicating the pregnancy."  J Cases Obstet Gynecol  3.4 (2016): 121-4. Kalmantis K, Petsa A, Alexopoulos E, Daskalakis G, Rodolakis A . Ovarian cysts in pregnancy. When surgical treatment required and when monitoring preferred? Rodriguez, S., Aviles, T. and Faro, R. (2021) ‘A Rapidly Enlarging Ovarian Cyst in a Pregnant Patient: The Surprise’, < i >Journal of Scientific Innovation in Medicine</ i >, 4(2), p. 39. Available at: https://doi.org/10.29024/jsim.140.