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 Table of Contents  
CASE SERIES
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 22-26

A review of surgically managed complicated ovarian cysts in pregnancy in a Northern Nigerian tertiary hospital


Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Submission27-Apr-2020
Date of Acceptance17-Jun-2020
Date of Web Publication06-May-2021

Correspondence Address:
Dr. Rabi'at Muhammad Aliyu
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_20_20

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  Abstract 


Ovarian cysts in pregnancy are usually managed conservatively but surgical treatment is done for complicated cases. The diagnosis of complicated ovarian cyst in pregnancy is challenging, management often poses a dilemma to the obstetrician and is a source of anxiety to the patient because it can be associated with adverse pregnancy outcome. Complicated ovarian cysts in pregnancy accounted for 16.7% of all surgically managed ovarian cyst accidents (3/18) in our institution. It was also the most common indication for non-pregnancy-related laparotomy in pregnancy (3/6). The mean age of the patients was 31 ± 5.6 years, 66.7% (2/3) were primigravidae and all had cyst complication in the second trimester. All women presented with abdominal pain but accurate initial preoperative diagnosis was made in only 33.3%. Mean presentation to surgery interval was 46.7 h. All patients received tocolytic argents. The mean size of the cyst was 10.9 cm, commonest complication was torsion, and all cysts were benign. The commonest surgery performed was salpingo-oophorectomy. Surgical intervention was associated with favorable perinatal outcome in most cases with fetal loss seen when cyst was rapidly increasing in size or ≥15 cm in size. Prompt diagnosis and intervention enables preservation of affected adnexa.

Keywords: Complicated ovarian cyst, surgery in pregnancy, emergency surgery, emergency salpingo-oophorectomy


How to cite this article:
Aliyu RM, Sada SI, Umar Hauwa S, Mahmud FA, Randawa AJ, Onwuhafua P. A review of surgically managed complicated ovarian cysts in pregnancy in a Northern Nigerian tertiary hospital. Arch Int Surg 2020;10:22-6

How to cite this URL:
Aliyu RM, Sada SI, Umar Hauwa S, Mahmud FA, Randawa AJ, Onwuhafua P. A review of surgically managed complicated ovarian cysts in pregnancy in a Northern Nigerian tertiary hospital. Arch Int Surg [serial online] 2020 [cited 2021 Jun 16];10:22-6. Available from: https://www.archintsurg.org/text.asp?2020/10/1/22/315393




  Introduction Top


Ovarian cysts in pregnancy is increasingly being diagnosed with the liberal use of prenatal ultrasound especially in early pregnancy.[1] Adnexal masses are seen in 0.1%–2.4% of pregnant women with ovarian cysts being the commonest adnexal masses in pregnancy.[2],[3],[4] Nearly all are benign functional simple cysts of less than 5 cm in diameter, most of which are either follicular or corpus luteum cysts.[3],[5] By 20 weeks' gestation, majority of ovarian cysts in pregnancy resolve spontaneously.[6],[7] Resolution is less likely when ovarian cysts are larger than 5 cm and of complex morphology.[3],[6],[7] The majority of persistent complex ovarian cysts in pregnancy are mature teratomas.[8]

Complications of ovarian cysts include torsion, infection, rupture, and hemorrhage. These complications lead to a significant symptomatic state and may warrant surgical intervention in pregnancy. These complications account for 5.6% of all gynecological emergencies in our center.[9]

Though ultrasound scan is commonly used to diagnose ovarian cyst in pregnancy especially in the first trimester, it is unable to detect ovarian cysts in 20% of cases because enlarged gravid uterus may limit visualization of the ovaries.[10] Ultrasound scan can characterize the nature of the ovarian cysts and is also important in monitoring of the cyst. Use of magnetic resonance imaging without gadolinium-based contrast is safe in pregnancy and is a useful tool in the assessment of suspected malignant ovarian cyst.

Management of ovarian cyst in pregnancy depends upon the size of the cyst, sonographic appearance, and associated clinical symptoms.[3] Because majority of ovarian cysts in pregnancy are benign and resolve spontaneously, the recommended optimal management is conservative, especially where the cysts appear benign and are asymptomatic with surgical management reserved for patients having complicated cysts or suspicious of malignancy.[4],[5],[11] Laparoscopy and laparotomy have been reported to yield similar obstetric outcome.[1] The timing of surgical intervention is key in the management of women with symptomatic ovarian cyst in pregnancy. Surgery in first trimester and beyond 24 weeks' gestation is associated with adverse pregnancy outcomes thus optimal gestational age for surgical intervention is 14–22 weeks.[11] Reported adverse pregnancy outcomes include miscarriages, preterm birth/prematurity and obstruction of labor.[5],[12] Thus, risks of surgical intervention in pregnancy must be weighed against perinatal outcome.[11]

Surgical treatment of complicated ovarian cyst in pregnancy causes anxiety to the patient because it may lead to adverse pregnancy outcome. We aimed to review the surgically managed complicated ovarian cysts accidents in pregnancy in our center.


  Patients and Method Top


Case folders of women who had surgical treatment of ovarian cysts in pregnancy in all trimesters at Ahmadu Bello University Teaching Hospital, Zaria between March 2014 and December 2018 were retrieved and reviewed. Socio-demographic data, reproductive profile, clinical presentation and course, ultrasound reports, surgical details, perioperative course, and histology reports were extracted and analyzed.


  Results Top


During the period under review, there were 18 cases of surgically managed ovarian cyst accidents, 3 of which were in pregnancy (3/18, 16.7%). Complicated ovarian cysts also accounted for 50% (3/6) of nonpregnancy-related indications for laparotomy in pregnancy. The mean age of women was 31 ± 5.6 years and two-third (2/3) were primigravidae. All women presented in the second trimester and abdominal pain was the consistent symptom in 100% of the women. The mean size of cyst was 10.9 cm, and the commonest accident was torsion. Other details are summarized in [Table 1], [Table 2], [Table 3].
Table 1: Summary of clinical presentation of ovarian cyst accidents in pregnancy

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Table 2: Summary of ovarian cyst accidents details

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Table 3: Peri-operative summary

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Case one

A 30-year-old gravida 4, para 3 (2 alive) who presented at a gestational age 19 weeks with a 2- day history of intermittent right sided lower abdominal pain, which worsened with micturition and during coitus. There was no associated fever, vomiting, vaginal bleeding, or cardiopulmonary symptom. Index pregnancy was booked in our hospital at six weeks' gestation and ultrasound done at booking revealed a right unilocular anechoiec ovarian cyst of 7.83 cm in its widest dimension. She was planned for conservative management due to the asymptomatic nature of the cyst. Antenatal period remained uneventful till index presentation at 19 weeks' gestation.

She was found to be in painful distress, not pale, well hydrated, and had pulse rate of 108 beats per min. There was generalized tenderness that was marked at the right iliac fossa. The fundal height was 26 weeks. Pelvic examination revealed bilateral adnexal tenderness. A diagnosis of ovarian cyst accident in the second trimester of pregnancy was made.

Pelvic ultrasound revealed a rounded cystic mass containing internal echoes and measured 9.8 cm × 6.73 cm located in the posterior wall of the uterus and an intrauterine live singleton fetus. Full blood count and serum biochemistry were within normal limits. She was admitted and had exploratory laparotomy within 15 h of admission with intraoperative findings of an intact right ovarian cyst of 8 × 8 cm in the pouch of Douglas containing turbid fluid and normal ipsilateral tube. She had right ovarian cystectomy done. She was placed on oral salbutamol, analgesics, and antibiotics. She had an uneventful post-operative period and was discharged after 8 days. Histology revealed a granulosa cyst. Antenatal period remained uneventful. She was delivered of a live infant at term by a caesarean section. The puerperium was uneventful.

Case two

A 37-year-old primigravida who presented at 22 weeks' gestation with a 5-day history of generalized abdominal pain, abdominal distension, and constipation. There was associated vomiting and obstipation. There was no associated fever, vaginal bleeding, or cardiopulmonary symptom. There was no history of passage of blood in stool or anal protrusion. She had no weight loss or jaundice.

The index pregnancy was booked in a Specialist Hospital at 16 weeks' gestation and was uneventful till presentation. She had no known comorbidity and had no previous abdomino-pelvic surgery.

She was found to be acutely ill-looking and in painful distress. She was febrile (T = 37.8°C), pale, anicteric and was well hydrated. The pulse rate was 110 beats per min and blood pressure was 100/60 mmHg. The abdomen was distended and moved minimally with respiration. There were generalized tenderness and guarding. Bowel sounds were absent. Bimanual pelvic examination was limited due to generalized abdominal tenderness and rectal examination was unremarkable. An initial diagnosis of intestinal obstruction to rule out peritonitis secondary to viscous perforation in pregnancy was made.

She had a hematocrit count of 26% and normal white cell count with relative neutrophilia. Abdomino-pelvic scan revealed a singleton intrauterine viable fetus at 23 weeks' gestation with hypoactive peristaltic motility of the bowel. There was no bowel dilatation, ascites, or lymphadenopathy noted. The adnexa were not visualized. She was co-managed with the General Surgeons. She was resuscitated and had exploratory laparotomy with left salpingo-oophorectomy and appendicectomy. The intraoperative findings included purulent peritoneal fluid of 200 mL; a twisted infected left ovarian cyst discharging pus from multiple rupture sites. An intraabdominal drain was inserted. Postoperative recovery remained uneventful till the 4th postoperative day when she developed progressively painless bilateral lower limbs swelling and had thromboprophylaxis with subcutaneous enoxaparin. Doppler studies of both lower limbs revealed normal venous systems. She had tocolysis with magnesium sulphate in the immediate postoperative period and was maintained on nifedipine till discharge. Histology of ovarian cyst revealed matured teratoma and cytology of peritoneal fluid was reactive. She had two units of blood transfused. Duration of hospital stay was 11 days. The rest of antenatal period was uneventful. She had a spontaneous vaginal delivery at term to a live baby that weighed 3.2 kg with a good Apgar score.

Case three

A 26-year-old primigravida presented at 24 weeks' gestation with a 3-week history of recurrent right-sided lower abdominal pain. Pain was described as colicky, radiates to the back, and of increasing severity in the last 24 h. There was associated vomiting but no associated fever, urinary symptoms, vaginal bleeding, or liquor drainage. The pregnancy was booked at 20 weeks' gestation and ultrasound at booking visit revealed a singleton intrauterine viable fetus at 21 weeks' gestation and a right simple ovarian cyst that measured 4.6 × 3.9 cm. She had earlier presented to our hospital 3 weeks prior with a 3-day history of similar symptoms. She was managed as a case of urinary tract infection in pregnancy with antibiotics, analgesics, and hydration with some relief of symptoms.

On examination, she was acutely ill looking, in painful distress, afebrile, not pale and well hydrated. Cardiovascular examination was normal. There was generalized abdominal tenderness, more marked in the right iliac fossa. There was no renal angle tenderness. The fundal height was 26 weeks and bowel sounds were absent. Pelvic examination revealed right adnexal tenderness. A diagnosis of acute appendicitis to rule out urolithiasis in pregnancy was made. General surgical and urological consultations were sought.

Abdomino-pelvic ultrasound showed a rounded, thick-walled, cystic mass between the gravid uterus and right kidney. The mass contains internal echoes and does not take flow on Doppler interrogation. She had a normal full blood count. Serum biochemistry was essentially normal. She was planned on conservative management after due counseling. She was commenced on parenteral antibiotics, analgesic, and hydration. By 72 h on conservative management, the pain worsened, and she developed pyrexia. Repeat scan revealed a complex round mass in the right hypochondrion that measured 4.7 × 6.5 cm with no vascularity within it. She had exploratory laparotomy and right salpingo-oophorectomy. Intraoperative findings were ascites of about 300 mL and a right ovarian cyst of 15 × 10 cm with multiple twists involving an ishaemic right tube. Tocolysis was commenced in the immediate postoperative period with intravenous magnesium sulphate. She had a spontaneous complete miscarriage about 36 h postoperation. Rest of postoperative period remained uneventful. Duration of hospital stay was 9 days. Histology of ovarian cyst revealed hemorrhagic infarction of a follicular cyst.


  Discussion Top


Despite symptomatic ovarian cysts in pregnancy occurring infrequently, surgery for complicated ovarian cyst was the commonest indication for nonpregnancy related laparotomy in pregnancy in our center during the period under review. The mean age of patients managed was less than 35 years, which is similar to reports by Chen et al.[13] This is because all the women in our series were pregnant and childbearing is highest in women aged less than 35 years. All cyst accidents in our series were associated with cyst size of ≥5 cm and presented in the second trimester, which has been proposed to be the optimal trimester for surgical treatment of ovarian cyst.[11] The mean cyst diameter of 10.9 cm was slightly larger than that found by Chen et al.[13]

Ovarian cyst complications include torsion, intracystic bleeding, and rupture.[14] Ovarian cyst torsion was the most common ovarian cyst complication in our series. This is supported by the fact that pregnant state favors torsion due to rapid change in size of pelvic organs and cysts >5 cm are known to be at increased risk of torsion.[15] This is consistent with other reports.[12],[16],[17] The commonest and consistent symptom in our series was abdominal pain, which is similar to findings in other series.[16],[17]

The diagnosis of ovarian cyst accident can be suspected clinically and complemented by imaging techniques with ultrasound being a valuable first line tool in detecting ovarian cyst. However, diagnostic dilemma can occur when features are nonspecific, especially during pregnancy leading to delay in diagnosis and intervention.[18] Diagnosis of ovarian cysts in pregnancy remains a challenge and as such a high index of suspicion should be maintained to make this diagnosis. Perillo et al. reported a case of an atypical dermoid cyst in pregnancy requiring multimodal approach to diagnosis using an ultrasound, magnetic resonance imaging, and a computed tomography scan before a diagnosis was made.[19] Multi-modal imaging for such diagnostic dilemmas is a luxury our poor-resource setting cannot afford. Two of the women in our series were misdiagnosed to have acute appendicitis and intestinal obstruction and thus had longer decision to surgery interval as compared to the accurately diagnosed case. Similar misdiagnosis has been reported by Gupta et al.[20]

Options for management of ovarian cyst accidents in pregnancy include conservative or surgical via laparoscopy and laparotomy. Though safety of laparoscopy in pregnancy is established, there is no consensus about the best surgical choice for ovarian cysts during pregnancy.[13] Laparoscopy is associated with less blood loss, better cosmesis, faster recovery, shorter hospital-stay, and fewer incidences of postoperative uterine contraction.[11],[13] Laparotomy was done in all patients in our series because it still remains the popular approach in low-resource setting where therapeutic laparoscopy is not readily available. Moreover, both laparoscopic and laparotomic approach have been found to have similar obstetric outcome.[11] The patient with cystectomy was the one with accurate preoperative diagnosis thus had the shortest diagnosis-intervention interval. This enabled salvage of affected adnexa. All patients with torsion had delayed intervention (greater than 24 h) due to diagnostic dilemma thus the affected adnexa could not be spared, necessitating a salpingo-oophorectomy.

All patients in this series received postoperative tocolysis. Robust data on use of prophylactic tocolysis during the postoperative period to prevent uterine contractions is not available, but tocolysis is recommended to be used when uterine manipulation occurs during surgery.[21] We found miscarriage in a third of the patients but no preterm delivery. This contrasts with findings of Fatema et al. who reported preterm births in a third of the women.[12] The miscarriage occurred in the patient that had the largest cyst of 15 cm that rapidly increased in size over 3 weeks (average growth of 3.5 cm per week). This may suggest rate of growth of an ovarian cyst and cyst size in pregnancy might affect pregnancy outcome. However, this is a case series that is not powered to determine such an association. Though we reported use of magnesium sulphate and salbutamol for postoperative tocolysis, Fatema et al. reported use of atosiban for perioperative tocolysis. Two-thirds of the patients in our series had term deliveries with favorable perinatal outcome. This is consistent with other studies, which documented similar obstetric outcome in majority of women managed surgically.[13],[21],[22],[23]


  Conclusion Top


Torsion was the commonest ovarian cyst complication and all cysts were benign. Surgical intervention was associated with favorable perinatal outcome in most cases with fetal loss seen when cyst was rapidly increasing in size and 15 cm in size. Prompt diagnosis enables preservation of affected adnexa. Maintaining a high index of suspicion in pregnant women presenting with acute abdomen will enhance accurate diagnosis and prompt intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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