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CASE REPORT

G4P3A0 Gravida 10- 11 weeks with Torsion Ovarian Cyst

Supervised by:
dr. Mutawakil J. Paransa, Sp.OG

Presented by:
Laila Farhana

2011730147

DEPARTMENT OF OBSTETRIC AND GYNECOLOGY


RSUD R. SYAMSUDIN, S.H., SUKABUMI
MUHAMMADIYAH FACULTY OF MEDICINE
2016

CHAPTER I
INTRODUCTION
Ovarian cysts are one form of the disease attacking women repoduksi. Cyst or tumor is a
form of interference that can be said the growth of smooth muscle cells in the ovary that
jinak. although thus it is possible to be a malignant tumor or cancer. Course of the disease is
often called sillent killer or secretly causing many women do not realize that he had been
stricken with ovarian cysts and only found out when the cyst is already palpable from the
outside or enlarged.
Every month, during the menstrual cycle, an egg is released from the ovary in a process
called ovulation. Travelling eggs from the ovaries through the fallopian tube to the uterus.
The ovary also a major source of the female hormones estrogen and progesterone. These
hormones affect the development of the female breast, body shape, and body hair. These
hormones also regulate the menstrual cycle and pregnancy.

CHAPTER II
CASE REPORT
II.1 Patient Identity
Name

: Mrs. E

Age

: 28 years old

Nationality

: Indonesian

Address

: JL. Babakan cirumput, Sukabumi

Marital Status

: Married

Occupation

: Housewife

Religion

: Moslem

Date of Visit

: October 14st, 2016

Date of Examination : October 16nd, 2016


II.2 History Taking
Conducted autoanamnesis on October 15st, 2016
Chief Complain
Lower left abdominal pain since 3 days ago.
History of Present Illness
G4P3A0 28 y.o came to emergency department RSUD R. SYAMSUDIN, S.H., Lower left
abdominal pain since 3 days ago. Initially felt pain in the upper left abdomen. Complaints are
accompanied by pain radiating to the thigh. Fever is not felt. Nausea and vomiting also in
patients complaining. Vomiting of food twice a day.
History of Past Illness
History of surgery

: denied

History of curettage

: denied

History of hypertension

: denied

History of stroke

: denied

History of diabetes mellitus : denied

History of allergic

: denied

History of asthma

: denied

Menstruation History
Menarche

: 12 years old

Menstrual cycle

: iregularly happens, 3-4 days duration, no history


of dysmenorrhea.

Amount of menstrual blood : 2-3 normal pads / day


First day of last menstruation : july, 30th 2016
Contraception History
History of using injected and oral contraception.
Marital History
Married once, has been going on for 11 years.
Gestational History
N

Date

Gestational Age

Labor History

Sex

Birth

O
1.
2.
3.

2005
2010
2013

9 years old (life)


6 years old (life)
3 years old (life)

Vaginal delivery
Vaginal delivery
Vaginal delivery

M
M
F

Weight
3000
3200
3000

4.

This pregnancy

II.3 Physical Examination


General condition

: good

Consciousness

: compos mentis

Blood pressure

: 120/80 mmHg

Heart rate

: 96 bpm

Respiratory rate

: 20x/m

Temperature

: 36,5oC

Weight

: 45 kg

Height

: 153 cm

: 19,23 kg/m2

BMI
General Examination
Eyes

: anemic conjunctiva -/-, icteric sclera -/-

Mouth

: wet oral mucosa membrane


: regular 1st and 2nd heart sounds, murmur -/-, gallop -/-

Heart
Lung
Inspection

: symmetric chest expansion in breathing

Percussion

: resonant +/+

Auscultation : VBS +/+, rhonchi -/-, wheezing -/Mammae

: hyperpigmentation of aerola +/+, nipple retraction -/-

Abdomen
Inspection

: rounded shape

Palpation

: supple in all abdominal region, tenderness

Auscultation : bowel sound +


Extremities

: warm, edema -/- -/-, CRT < 2 second

Obstetric Examination
Inspection

: convex

Palpation

: fundus impalpable
defans local and tenderness in the left iliac region
no palpable mass

Fetal Heart Rate : +


His

:-

Vaginal toucher : Fluksus (-)


portio : rubbery, closed ostium
A/P Sinistra

: palpable cystic adnexal mass, tenderness (+)

Laboratory Examination (Oktober, 14 2016)

Hemoglobin
Hematocrit
Leucocyte
Erythrocyte
Platelets

: 12,0 gr/dL
: 35%
: 18.600/L
: 4.1 juta/L
: 284.000/L

USG Examination

Interpretation :
looks picture enlarged uterus with a single fetus. fetal movement (+), pulsatif (+), 1011 weeks gestation

looks picture cyst with a diameter of 8 x 6 cm


II.4 Diagnose
Ny. E, 28 years old G4P3A0 Gravida 10-11 weeks with the left ovarian cyst torsion
II.5 Management
Laparotomy and antibiotics
II.6 Operation Report
Begins operation : 20.45 pm
Exploration : the impact of the left ovarian cyst with a diameter 8x6 cm with a torque
2x 360
gravidarum enlarged uterus
abnormality (-)
tubes and ovaries normal right
Diagnosis: ovarian cyst torsion of the left
Plan : Salpingo oophorectomy sinistra
Finish Operation : 21.15 pm
II.7 Final Diagnosis
Salpingo-oophorectomy post on indications cyst torsion with 10-11 weeks of pregnancy
gravida

II.6 Follow up

15-10-2016

s
Scar pain (-)

0
General

A
condition: salpingo-oophorectomy

moderate ill

post on indications cyst

Level of consciousnes torsion


: CM
Fundal

weeks
Height

with
of

10-11

wound care operation

Antibiotic

analgesic

pregnancy

: gravida

within normal limits


Abomen : signs of
local infection (-)
The surgical wound:
good
16-10-216

the

patient

is

discharged,

suggested control poly

II.7 Prognosis
Functionam

: Dubia ad Bonam

Sanationam

: Dubia ad Bonam

Vitam

: Dubia ad Bonam

CHAPTER III
CASE ANALYSIS
Patient mrs. E age 28 years old came to emergency department RSUD R. SYAMSUDIN,
S.H., with the main complaint of the lower left abdominal pain since 3 days ago. Based on

the results of anamnesis, physical examination, and investigations, in patients final diagnosis
G4P3A0 Gravida 10-11 weeks with Torsion Ovarian Cyst.
Whether the diagnosis made correctly ?
Whether the management of this patient correct ?
is there any effect on pregnancy ?
1. whether the diagnosis made correctly?
The ovary is one important part of the female reproductive organ system. However, fluidfilled sacs called cysts can grow into it. These cysts are usually harmless, but can be a serious
medical problem if it causes ovarian cyst twisted / (torsion). Watch for signs and symptoms
of the cyst so that torque can be identified and treated early.
factors causing the cyst twisted

Trauma
Uterine contractions in pregnancy
Intestinal peristalsis

mass in the ovary is one that is quite often found in gynecology. Most of the ovarian mass is
functional ovarian cysts and the rest is a benign mass. Ovarian cysts can be divided into two
kinds of ovarian cysts and neoplasms of functional ovarian cysts. Lower abdomen Lower
abdominal pain is an indicator of torque cyst. Pain in the form of a dull pain in the lower
abdomen from time to time continue to grow great to unbearable. irregular menstruation
because most ovarian cysts are usually formed during the menstrual cycle, so that it can
disrupt the menstrual cycle, make your period come earlier or later than usual.
According to the theory for this case torsio cyst lot of reproductive age is 20-44 years.
According to anamnesis of the symptoms in the can Lower abdominal pain (dull pain, pain is
usually increasingly severe), fever, nausea and vomiting, irregular menstruation. In case
patient age 28 years complaint lower left abdominal pain, nausea, vomiting, irregular
menstruation. Classically, the woman with adnexal torsion complains of sharp lower
abdominal pain with sudden onset that worsens intermittently over several hours. The pain
usually is localized to the involved side, with radiation to the ank, groin, or thigh. Low-grade
ever suggests adnexal necrosis. Nausea and vomiting requently accompany the pain.

Lack of clear physical ndings can make diagnosis difficult. An adnexal mass may not be
palpable, and during its early stages, signi cant discom ort may not be elicited during
examination. Sonography plays an essential role. However, sonographic findings can vary
widely depending on the degree of vascular compromise, the characteristics of any associated
intraovarian or intratubal mass, and the presence or absence of adnexal hemorrhage.
Sonographically, torsion may mimic ectopic pregnancy, tuboovarian abscess, hemorrhagic
ovarian cyst, and endometrioma. Accordingly, rates o correct diagnosis range rom 50 to 75
percent
Was the management of this patient correct ?
Torsion / rotation stalk stalk may occur in ovarian cysts with a diameter of 5 cm or more.
Conditions that facilitate torque is pregnancy and after childbirth.
In pregnancy, the enlarged uterus will change the location of the cyst, while in labor may
occur after sudden changes in the abdominal cavity.
Torsion on tumor stem will cause disruption for venous circulation is depressed, there is
blood in the dam resulting tumors greater tumor with bleeding inside. If the torque continues
hemorrhagic necrosis will occur and if left unchecked can occur with a tear in the cyst wall
from bleeding or inflammation intra adominal sekunder with the clinical manifestations of
acute abdomen. So, the most appropriate action for the management of torque cysts are
laparotomy.
Salvage of the involved adnexa, resection of any associated cyst or tumor, and possible
oophoropexy are treatment goals. Findings of adnexal necrosis or rupture with hemorrhage,
however, may necessitate removal of adnexal structures. Torsion may be evaluated by
laparoscopy or laparotomy. Previously, adnexectomy was usually done to avoid possible
thrombus release and subsequent embolism during untwisting. Evidence does not support
this. McGovern and coworkers (1999) reviewed nearly 1000 cases of torsion and ound the
rare occurrence of pulmonary embolism in only 0.2 percent. T ese cases of embolism were
associated with adnexal excision, and none were linked to untwisting of the pedicle. In a
study of 94 women with adnexal torsion, Zweizig and associates (1993) reported no increased
morbidity in women undergoing untwisting o the adnexa compared with those undergoing
adnexectomy.
Management during pregnancy does not different. However, if the corpus luteum is removed
be ore 10 weeks gestation, progestational support is recommended until 10 weeks gestation

to maintain the pregnancy. Suitable regimens include: micronized progesterone (Prometrium)


200 or 300 mg orally once daily; 8-percent progesterone vaginal gel (Crinone) one
premeasured applicator vaginally daily plus micronized progesterone100 or 200 mg orally
once daily; or intramuscular 17-hydroxyprogesterone caproate (Delalutin), 150 mg. With
the last option, if between 8 and 10 weeks, then only one injection is required immediately a
after surgery. If the corpus luteum is excised between 6 to 8 weeks, then two additional doses
should be given 1 and 2 weeks a ter the rst.
is there any effect on pregnancy ?
In some women, cysts precisely detected during pregnancy. These cysts could have been
there before you get pregnant, but not detected. An increase in estrogen during pregnancy can
indeed trigger a cyst enlargement. Ovarian cysts during pregnancy may grow in the ovaries
which is where most overgrown tumor. Tumors in the form of cysts, solid, and the effect on
the mechanism of action of hormones. In pregnancies with ovarian cysts occur as if the
seizure of the room, where the pregnancy continues to expand.
During does not interfere with pregnancy, cysts generally be left as she monitored whether to
shrink, disappear, fixed size, or even larger. Cysts are small and do not exaggerate generally
will not interfere with pregnancy and fetal growth. Only cysts Woe (above 7 cm) which is
feared likely to cause complications and gravity in pregnancy such as miscarriage, premature
birth and infant mortality.
Cysts may interfere with the development of the uterus if its existence until urgent abdominal
cavity. Fetal growth may be hampered because of the blood vessels that supply oxygen and
food ingredients for infant hampered by being pressured by the cyst. Large cysts can cause
abnormal location of the fetus in the womb, or impede the decline in the head in the birth
canal during delivery. Therefore, when the permanent large cysts, it is necessary surgery at
about 18 weeks gestation.
At position cysts in the pelvis, delivery can be interrupted and require the completion of the
road cesarean section operation. At position ovarian cysts in the fundus, delivery can take
place normally, but the dangers of postpartum possible torque cysts and infections to
abscesses. Therefore, immediately after the normal delivery when there is a known ovarian
cyst laparotomy to remove the cyst.

Patients with ovarian cysts in pregnancy should be aware if there is suspicion of a cyst but is
accompanied by signs of early pregnancy. Cyst must be detected accurately. Because in
passing, ovarian cysts form similar to the corpus luteum. Corpus Luteum is the rest of the
nest egg that did exist during pregnancy. If the Corpus luteum taken as presumed as ovarian
cysts (ovary), there can be a miscarriage, because it serves to maintain the corpus luteum
hormone function during early pregnancy. Later, after the placenta is formed, then this
function will be taken over by the placenta.
in this case a cyst torsion (twisting), which is already required for surgical indications for
decision that cyst because of severe pain and can disturb the mother and fetus.
in this case, if the cyst is maintained during pregnancy, will be complications, that is;
acute abdomen
abortion
premature birth

CHAPTER IV
CONCLUSION
Patient mrs. E age 28 years old came to emergency department RSUD R. SYAMSUDIN,
S.H., with the main complaint of the lower left abdominal pain since 3 days ago. Based on

the results of anamnesis, physical examination, and investigations, in patients final diagnosis
G4P3A0 Gravida 10-11 weeks with Torsion Ovarian Cyst.
The ovary is one important part of the female reproductive organ system. However, fluidfilled sacs called cysts can grow into it. These cysts are usually harmless, but can be a serious
medical problem if it causes ovarian cyst twisted / (torsion). Watch for signs and symptoms
of the cyst so that torque can be identified and treated early.
factors causing the cyst twisted

Trauma
Uterine contractions in pregnancy
Intestinal peristalsis

Torsion / rotation stalk stalk may occur in ovarian cysts with a diameter of 5 cm or more.
Conditions that facilitate torque is pregnancy and after childbirth.
In pregnancy, the enlarged uterus will change the location of the cyst, while in labor may
occur after sudden changes in the abdominal cavity.
So, the most appropriate action for the management of torque cysts are laparotomy.