OBSTETRICS ROTATION (FIRST LOOP) 

SGD: Ovarian Cyst in Pregnancy 
TBM 
July 21, 2020 

Joint session under TBM

Case: CASE: A 26 y/o G1 P0 consulted because of pain on the right side of the abdomen. One week prior to consult, she noted
intermittent pain that comes and goes on the right side of the abdomen, 2 fingerbreadths below the umbilicus. No consult was
done, because she felt relieved after passing out flatus. She felt the same pain two days ago and resolved spontaneously. A few
hours prior to consult, she was awakened from sleep because of severe pain. She felt nauseous, and reported cold clammy
perspiration. LMP April 12-15, 2020. PMP March 13-25, 2020

On admission,
● VS : BP - 120/80. PR - 90/min. RR - 20 cpm T - 36.8
● HEENT, Chest, lung and heart findings normal
● Abdomen: slightly globular, (+) direct tenderness on the right lower quadrant area, FHR 150 bpm left lower quadrant
● Speculum exam: Cervix - violaceous, minimal discharge, no bleeding
● IE: Cervix - soft, long, closed; Uterus - enlarged to AOG, (+) tenderness right supero-lateral portion of the uterus

Ovarian new growth, right, probably endometrial cyst, located lateral to the uterus.
Unilocular with a cystic mass containing low level echoes, 6.58 x 7.95 x 8.67 (vol: 237.47 cc), with color flow negative
Note the white line/curve on top of the picture: this denotes a transabdominal UTZ was done

1. What is your admitting diagnosis? 2. Give the differential diagnoses

G1P0 * In red are what applies to the patient*
Pregnancy uterine
14-15 weeks AOG Corpus Luteum Cyst
Adnexal Torsion secondary to Ovarian New growth, right ● Present only during the 1st trimester, then regresses
Ovarian cyst (or ovarian new growth, benign), right, ● Maybe asymptomatic
probably in torsion ● Rupture: trauma or spontaneously
● Mild, chronic lower abdominal discomfort that
Torsion suddenly intensifies
● most important symptom of tubal torsion is acute ● Sudden, unilateral, ​sharp pelvic​ pain
lower abdominal and pelvic pain accompanied by ● Tachycardia, hypotension
nausea and vomiting ● Moderate to ​severe unilateral or bilateral ​lower
● Sonography aids in the diagnosis abdominal tenderness
● Presence of ovarian mass with absent flow
● Pregnancy predisposes to this problem Dermoid Cyst
● Torsion of the fallopian tube is secondary to an ● Found in younger and reproductive age groups
ovarian mass in approximately 50% to 60% of ● Movable mass
patients. ● Unilateral​ or bilateral
● Nontender
● Some have doughy or both cystic and solid
components
● Majority asymptomatic
● Pressure symptoms
● Abdominal pain

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 SGD: Ovarian Cyst in Pregnancy 

● Adnexal mass Imaging

● Mass has smooth border Ultrasound
● May present with torsion, rupture, or perforation: ​on ● initial modality of choice for appendicitis
and off pain, severe pain​ due to inflammation ● gold standard for the assessment of ovarian cysts
● TVS is preferred
Acute Appendicitis ● IOTA Scoring ​(for evaluation of possible malignancy)
● Any of the 3 trimesters (highest incidence during 2nd ○ In the patient, only B features is present and
trimester) no M features = benign
● Pain presents initially at the periumbilical area then
localizes to the ​RLQ MRI​, ​CT Scan
● (+) Abdominal guarding ● if UTZ is inconclusive; CT if MRI is unavailable
● (+)McBurney’s sign
● (+) Rebound tenderness Color Doppler
● Alvarado score: ● detect the movement of blood in vessels
○ RLQ pain migration ● If with ovarian mass and there is absent flow, it is
○ Anorexia usually associated with torsion ​kasi naiipit yung
○ Nausea​ and vomiting ​(1) vessels.
○ Tenderness in RLQ (2)
○ Rebound pain
○ Elevated temp
○ Leukocytosis
○ WBC shift to the left
● Actually coincides with the presentation of the patient
but is ruled out due to the ultrasound findings.

Adnexal Torsion
● Ovarian mass
● Right​ > left (3:2) Physiological corpus luteum cyst or benign cystadenoma
● 1st trimester ​> 2nd trimester > 3rd trimester
● Pain:
○ Moderate to ​severe
○ Acute​, colicky, ​unilateral
○ Lower abdominal / pelvic
○ Prior intermittent episodes
● Adnexal mass
● Nausea​ and vomiting
● Low grade fever

3. What ancillary procedures will be requested? Endometrioma or Hemorrhagic corpus luteum cyst
Laboratory Tests Low level echoes (may puti puti, hindi completely black) seen
CBC in the cyst due to the blood present.
● Get the baseline for future management
● Leukocytosis WBC >10,000 with a left shift in the
differential

Fasting Blood Sugar

● Filipinos are at high risk for gestational diabetes
● Done at first prenatal check up
● 75g OGTT - at 24-28 weeks

Urinalysis
● Check for hematuria, pyuria
● Routine screening for STI must be done to the Mature cystic teratoma - m​ ost common pathologic growth; first
patient, and it is the most cost-effective. thing to think of when there’s pathologic growth in pregnancy
● If, through history we find out that the patient is high hair- linear streaks
risk for other STIs such as HIV, chlamydia, then we Presence of Rokitansky protuberance/nodule — ​responsible
can do additional serological tests specific to these for acoustic shadowing
(nucleic acid amplification test [chlamydia], rapid
plasma reagin test [syphilis]) 4. What is the management?
Goals of Treatment:
CRP ● Pain relief
● elevated ● Removal of mass
● Monitor the mother and the fetus
Cancer antigen 125 (CA125)
● May be used if there is suspicion of malignancy

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Since the patient is symptomatic already, ​definitive
management is surgery.
Elective surgery
● Indicated if highly suspicious of malignancy or
presented with ​rupture, ​torsion​ or hemorrhage
○ In torsion, there is necrosis so the ovary
becomes black-blue color. Grossly, it doesn’t
really look good
○ Normal ovary- looks pearly white
● In general, we plan resection at ​14 to 20 weeks’
gestation because most masses that will regress will
have done so by this time.
○ 2nd trimester is always the best time for
surgery
○ Patient is 14-15 weeks of gestation, so she
can proceed with surgery.
● Ovarian cystectomy
○ Laparotomy is the standard approach​,
laparoscopy can be an option
○ Outright oophorectomy is seldom done in
torsion. Trial of unwinding the torsion is
initially done and condition is assessed.
● Frozen section assessment performed
● Careful examination of contralateral ovary
● Preoperatively, prophylactic tocolytics (e.g.
ixosuprine) are started and continued up to 24 hours
postoperatively. This is to ensure that maternal stress
will not cause uterine contractions that may lead to
abortion.
○ This is done for all pregnant women
undergoing surgery and not just for torsion
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SGD: Ovarian Cyst in Pregnancy 
Postoperative Care
● Prenatal surveillance
○ Fetal Heart Doppler Ultrasound
■ To confirm fetal well-being
■ To reassure the mother
MANAGEMENT OF UNCOMPLICATED OVARIAN CYST
( WITHOUT TORSION)
Pain Relief
● Rest
● Pain Management
Conservative Management
● Intervention should be delayed until 14–16 weeks
to allow spontaneous resolution of functional cysts
● Usually resolve by the second trimester
● Usually done in asymptomatic patients or ovarian
cysts < 5cm without suspicion of
malignancy/M-features on ultrasound
Further ultrasound assessment
● Should take place at 4-week intervals
● Monitor the size and condition of the cyst
Ultrasound-guided fine needle aspiration
● Persistent, simple, unilocular cysts without any
solid elements that are larger than 10 cm can be
aspirated
● Fine needle aspirations should be done after 14
weeks AOG in order to minimize disturbance to the
corpus luteum
● Useful in relieving acute pain and can reduce the
risk of cyst torsion and rupture
● Prone to recurrence, because the capsule is not
removed
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 SGD: Ovarian Cyst in Pregnancy 

ALGORITHMS FOR MANAGEMENT

Note: this is just a recommendation

Usually for complex cysts, further measures are done to assess for malignancy (e.g. doppler flow).
We do not just wait to rescan in 4 weeks.

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