Conservative management of ovarian cystic teratoma during pregnancy and labor

Ovarian Mature Cystic Teratoma is an Independent Risk Factor for the Premature Rupture of Membranes in Pregnancy: A Single-Center Retrospective Study

Background

Ovarian mature cystic teratomas (MCTs) are the most common tumors in pregnant women. The premature rupture of membranes (PROM) is a typical complication of pregnancy; however, the relationship between MCT and PROM is unknown. Therefore, we aimed to determine whether MCT is associated with the occurrence of PROM during pregnancy.

Methods

The data of patients with adnexal masses during pregnancy between January 2017 and August 2021 were retrospectively analyzed. Ovarian cystectomy was performed during cesarean delivery or after vaginal delivery. Univariate and multivariate logistic regression models were used for statistical analysis.

Results

A total of 234 patients with histopathological results were included. Among these patients, 21 occurred PROM during pregnancy, of which 11 were diagnosed with MCT. Compared with other subtypes, MCT (p=0.025) showed a stronger correlation with PROM and was an independent risk factor for PROM (odds ratio [OR], 2.811; 95% confidence interval [CI], 1.096-7.215; p=0.032). Furthermore, we found that MCT with a diameter >5 cm (p=0.0037) was more likely to promote the development of PROM than those that with a diameter <5 cm.

Conclusion

MCT was an independent risk factor for PROM during pregnancy. Positive actions and preventative clinical treatments should be fully taken into consideration by clinicians for pregnant women with MCTs, especially those ≥5 cm in diameter, to reduce the clinical complications related to MCT-associated PROM.

Ovarian Cystic Teratoma in Pregnant Women: Conservative Management or Prophylactic Oophorectomy?

Acute abdominal pain in pregnancy is common and the differential diagnosis is vast. Mature cystic teratomas are rarely the cause of adnexal torsion during pregnancy and can be difficult to diagnose. Timely surgical intervention is required to avoid ovarian infarction. We report a 22-year-old patient presenting with sudden right lower abdominal pain. Imaging including bedside Doppler ultrasonography and MRI were negative for signs of acute ovarian torsion. Despite no definitive imaging findings, due to severe pain, we made the decision for diagnostic multi-port laparoscopic examination with possible oophorectomy. The right cystic ovary was noted to be torsed three times around the utero-ovarian ligament. A right oophorectomy was performed. Grossly, cystic teratoma was confirmed with a large amount of hair and sebum, and pathological analysis also confirmed a benign mature teratoma. The patient recovered well and delivered without any complications. Bedside ultrasonography is a highly accessible tool; however, imaging can be uncertain. Despite the rarity of ovarian torsion due to mature teratomas in second- and third-trimester pregnancies, physicians should be aware of the possibility of acute ovarian torsion in a pregnant patient even with uncertain imaging results, especially those with a documented ovarian mass. Early prophylactic surgical intervention preferably with laparoscopy should be pursued for ovarian masses between 5 cm and 10 cm.

Adnexal Masses in Pregnancy

Importance

Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Objective

The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy.

Evidence Acquisition

This was a literature review using primarily PubMed and Google Scholar.

Results

Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy.

Conclusions and Relevance

Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Ruptured ovarian dermoid cyst - an unusual cause for peritonitis in pregnancy: a case report

Computed tomography scanning could be safely used in later pregnancy to aid diagnosis and target management of the acute abdomen.

Emergent MRI for acute abdominal pain in pregnancy-review of common pathology and imaging appearance

Acute abdominal pain in pregnancy remains a clinically challenging presentation, often requiring imaging. The threat of morbidity and mortality to both mother and fetus necessitates quick and accurate imaging diagnosis, often via ultrasound. However, many of the common causes of acute abdominal pain are not readily diagnosed with sonography, and magnetic resonance imaging (MRI) is increasingly favored in this setting. The purpose of this review is to familiarize the reader with common pathologies which may be encountered in pregnant females presenting with acute abdominal pain requiring emergent MRI.

Iatrogenic Teratoma Rupture during TVOR Complicated with Peritonitis, Pleuritis, and Septic Shock

Objective

To obtain a better understanding of the clinical course and the subsequent complications of teratoma rupture.

Case

We report a rare case of chemical peritonitis and pleuritis caused by teratoma rupture during ultrasonographically guided transvaginal oocyte retrieval (TVOR). The patient initially presented with nonspecific and digestive symptoms after TVOR, but the condition deteriorated rapidly after three weeks with peritonitis and septic shock. Thus, exploratory laparoscopy was performed with the findings of a ruptured teratoma at left adnexa, severe adhesions, and purulent fluid in her peritoneal cavity. Bilateral pleuritis was also noted after the operation, which was suspected to be caused by chemical irritation of the spilled contents of the teratoma. The patient's condition improved after surgical treatment and was discharged 28 days after admission.

Conclusion

Our case showed that the timing of peritoneal irritation caused by teratoma rupture converting to severe chemical peritonitis was approximately 3 weeks. Physicians should avoid cyst puncture during TVOR and closely observe or even perform surgical treatment when iatrogenic teratoma ruptures are suspected.

Repeated pregnancy with concomitant presence of ovarian teratoma: A case report and literature review

OBJECTIVE

Benign mature teratoma during pregnancy is common, mostly discovered incidentally by antenatal sonography. However, repeated pregnancy coincident with ovarian mature teratoma is rarely reported. The cases of teratoma with rapid growing characteristics are even more unique.

CASE REPORT

A 17-year-old woman was pregnant at 6 weeks of gestation with a left ovarian teratoma. She underwent artificial abortion followed by surgical removal of the teratoma. However, eleven years after the surgery, a right ovarian teratoma was found incidentally by antepartum sonography at 21 weeks of gestation. The right ovarian teratoma developed uneventfully, with rapid growth during pregnancy. Abdominal delivery at term was accomplished without any complication.

CONCLUSION

Younger patients and patients with bilateral or large size dermoid cysts should be followed up closely. Further studies are needed for better understanding of its natural clinical course and the mechanism of progression. The treatment options should be made individually, weighing the risks of torsion, rupture, or obstruction of labor versus the potential for unnecessary surgical risk to mother and fetus.

Prevalence of extrauterine pelvic lesions on transvaginal ultrasound in asymptomatic 20-39-year-old women

OBJECTIVES

To estimate the prevalence of extrauterine pelvic lesions on transvaginal ultrasound examination of gynecologically asymptomatic women of fertile age, and to compare this prevalence between women with spontaneous menstrual cycles, those using the combined oral contraceptive (COC) pill and those using a gestagen intrauterine contraceptive device (IUD).

METHODS

Six hundred and forty-four gynecologically asymptomatic 20-39-year-old Caucasian women with no current or previous gynecological problems, who were recruited from a Swedish population registry, were examined with transvaginal ultrasound on cycle day 4-8. Our definition of ovarian cyst was a unilocular cyst with anechoic cyst contents ≥ 35 mm in mean diameter, or any other type of intraovarian lesion. The prevalence of extrauterine pelvic lesions was compared between women not using hormonal contraception and those using COC or a gestagen IUD.

RESULTS

Ovarian lesions were found in 24 (3.7%) women. One woman had bilateral ovarian lesions. An ultrasound diagnosis of paraovarian cyst was made in 41 (6.4%) women, of peritoneal cyst in four (0.6%) women and of hydrosalpinx in one (0.2%) woman. All incidentally detected lesions had a mean diameter of ≤ 5 cm. One 17-mm intraovarian lesion was suspicious for malignancy, and histology confirmed a Sertoli-Leydig cell tumor. The ultrasound diagnoses in the remaining 23 women were endometrioma (n = 10 (1.6%)), dermoid cyst (n = 5 (0.8%)), cystadenofibroma (n = 1 (0.2%)), mature teratoma (n = 1 (0.2%)) and functional cyst, i.e. a cyst that resolved within 3-5 months (n = 6 (0.9%)). Four women with an ultrasound diagnosis of a benign lesion were operated on, and the ultrasound diagnoses of endometrioma (n = 2), dermoid cyst (n = 1) and mature teratoma (n = 1) were confirmed histologically. The prevalence of persisting ovarian lesions was highest in women with spontaneous menstrual cycles (4.4% vs 0.9% and 0% in women using COC and gestagen IUD, respectively; P = 0.025), but age was the only factor independently associated with persisting ovarian masses, the prevalence increasing with age.

CONCLUSIONS

Benign ovarian lesions are found in about 1 in 25 gynecologically asymptomatic women aged 20-39 years with no history of gynecological disease. To be able to offer optimal management of such masses, their natural history needs to be elucidated in a large prospective observational study.

Retinal tissue in mature cystic teratoma of ovary presenting with full-term pregnancy

Mature cystic teratomas are benign ovarian neoplasms which account for around 95% of all ovarian germ cell tumours and contain tissues derived from two or three embryonic germ layers. These tumours are frequently diagnosed in women of reproductive age group and can result in fetomaternal distress if concurrent pregnancy occurs. The authors describe a case of successful natural pregnancy in a 30-year-old woman with coexisting mature cystic teratoma of ovary that culminated in viable childbirth at term. Subsequent histopathological examination of the tumour revealed a mature teratoma composed predominantly of ectodermal elements along with retinal tissues--a rare finding that prompted this case report.

Diagnosis and management of adnexal masses in pregnancy

Widespread use of ultrasound in early pregnancy has led to the detection of incidental adnexal masses more frequently. This article reviews the diagnosis and management options for adnexal masses in pregnancy. The availability of high-resolution ultrasound has made observation to be a viable option in some cases. However, for those masses suspicious of malignancy, at risk of torsion, rupture, or clinically symptomatic, surgical treatment is warranted. Laparoscopy has been successfully used in pregnancy and is safe in experienced and trained hands in properly equipped units.

The role of 3-dimensional power Doppler imaging in the assessment of ovarian teratoma in pregnancy: a case report

Background. Conventional sonography is the primary imaging tool for these pregnant women who present with an ovarian teratoma. In some cases, however, sonography diagnosis is difficult. We report a case of ovarian teratoma during pregnancy diagnosed by three-dimensional Power Doppler. The cyst was removed via laparotomy without fetal or maternal complications. Three-dimensional ultrasound with multiplanar view can better discriminate a benign ovarian teratoma from complex ovarian lesions or malignant tumors. Its role is significant especially during pregnancy as it may assist in determining which patients are requiring surgery and which are not. The results of three-dimensional sonography and magnetic resonance (MR) were equal but the role of MR imaging is limited in early pregnancy. Conclusions. Three-dimensional technique is a reliable diagnostic modality for preoperative assessment of an ovarian teratoma as it can be performed during the first trimester of pregnancy.

Large luteinized follicular cyst of pregnancy

A large (165 × 235 × 250 mm) solitary, unilocular cyst with a thin, smooth wall and homogeneous anechoic content was detected during a routine ultrasound scan at 24 weeks of gestation in an asymptomatic 39-year-old woman with a singleton pregnancy. The cyst was aseptate, lacked mural blood flow and was not associated with ascites. It was located in the central abdominal area above and anterior to the uterus. Gradually increasing abdominal discomfort developed, and a laparotomy was performed at 27 weeks; the cyst was removed after aspiration of 6.3 L of serous fluid and the ipsilateral ovary was preserved. Pathological examination indicated a large luteinized follicular cyst of pregnancy. A healthy male infant was delivered vaginally at term. A rapidly enlarging ovarian mass in pregnancy poses significant diagnostic problems. Large luteinized cysts of pregnancy are uncommon and thought to involve stimulation by human chorionic gonadotropin (hCG), or increased tissue sensitivity to hCG. A literature search identified four previous cases that had been detected prenatally. With one exception, the cysts appeared to enlarge during pregnancy, eventually becoming symptomatic, and two previous cases also required removal of the cyst before birth. Adverse pregnancy outcome was only reported in one of the previous cases. In summary, large luteinized cysts of pregnancy are an uncommon type of cystic mass particular to pregnancy, characterized by the combination of a benign appearance and a tendency to enlarge rapidly, eventually becoming symptomatic and most often necessitating surgery.

An unusual growth of ovarian cystic teratoma with multiple floating balls during pregnancy: a case report

We report a case of ovarian cystic teratoma with an important growth during pregnancy and the sonographic appearance of intracystic multiple, mobile, polygonal structures called intracystic "fat balls." Due to the rapid growth of the lesion, which exceeded 15 cm in diameter, a right oophorectomy was performed. Histopathologic diagnosis confirmed the mature cystic teratoma. The presence of floating balls composed of keratin and fat is rarely seen but is pathognomonic of mature cystic teratomas. Growth of a teratoma during pregnancy is a rare condition.

Chemical peritonitis caused by an iatrogenic rupture of mature cystic teratoma of the ovary during labor: a report of a case didactic to all the maternity health care workers

A 37-year-old postpartum woman was presented with abdominal pain supposed to be caused by uterine involution or puerperal endometritis after vaginal delivery. During the pregnancy, she was suspected to have a subserosal myoma by ultrasound examination. The pain was finally revealed to be originated from the chemical peritonitis caused by the rupture of the mature cystic teratoma of the ovary by Kristeller's maneuver performed during vaginal delivery. When a pregnant or puerperal woman complains about abdominal pain, we need to consider the possibility of chemical peritonitis resulting from the rupture of mature cystic teratoma of the ovary.

Adnexal Masses in Pregnancy: Diagnosis and Management

The widespread use of ultrasound in obstetrics has led to an increase in the diagnosis of asymptomatic adnexal masses in pregnancy. Ultrasound is an accurate and safe method for diagnosing the etiology of an adnexal mass and distinguishing benign from malignant pathology. The management of an adnexal mass in pregnancy is controversial. Historically, it was recommended that any adnexal mass be removed electively in the second trimester to exclude malignancy and prevent complications such as torsion, rupture, and obstruction of labor. More recent recommendations have limited surgical intervention in pregnancy to symptomatic adnexal masses and those that are highly suggestive of malignancy. Surgery in pregnancy is associated with an increased risk of adverse pregnancy outcomes. However, laparoscopy appears to be a safe alternative to laparotomy for benign masses when performed by experienced surgeons.

Learning objectives

To list the differential diagnoses of adnexal masses in pregnancy

To interpret ultrasound images of adnexal masses and distinguish benign from malignant masses

To describe the management options for adnexal masses in pregnancy, including the indications and options for surgical intervention.

Ovarian cysts during pregnancy: dilemmas in diagnosis and management

With routine obstetric ultrasound examinations, ovarian cysts are now more commonly diagnosed during pregnancy and their management is still a challenging clinical issue among obstetricians. The aim of this paper is to review the different management options of ovarian cysts detected during pregnancy, and it highlights the emergence of laparoscopic technique as a valuable therapeutic tool in these conditions. The review shows that conservative management and ultrasound follow-up is sufficient for the majority of cases of ovarian cysts during pregnancy. It also discusses the limitations of tumour markers during pregnancy, and the controversy around ultrasound-guided aspiration procedures. Emerging evidence suggests that if surgery is necessary, then it is preferable to perform an elective laparoscopic procedure at 16 - 23 weeks' gestation. It is time to consider establishing a UK registry to monitor the treatment offered to those women and to develop national guidelines to help in the management of this controversial issue.

Management of ovarian cysts

BACKGROUND

The treatment of an ovarian cyst relies on its nature, and accurate preoperative discrimination of benign and malignant cysts is therefore of crucial importance. This study was undertaken to review the literature concerning the preoperative diagnosis and treatment of ovarian cysts.

METHODS

Articles concerning ovarian cysts from a medline literature search during the period 1985-2003 were included in addition to articles found as references in the initial publications.

RESULTS

Different methods for discriminating between benign and malignant ovarian cysts are discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status, pregnancy, and whether the cyst is presumed to be benign or malignant. In general, expectant management is the choice in premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular, anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels of CA-125. Women with symptoms should be operated regardless of age, menopausal status, or ultrasound findings.

CONCLUSIONS

The preoperative discrimination between benign and malignant ovarian cysts is a challenge. Multimodal methods improve the results of single modalities, but we still need improved preoperative diagnostic tools. Furthermore, these methods should be validated in consecutive patient populations large enough to give a reliable estimate of the method's sensitivity and specificity.

Ovarian teratoma diagnosis and management: case presentations

BACKGROUND

Ovarian teratomas (OTs) may be of mature or immature morphologies. Mature cystic teratomas (MCTs), often referred to as dermoid cysts, are the most common germ cell tumours of the ovary in women of reproductive age. OTs are usually asymptomatic until they reach considerable size. Frequently, ultrasonography is diagnostic. Women requiring surgery for OTs should be appropriately counselled about the risks and benefits of laparoscopic and open approaches.

CASE PRESENTATIONS

Case I: An 18-year-old woman presented with hirsutism and irregular menses, both of which reversed after bilateral MCT removal by laparoscopy. Case II: A 47-year-old multigravid woman presented with a large unilateral OT, with a focus of malignancy. Case III: A 19-year-old woman presented with a large unilateral OT associated with gliomatosis peritonei.

CONCLUSION

Experienced laparoscopic surgeons should consider laparoscopy as an alternative to laparotomy in management of OT in selected cases. Women younger than 15 years of age or older than 45 years of age who have large, solid teratomas on ultrasound or positive markers for germ cell tumours are at risk for malignant variants, and for these women laparotomy is the preferred approach.

Elective vs. conservative management of ovarian tumors in pregnancy

OBJECTIVES

To determine optimal management of the ovarian tumors in pregnancy.

METHODS

This study included 89 cases of the ovarian tumor in pregnancy that required surgery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001. Among 89 cases, 36 and 53 were emergency and elective surgery, respectively. Student's t-test and the chi(2)-test were used for statistical analysis and a P-value of <0.05 was considered statistically significant.

RESULTS

The most common size of torsion of ovarian tumors during pregnancy was 6-10 cm and the incidence was the most frequent during the first trimester of pregnancy. The incidence of preterm delivery (<37 weeks) was higher in emergency surgery, but there was no difference in the gestational age at delivery, also no difference in the birth weight or the method of delivery.

CONCLUSIONS

Although surgery for ovarian tumors in pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with that after elective surgery. We propose that conservative management would be used in optimal management of pregnant women with ovarian tumors.

Adnexal masses and pregnancy: a 12-year experience

OBJECTIVE

Our purpose was to describe pregnancy-associated adnexal masses in eastern North Carolina.

STUDY DESIGN

A retrospective study was performed of 60 adnexal masses resected during pregnancy at a regional referral hospital from January 1990 to March 2002.

RESULTS

Adnexal masses occurred in 0.15% of pregnancies. Average gestational age at diagnosis and surgery was 12 and 20 weeks, respectively. Fifty percent of ovarian tumors were mature cystic teratomas, 20% were cystadenomas, and 13% were functional ovarian cysts. Malignancy occurred in 13%. Tumors with low malignant potential comprised 63% of malignancies. Average cyst size was 11.5 cm for malignancies and 7.6 cm for benign lesions (P value <.05). The preterm birth rate was 9%, the miscarriage rate was 4.7% after elective cases, and average Apgar scores were 7.5 and 8.7 at 1 and 5 minutes.

CONCLUSION

The incidence of malignancy in pregnancy-associated adnexal masses was high. Ultrasonography detected internal excrescences in the majority of tumors with low malignant potential. Fetal outcomes were not affected.

The cystic adnexal mass: patient selection, surgical techniques and long-term follow-up

The continuous change in the treatment and management of ovarian tumours is an excellent example of the changes that have occurred in gynaecological laparoscopic surgery. This paper evaluates the management of the adnexal mass in 2001. Second, it reviews ovarian tumours treated at the Department of Obstetrics and Gynaecology, University of Kiel, between January 1997 and December 1998, and the place of laparoscopy in the management of these lesions. Third, the review attempts to give an insight into the long-term follow-up of patients treated laparoscopically for the removal of ovarian cysts. Finally, a retrospective survey is given of the clinical pathology and prognostic features of adnexal masses operated on during pregnancy. With regard to long-term follow-up, no difference was found between laparoscopic or laparotomic treatment of ovarian tumours.