Prenatal diagnosis and perinatal management of a fetal ovarian cyst

Enlarged Abdominal Lymph Node as a Cause of Polyhydramnios in the Course of Congenital Neonatal Leukaemia: A Case Report and Review of the Literature on Foetal Abdominal Tumours with Coexisting Polyhydramnios

Polyhydramnios represents a complication found in 0.2–2% of pregnancies, and it is usually diagnosed between 31 and 36 weeks of pregnancy. Although most cases of polyhydramnios are idiopathic, maternal diabetes or foetal malformations constitute frequent causes of the excessive accumulation of the amniotic fluid. Considering the latter, polyhydramnios may rarely be caused by foetal abdominal tumours, with the incidence rate of 2–14 cases per 100,000 live births. Congenital neonatal leukaemia (CNL) is a rare disease with a reported incidence rate of 5–8.6 cases per million live births. In the prenatal period, the ultrasound abnormalities associated with CNL include hepatomegaly and splenomegaly. In this paper, we presented a case of polyhydramnios caused by mechanical pressure on the foetal gastrointestinal tract by an enlarged lymph node in the course of CNL, as well as reviewing the available literature on foetal abdominal tumours with concurrent polyhydramnios.

Diagnosis, Management, and Therapy of Fetal Ovarian Cysts Detected by Prenatal Ultrasonography: A Report of 36 Cases and Literature Review

BACKGROUND

Fetal ovarian cysts are the most frequently diagnosed intra-abdominal cysts; however, the evidence for perinatal management remains controversial.

METHODS

We retrospectively reviewed cases of fetal ovarian cysts diagnosed by prenatal ultrasonography at our institution between January 2010 and January 2020. The following were investigated: gestational age at diagnosis, cyst size, appearance, prenatal ultrasound findings, and postnatal outcomes. Prior to 2018, expectant management was applied in all cases; after 2018, in utero aspiration (IUA) of simple cysts ≥40 mm was performed.

RESULTS

We diagnosed 29 and seven simple and complex cysts, respectively. Fourteen patients had simple cysts with a maximum diameter <40 mm, and two of them progressed to complex cysts during follow-up; however, when the diameter was limited to <35 mm, no cases showed progression to complex cyst. Fifteen of the simple cysts were ≥40 mm; three progressed to complex cysts, and two of them were confirmed to be ovarian necrosis. In four patients who underwent IUA, the ovaries could be preserved.

CONCLUSIONS

IUA is a promising therapy for preserving ovaries with simple cysts ≥40 mm in diameter; however, the indications for fetal surgery and the appropriate timing of intervention require further study.

Prenatal Diagnosis of a Cyst of the Canal of Nuck Associated With an Ovarian Cyst and Acute Polyhydramnios

In the female, the canal of Nuck is a tubular fold of parietal peritoneum that travels along with the round ligament through the inguinal canal to its attachment on the labia majora. The canal of Nuck is analogous to the processus vaginalis in the male. In embryonic development, this pathway typically obliterates early in life; however, in some cases, it may partially or completely fail to close. This failure to obliterate can lead to complications ranging from a cyst of the canal of Nuck (also known as a female hydrocele) to herniation and incarceration of abdominal and pelvic organs. There is little information available in the medical literature concerning this rare condition; therefore, it is important for sonographers, physicians, and surgeons to be familiar with this developmental abnormality. This report represents the first prenatal case of a cyst of the canal of Nuck, along with the unique combination of a large left fetal ovarian cyst and acute polyhydramnios. The embryology, incidence, differential diagnosis, management, and treatment of these female conditions are discussed.

Management of ovarian lesions diagnosed during infancy

PURPOSE

Prior studies of infant ovarian cysts have recommended intervention for those larger than 4 cm. We reviewed the natural history and features of those managed operatively versus nonoperatively.

METHODS

A retrospective study was performed of ovarian lesions in children <1 year-old from 2000 to 2014.

RESULTS

Forty patients were identified. Twenty-eight (70%) underwent operative management, while 12 (30%) were managed conservatively, including one undergoing aspiration. The mean age at surgery was 125 days. All but one patient (96%) had evidence of antenatal torsion intraoperatively or on final pathology. All resected lesions were benign. Ultrasound findings more common in those undergoing surgery included intracystic debris (p < 0.001), fluid-fluid or fluid-debris levels (p = 0.002), absence of Doppler flow (p = 0.014), solid components (p = 0.04), and calcifications (p = 0.001). Cysts managed nonoperatively had an average diameter of 2.5 cm, compared to 5.1 cm in the operative group (p < 0.001). Three of the lesions managed nonoperatively had a diameter greater than 3.5 cm (mean 5.1 cm) and were followed for an average of 153 days until resolution.

CONCLUSIONS

The majority of infant ovarian lesions were excised, although none were malignant. Aspiration or observation of larger cysts was feasible and safe. Ovarian cysts in this age group should be considered for nonoperative management and closely followed.

LEVEL OF EVIDENCE

IIC.

Neonatal ovarian torsion complicated by intestinal obstruction and perforation, and review of the literature

We present a case of neonatal ovarian torsion complicated by bowel obstruction and perforation and review the literature regarding the incidence of bowel obstruction in neonatal ovarian cysts, the presentation, and treatment. A term neonate was prenatally diagnosed with a cystic abdominal mass palpable on physical examination. A postnatal abdominal x-ray showed paucity of gas in the left hemiabdomen with rightward displacement of bowel loops. Exploratory laparotomy on day 2 of life revealed a large cystic mass in the left lower quadrant consistent with a torsed left ovary, an omental band causing strangulation of the bowel mesentery, and a perforation of the distal ileum. Our literature search revealed 19 reported cases of neonatal ovarian cysts resulting in bowel obstruction. Infants may present with a palpable abdominal mass, respiratory distress, as well as signs and symptoms of intestinal obstruction. Two mechanisms exist for bowel obstruction: adhesions caused by a torsed necrotic ovary and mass effect of a large ovarian cyst, often measuring 9 to 10 cm in diameter. Options to treat ovarian cysts include antenatal or postnatal aspiration, laparoscopy, and laparotomy. Cysts less than 4 to 5 cm can be observed, whereas operative intervention is indicated in symptomatic cases and in persistent or enlarging ovarian cysts.

Clinical experiences of fetal ovarian cyst: diagnosis and consequence

Ovarian cysts are the most frequent, prenatally diagnosed intra-abdominal cysts. Fetal ovarian cyst often presents complication such as torsion and seems to be an indication for surgical intervention. In this study, we reviewed pre- and post-natal medical records and ultrasonography of 17 fetuses that were diagnosed with ovarian cysts. In a total of 17 cases, postnatal surgery was performed in 7 infants. Of these cases, four cases of ovarian cyst torsion were confirmed. In the remaining 10 fetuses, one case regressed completely during pregnancy, and the other nine cases including two complex cysts resolve spontaneously after birth. Postnatal symptomatic cysts or cysts with a diameter greater than 5 cm that do not regress or enlarge should be treated, but uncomplicated asymptomatic cysts less than 5 cm in diameter should only be observed and reassessed by serial ultrasonography. If they regress spontaneously, no surgical intervention is necessary independent of their sonographic findings.

Fetal ascites immediately after rupture of ovarian cysts

Ruptured fetal ovarian cysts are difficult to diagnose. We report on ultrasonograms recorded before and immediately after spontaneous rupture of fetal ovarian cysts followed by transient ascites. Ultrasound findings of transient ascites accompanied by rapid reduction in cyst size could aid in diagnosing rupture of fetal ovarian cysts.

Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome

OBJECTIVE

In female fetuses ovarian cysts represent the most important differential diagnosis for intra-abdominal masses. Analyzing our own patient population we investigated whether there was a connection between sonographic parameters and postnatal course, especially with regard to the need for surgical intervention.

PATIENTS AND METHODS

This was a retrospective analysis of cases from the years 1986-1999. The pre- and postnatal data of 64 fetuses who were suspected prenatally to have an ovarian cyst were analyzed. The postnatal outcome was known for all the children.

RESULTS

The diagnosis was made in all cases in the third trimester (median, 35; range, 26-40 weeks' gestation). In 34 of the 64 (53%) cases, resolution of the cyst occurred either prenatally (n = 18, 53%) or postnatally (n = 16, 47%). The cystic structure in the cases with resolution was isolated, smooth-walled (n = 29) or heterogeneous (n = 5). Postnatal surgery was performed in 30 of the 64 (47%) children. In 18 of the 30 children a fenestration of the ovary was performed (60%). In this group there were 13 children with an isolated, smooth-walled ovarian cyst and five children with a heterogeneous cyst. Twelve of the 30 (40%) children underwent an ovariectomy. Among these 12 children there were eight cases with a heterogeneous cystic structure and four cases with an isolated, smooth-walled cystic structure. Of the 30 cases that underwent surgery, 29 had a follicular cyst and one had an ovarian teratoma (with a heterogeneous internal structure). In three fetuses aspiration of cyst fluid was undertaken and subsequent resolution occurred in one case. The other two cases had to undergo postnatal fenestration.

CONCLUSIONS

When an ovarian cyst is suspected prenatally, serial ultrasound monitoring should follow and delivery should take place in a perinatal center. The prenatal findings should also be checked postnatally by ultrasound. Prenatal aspiration of the cyst seems to be of no advantage and should be carried out only in special individual cases.

Fetal ovarian cyst decompression to prevent torsion

BACKGROUND/PURPOSE

Neonates who have ovarian torsion caused by an ovarian cyst often lose their ovary because the torsion and infarction occurred antenatally. Because ultrasound scan has been so effective in diagnosing ovarian cysts in utero, we have a better understanding of their natural history and can select appropriate cases for cyst decompression in utero to prevent torsion. The authors reviewed experience with seven fetuses who had fetal ovarian cyst.

METHODS

During a 26-month period, seven patients were referred for the evaluation of fetal ovarian cyst. The mean gestational age at presentation was 31.9 +/- 3.6 weeks (+/-SD; range, 27 to 37 weeks). There was no history of maternal risk factors such as diabetes mellitus or fetal risk factors such as hyperthyroidism or placentomegally. All seven cases involved isolated unilateral cysts without associated anomalies or chromosomal abnormalities. Mean initial cyst diameter was 3.4 +/- 1.7 cm (+/-SD; range, 1 to 6.1). Indications used for ovarian cyst decompression included anechoic cysts with a diameter > or =4 cm, a cyst "wandering" about the abdomen on serial sonograms, or demonstrating rapid enlargement (>1 cm/wk).

RESULTS

All but one cyst progressed in size during observation. One fetal ovarian cyst (diameter, 2 cm) subsequently regressed spontaneously and another (diameter, 2.1 cm) stabilized during prenatal ultrasound surveillance. One "cyst" observed with a diameter of 3.5 cm proved to be a persistent cloaca. Four fetal ovarian cysts met criteria for decompression. Because of fetal position, decompression could not be performed in one. One cyst (seen before defining criteria for decompression) with a diameter of 5 cm was observed only and underwent torsion. Two cysts (diameters, 6.1 cm and 4 cm) were decompressed in utero under local anesthesia with ultrasound guidance, of 95 mL and 35 mL, respectively. High cyst fluid progesterone (12,041 and 1,990 ng/dL, respectively) and testosterone (1,298 and 2,900 ng/dL, respectively) confirmed the etiology of the cyst as ovarian. Neither cyst recurred, and postnatal ultrasound scan confirmed resolution. There was no maternal or fetal morbidity or mortality and only the patient observed before development of criteria for decompression lost her ovary because of torsion.

CONCLUSIONS

Fetal ovarian cysts tend to present as isolated unilateral lesions in normal fetuses in the third trimester. Spontaneous regression of fetal ovarian cysts may occur. Fetal ovarian cyst decompression, in select cases, may preserve ovaries at risk for torsion.

Antenatally detected ovarian cysts--a therapeutic dilemma

Twenty-four instances of ovarian cysts detected antenatally are reported. Most cysts were functional in origin, histologically benign simple cysts. Pregnancy was clinically uncomplicated in all, followed by a spontaneous vaginal delivery in 20 cases between the 33rd and 41st week, four neonates were delivered by a cesarean section for obstetrical reasons. Nine cysts more than 5 cm in diameter at birth were treated surgically. The operative indications were as follows; 5 neonates had clinical symptoms caused by abdominal distention or vomiting. The remaining four showed a sign of hemorrhage following torsion. Thirteen cysts less than 5 cm in diameter, and two cysts more than 5 cm in diameter began to regress spontaneously within 6 months after birth and finally 10 of them disappeared between 2 weeks and 2 years.

Surgical indications in antenatally diagnosed ovarian cysts

The antenatal diagnosis of ovarian cysts poses a therapeutic dilemma because the natural history of these lesions is not well known. A retrospective review from 1980 to 1989 showed 29 ovarian cysts in 27 patients diagnosed by prenatal ultrasonography performed between 28 and 36 weeks of gestation. Nineteen cysts were initially observed. Eleven cysts resolved (diameter less than 2 cm), three are decreasing, three were lost to follow-up, and two underwent resection. Eight patients underwent surgical exploration immediately following birth. The diagnosis of benign ovarian cyst was confirmed histologically in all cases. A review of the literature showed an additional 230 cases of antenatally diagnosed ovarian cysts. Simple cysts of the ovary tend to resolve spontaneously and, therefore, may be treated conservatively. Serial ultrasonography allows accurate diagnosis and long-term assessment of ovarian cysts in the neonate and may prevent unnecessary oophorectomy. Patients with cysts larger than 4 cm may be candidates for percutaneous aspiration, or should undergo removal of the cyst because of a significant risk of torsion. Complex cystic masses, symptomatic ovarian cysts, and cysts that do not resolve should be removed.

Ultrasonic diagnosis and perinatal management of complicated and uncomplicated fetal ovarian cysts: a collaborative study

Ovarian cysts can be demonstrated in the ovaries of fetuses and full term infants at birth. Small cysts involute spontaneously during fetal life or within the first few months of life. Large cysts may cause mechanical complications or respiratory distress. Sonographic detection of fetal ovarian cysts has been reported, as well as intrauterine surgical treatment. The sonographic findings and the outcome of the smaller and the complicated cysts were studied in 25 pregnant women. Uncomplicated fetal ovarian cysts should be monitored by weekly examination until delivery. Huge ovarian cysts may be an indication for cesarean section; or, intrauterine aspiration may be the alternative. Complicated fetal ovarian cysts represent an indication for neonatal surgery.

Neonatal ovarian torsion: report of three cases and review of the literature

Ovarian cysts are common incidental findings in term infants and, if unusually large, may result in dystocia, torsion, or rupture. Torsion and infarction of a normal ovary tend to occur in older childhood. During a 4-month period, 3 cases of neonatal ovarian torsion were observed after antenatal ultrasonography had detected fetal pelvico-abdominal cystic lesions. The three infants were explored between 4 and 16 days of age. Ovarian torsion was right-sided in all 3, and 1 ovary had been autoamputated. The resected specimens were nontense, thin-walled cysts, filled with hemorrhagic fluid, that measured between 4.5 and 8 cm in diameter. Microscopically, focal calcification and widespread necrosis precluded recognition of underlying histologic landmarks. Neonatal ovarian cysts or cystic ovaries greater than 4 cm in diameter should be excised, even if asymptomatic, because they are prone to, or have undergone, torsion.

Postnatal resolution of large ovarian cysts detected in utero. Report of two cases

Two cases of spontaneous resolution of large ovarian cysts in newborns are presented. In both cases the cysts were detected prenatally with ultrasound. In one case the cyst disappeared before birth; in the other, the cyst resolved several weeks postnatally. Both infants also displayed labial, uterine and vaginal enlargement, signs of maternal estrogen stimulation. These large ovarian cysts are also most likely under some hormonal stimulation and may undergo spontaneous resolution and therefore obviate the need for surgery.