CHAPTER III

CASE ANALYSIS
I. PROBLEMS
1. How to diagnose this patient?
2. What is the treatment for this patient?
3. How is the future of this patients pregnancy?
II. DISCUSSION
1. How to diagnose this patient?
Theory
ANAMNESIS
- Pain:
Chronic: caused by stretched ovary

capsule
Cyclic: caused by endometriosis and

endometrioma
Intermittent: torsion of the cyst that

Case
ANAMNESIS
- Cyclic pain since a week ago

caused ischemia and

infundibulopelvikum ligament

traction
Acute: caused by ruptured cyst and
the content filled and irritated the

peritoneum
- Gastrointestinal Tract Problem:
Feeling full in the stomach caused by

dilated ovary or ascites

Abdominal distension because of

ascites
Constipation because the cyst could

- Patient always feel full in the stomach

and could not eat
- No defecation problem

press the rectum

- Urinary problem caused by pressed vesica
urinaria by the cyst
- Hormonal problem that could leads to
menstrual problem

- No urinary problem
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- Hypomenorrhea with dysmenorrhea since

a year ago before the patient getting
pregnant
PHYSICAL EXAMINATION
- Abdomen distension, shifting dullness
- Mass in lateral of the uterus

PHYSICAL EXAMINATION
- Palpated mass in regio iliaca dextra with
size 3-4 cms, flat surface, cystic
consistency and mobile with no pain if

moved.
Benign
Malignant
Unilateral
Bilateral
Flat surface
Nodular surface
Cystic consistency
Solid consistency
Mobile
Immobile
GYNECOLOGY EXAM
GYNECOLOGY EXAM
- Inspeculo: no anomaly is usually found
- Lump in right adnexa the size of an egg
- Vaginal toucher and rectal toucher: mass is
rarely felt
LABORATORY TEST
Tumor marker Ca-125: raised in malignant

LABORATORY TEST
Tumor marker Ca-125 was not examined

neoplastic tumor (ovary epithelial tumor)

IMAGING
- Laparoscopy: determine the location and
characteristic of the mass
- Transabdominal sonography (TAS) or

IMAGING
Transabdominal sonography (TAS)
August 9th 2016: found a 3.5 x 2.6 cm
unilateral cyst in right ovary

Transvaginal sonography (TVS):

determine the type of the cyst
Benign
Malignant
Cystic consistency, Solid consistency or
size < 10 cm
Unilateral

solid & cystic

Bilateral

Septa < 3mm

Septa > 2-3 mm

Irregular cyst wall
thickening
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2. How is the treatment in this patient?

If the cysts are already grown and was diagnosed as dangerous ovarian cysts, usually
medical action needs to be done. Surgical removal usually will be done to prevent ovarian
cysts to grow larger. Healing of the cyst also depends on the type. Neoplastic ovarian
cysts require surgery and nonneoplastic doesnt need one. The cyst that does not give any
symptoms or complaints in patients and the size does not exceed a diameter of less than 5
cms, chances are these cysts are follicular cysts or corpus luteum cyst, which are a
nonneoplastic cyst. Not infrequently the cysts experience diminution spontaneously and
disappear, so that the re-examination after a few weeks of the ovaries can be found
roughly the normal size. Therefore, in this case the need to wait for 2 to 3 months, while
redoing gynecologic examination. If during the time of observation found an increase in
the growth of the cyst, it can be concluded that it is likely that cysts are neoplastic, and
can be considered operative treatment. (Prawirohardjo, 2002)
Surgery on a non malignant neoplastic ovarian cyst include the removal of the cyst
with resection on the ovary containing cyst. However, if the cyst is large or there are
complications, removal of the ovaries, usually accompanied by removal of the tube
(Salpingo-oophorectomy) is needed. At the time of the operation of both ovaries should
be checked to determine whether the cyst found in one or two ovaries. (Prawirohardjo,
2002)
In operation, removed ovarian cyst should be opened, to find out if there is
malignancy. In dubious circumstances, it is necessary to do preparation

for frozen

examination (frozen section) by an anatomical pathologist to obtain certainty whether the

cyst is malignant or not in operating time. If there are malignancy, proper operation is
hysterectomy and bilateral salpingo-oophorectomy. However, the young woman who still
wants gets descent and low malignancy cysts (eg cyst cells granulosa), accountable to
take risks to perform an operation that is not too radical.
Treatment depends on the size and consistency of the cyst and appearance on
examination of ovarian cysts can be observed ultrasonografi. Screening if diameter less
than 80 mm, and repeat to see if the cyst is growing. If decided to do therapy, do cyst
aspiration or cystectomy ovarium.
3. How is the future of this patients pregnancy?
Cyst that happens in pregnant women with the size > 80 mm with wall thickness or
semisolid require surgery after 12 week of gestation.Cyst that detected after 30 weeks of
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pregnancy may be difficult to remove and can make premature labor. Decision to perform
the operation can only be made after careful consideration by involving patients and
partner. If the cyst causing obstruction of the birth canal and can not be digitally moved,
consider to do a cesarean section and cystectomy ovary. (Moore, 2001)

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