CHAPTER I

INTRODUCTION

Neoplasm is a period of abnormal, uncontrolled, and uncoordinated tissue with normal

tissue, growing continuously continues to transform and continues to divide. Tumors are one of
the five inflammatory characteristics derived from Latin, which means swelling. The term tumor
is used to describe abnormal tissue biological growth.1,2,3

Ovarian cyst is a fluid-filled bag like a balloon filled with water in the ovary. The most
common type of ovarian cyst is called a functional cyst, which usually forms during the normal
menstrual cycle. Every month, a woman's ovary grows a small cyst that holds the egg. When an
egg is mature, the ovary opens to expel the egg, so it can pass through the fallopian tubes to
fertilize. One of the types of functional cysts is called follicular cysts. This bag is not open to
remove the egg but continues to grow. This type of cyst will usually disappear after 1-3 months.
The corpus luteum cyst, another form of functional cyst, forms when this cyst pocket does not
disappear, but the cyst sac closes again after the egg cell has been removed. Ovarian cysts usually
occur in women aged over 40 years. Ovarian cysts are one of the most common gynecological
benign tumors in women during their reproductive period.2,3

Ovarian cysts are ovarian tumors that are neoplastic and non-neoplastic. Ovarian cysts are
a tumor, both small and large, cystic or dense, benign or malignant in the ovary. In pregnancy the
most common ovarian tumor is dermoid cyst, chocolate cyst or lutein cyst. Ovarian tumors that
are large enough can cause abnormalities of the location of the fetus in the uterus or can obstruct
the entry of the head into the pelvis.

Ovarian cysts are benign tumors that are thought to arise from parts of the ovum that
normally disappear during menstruation, their origin is not identified and consist of
undifferentiated embryonal cells, these cysts grow slowly and are found during surgery containing
yellow thick sebaceous material arising from the layer skin.

1
 CHAPTER II

CASE REPORT

Patient’s Identity

 Name : Mrs. I
 Age : 33 years old
 No. Medrec : 96 21 36
 Occupation : housewife
 Address : Padang
 Education : senior high school

 Date of admission : September 7th, 2018

Husband’s identity

 Name : Mr. B
 Age : 34 years old
 Occupation : Enterpreneur
 Education : senior high school

General History Taking

A 33 years old patient was admitted to the emergency obstetric room of Dr. M. Djamil
Central General Hospital on September 7th, 2018 refered from Pasaman Barat Distric hospital
with diagnose G3P2A0L2 preterm pregnancy 28-30 weeks + Neoplasm ovarian cyst suspected +
observation of pain

2
 The history of Present Illness

 Patient has known have cyst on 20 weeks of pregnancy and enlarge until now. At that time
found that there was multilokulare ovarian cyst size 12 cm x 10 cm and 20 weeks pregnancy
but patient never control anymore.

 Pelvic pain radiating to the groin (-)

 Bloody show from the vagina (-)

 Fluid leakage from the vagina (-)

 Massive bleeding from the vagina (-).

 Amenorrhea since 7,5 months ago.

 First date of last menstrual periode was forgotten ( februari 2018)

 Estimation date of delivery can’t be predicted

 Fetal movement was felt since 3 months ago

 No complain of nausea or vomiting neither during early nor late pregnancy.

 Prenatal care to midwife once, and control to RSUP M. Jamil once at 20 weeks of
pregnancy

 Menstrual History : menarche at 13 years old, irregular cycle, once in every 25-30 days
which last for 5 to 7 days each cycle with the amount of 2-3 times pad change/day without
menstrual pain.

3
 Previous Illness History :

 Found multilokulare ovarian cyst size 12 cm x 10 cm and 20 weeks pregnancy.

 There was no history of heart, lung, liver, or kidney desease

 There was no history of DM, hypertension, or allergy

Family Illness History :

 There was no family member with hereditary, contagious or psychiatric disease.

 Marital history : once in 2009

 History of pregnancy/abortion/delivery : 3/0/2

1. 2010, male, 3200 gr, term, spontaneous delivery, midwife, alive

2. 2012, male, 2900 gr, term, spontaneous delivery, midwife, alive

3. Present pregnancy

 History of family planning : -

 History of immunization : -

 Education : Senior High School graduate

 Occupation : Housewife

4
 Physical Examination :

GA Cons BP HR RR T

weak CM 120/80 90 22 af

urine volume : 300 cc/random

BW Before/after : 60kg/75kg

BH/BMI : 155 / 25

 Eyes : Conjunctiva was not anemic, Sclera wasn’t icteric

 Neck : JVP 5-2 cmH2O, no enlargement on thyroid glands

 Chest : heart/lungs within normal limits

 Abdomen : OR

 Genitalia : OR

 Extremity : Oedema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Obstetric record

 Abdomen :

I : Enlarge according term pregnancy ,median line hyperpigmentation, striae gravidarum

(+), cicatrix (-)

 Pa : FUT difficult to determine, upper of abdoment enlargement felt 1 finger bellow PX.

abdominal tendernes (-), reverse abdominal tendernes (-) , Defans Muscular (-)

 Pe : dull on mass

5
  Au : Peristaltic sound was normal

Fetal Heart Rate : 140-150

Genitalia : I: V/U within normal limit, vaginal bleeding (-)

USG

USG Interpretasion :

Fetal alive, singleton, intrauterine, head presentation

Fetal movement (+)

Biometric :

BPD : 72 mm

AC : 264 mm

FL ; 58 mm

6
AFI : 93

SDAU : 2,27 mm

EFW : 1500-1600 GR

Placenta was implanted on anterior corpus grade II

Septum hypoechoic mass exceeds the monitor screen, the wall comes from adnexa
RI: 0.32

Impression:

• 30-31 weeks of preterm pregnancy

• Fetal alive
• Multiloculare ovarian cyst neoplasm

Laboratory Finding : September 7th, 2018

Routine blood testing Laboratory finding Normal value for 3rd TM

Haemoglobin 13,3 g/dl 12,00 – 14,00

Leukocyte 18000/mm3 5,00-10,00

Hematocryte 38 % 37,00-43,00

Thrombocyte 233.000/mm3 150,00-400,00

PT 12,3 sec 10,0-13,6

APTT 31,3 sec 29,2-39,4

7
 Calcium 7,8 mg/dl 8,6-10,3

Potassium 4,1 mmol/L 3,5-5,1

Sodium 136 mmol/L 139-145

Chlorida 107 mmol/L 97-111

Random blood glucose 114 mg/dl <200,00

Total protein 5,3 g/dl 5,6 – 6,7

Albumin 2,7 g/dl 2,3 – 4,2

Globulin 2,6 g/dl 2,5-3,3

LDH 457 u/l < 480

Ureum 17 mg/dl 16,6 – 48,5

Creatinin 0,4 mg/dl 0,6 – 1,2

Ca 125 34,25 <35

SGOT 25U/L 0,00-31,00

SGPT 11U/L 0,00-34,00

Bilirubin Total 0,4u/L 0,3- 1,0

Bilirubin direct 0,1 <0,2

Bilirubin indirect 0,3 <0,8

 MRI : 3 x 1 x 34,25 = 102,75

8
 Diagnose :

 G3P2A0L2 preterm pregnancy 30-31 weeks + multilokulare ovarian cyst

 Fetal alive, singleton, intra uterine.

Management :

 Control GA, VS, FHR, Uterine contraction, Σ urine

• Informed consent

• Dexametason inj 2x10 mg (2 days)

• Tocolityc : mefenamic acid 3x500 mg

• Nipedipin 3x 10 mg

Plan :

Ekspektatif

Follow UP September 8th, 2018

S/ inpartu(-), hard to breath (+), acute abdomen sign (-),fetal movement (+)

PE/ GC CON BP HR RR T

mod cmc 120/80 80 30 af

Abd : abdominal tendernes (-), reverse abdominal tendernes (-) , Defans Muscular (-)

FHR : 150-160 bpm

Gen : I : v/u normal, vaginal bleeding (-)

9
 Diagnosis :

 D/G3P2A0L2 preterm pregnancy 30-31 weeks + multilokulare ovarian cyst

 Fetal alive, singleton, intra uterine.

Management :

 Control GA, VS, FHR, Uterine contraction, Σ urine

• Informed consent

• Ceftriaxon inj 2x1 gr

• Crosmatch PRC 4 unit

• P/ laparatomy

• Consult to oncology departement  MRI : 103, laparatomy performed by

gynecologist, pregnancy continue

September 11th, 2018

 At 13.00 am laparatomy was perfomed

when peritoneum was opened, there was ascites, aspirated about 4.000 cc. Exploration was
performed there are cystic multilokulare mass as big as baby’s head, greyish-white in colour, the
mass was from left ovary. Impression: left multilokulare ovarian cystic.

Plan : SOS

SOS was performed.

blood during operation ± 1000 cc.

10
Diagnose/

Post SOS oi left multilokulare ovarian cystic on G3P2A0L2 preterm pregnancy 30-31 weeks

P/

 Control post op

 Controlling general condition, vital sign, fluid balance,

 Post laparatomy Laboratory examination

 Transfusion PRC

 Pronalges supp

 Ceftriaxon inj 2x1 gr

 Cygest 400 mg

Laboratory post Operation

Parameter Result Normal Value

Hemoglobin 11,9 g/dl 12,00-14,00

Leukocyte 9400/mm3 5,00-10,00

Hematocryte 14% 37,00-43,00

Thrombocyte 137.000/mm3 150,00-400,00

11
 Follow Up September 12th, 2018

S/ inpartu(-), hard to breath (-), acute abdomen sign (-), fetal movement (+)

PE/ GC CON BP HR RR T

mod cmc 120/80 80 30 af

Abd :

abdominal tendernes (-), reverse abdominal tendernes (-) , Defans Muscular (-)

FHR : 150-160 bpm

Gen :

 I : v/u normal, vaginal bleeding (-)

Diagnose :

post SOS oi left multilokulare ovarian cystic on G3P2A0L2 preterm pregnancy 30-31 weeks

 Fetal alive, singleton, intra uterine.

Management :

 Control GA, VS, FHR, Uterine contraction,

 Informed consent

• Ceftriaxon inj 2x1 gr

• Mefenamic acid 3x500 mg

• Sf 2x1 tab

• Cygest 400 mg

12
13
 CHAPTER III

LITERATURE REVIEW

A. Definition

An ovarian cyst is a sac or pouch filled with fluid or other tissue that forms in or on an
ovary. Ovarian cysts are very common. They can occur during the childbearing years or after
menopause. Most ovarian cysts are benign (not cancer) and go away on their own without
treatment. Rarely, a cyst may be malignant.1,2,5

Most common ovarian masses encountered during pregnancy are functional cysts of ovary
and luteomas being unique to pregnancy. Based on the level of malignancy, ovarian cysts are
divided into two, namely non-neoplastic and neoplastic. Non-neoplastic cysts are benign and
usually deflate on their own after 2 to 3 months. While neoplastic cysts generally have to be
operated on, they also depend on their size and nature.

The other ovarian masses in order are benign cystic teratomas, serous cystadenoma,
paraovarian cyst, mucinous cystadenoma and endometrioma.

Types of cysts include the following:

 Functional cyst
This is the most common type of ovarian cyst. It usually causes no symptoms.
Functional cysts often go away without treatment within 6–8 weeks.
 Teratoma
This type of cyst contains different kinds of tissues that make up the body, such as
skin and hair. These cysts may be present from birth but can grow during a woman’s
reproductive years. In very rare cases, some teratomas can become cancer.

14
  Cystadenoma
These cysts form on the outer surface of the ovary. They can grow very large but
usually are benign.
 Endometrioma
This cyst forms as a result of endometriosis

Neoplastic cysts in the ovary or Neoplasm ovarian Cyst (NOK) are divided into 3 types,
namely cystadenoma ovarii serosum, cystadenoma ovarii mucinous, and dermoid cyst.

1. Kistadenoma Ovarii Serosum

Cystadenoma serousum covers about 15-25% of all benign ovarian tumors. Age of
sufferers ranges from 20-50 years. In 12-50% of cases, this cyst occurs in both ovaries
(bilateral). Cyst sizes range from 5-15 cm and this size is smaller than the average size of
mucous cystadenoma. Cysts contain serous, clear yellowish liquid. Focal proliferation of
the cyst wall causes a papillomatous projection to the center of the cyst that can transform
into a fibroma cystadeno. This papillomatous projection must be considered carefully in an
effort to distinguish it from atypical proliferation.1,2,3

Serosum cystadenomas found at the age of 20-30 years are classified as low-
potential neoplasms for malignant transformation and this is in contrast to patients in peri
or postmenopausal age who have high anaplastic potential. As with most ovarian epithelial
tumors, no special clinical symptoms can be found that can be a marker of serosum
cystadenoma. In most cases, these tumors are found by chance during routine
examinations. Under certain conditions, sufferers will complain of discomfort in the pelvis,
abdominal enlargement, and symptoms such as ascites.1,2,4

The chosen treatment for serosum cystadenoma is surgery (excision) with thorough
exploration of intrapelvic and abdominal organs. For this reason, the type of incision
chosen is mediana because it can provide sufficient access for exploration actions. It is best
to do a PA examination during surgery in anticipation of the possibility of malignancy.1,2,5

15
2. Kistadenoma Ovarii Musinosum

Muccal ovarian cystadenoma includes 16-30% of the total benign ovarian tumors and 85%
of them are benign. These tumors are bilateral in 5-7% of cases. These tumors are generally
multilocular and the locus containing mucous fluid appears bluish in the capsule with a
tense wall. The tumor wall is composed of a high columnist epithelium with a dark cell
nucleus located on the basal part. This wall of the musinosum kistadenoma, in 50% of cases
is similar to the endocervical epithelial structure and 50% is similar to the colonic epithelial
structure in which mucin fluid in the cyst loculus contains goblet cells. It is necessary to
select PA examination samples from several places because of the wide range of areas with
a benign description. Malignant, or malignant potential is very varied.1,2,4

This mucin tumor is the tumor with the largest size of tumors in the human body.
There were 15 reports which stated the tumor weight was above 70 kg. As a consequence,
the greater the size of the tumor in the ovary, the more likely the diagnosis is cystadenoma
ovarian mucus. These tumors are also asymptomatic and most patients only feel weight
gain or feeling full in the stomach. Under certain conditions, postmenopausal women with
this tumor can experience hyperplasia or vaginal bleeding because the tumor cell stroma
undergoes a process of luteinization so that it can produce tumors (especially estrogen). If
this happens to pregnant women, excessive hair growth (virilization) can occur in
patients.1,2,4

Musin fluid from the cystoma can flow to the pelvic or abdominal cavity through
the ovarian stroma so that there is accumulation of intraperitoneal mucin fluid and this is
known as pseudomiksoma peritonii. Similarly, it can also be caused by kistadenoma of the
appendix (appendiceal mucinous cystadenoma).1,2,4

If it turns out that the mucous ovarian cystadenoma stroma disseminates mucin
fluid to the peritoneal cavity (pseudomyxoma) and this is found during laparotomy,
unilateral salpingo-oophorectomy should be performed. To empty mucin from the
peritoneal cavity, dilute the mucin first with a 5-10% dextrose solution before suctioning.
1,2,4

16
3. Dermoid cysts

Cystademoid is the most tumor (10% of total ovarian tumors) originating from
germinativum cells. This tumor is a benign germinativum cell tumor and is most common
in girls aged 20 years. This germ cell tumor covers 60% of cases compared to 40% from
non-germinal cells for the age group mentioned earlier.1,2,3,4

Although there are several tissues that make up tumors, but ectodermal is the main
component, which is then followed by mesodermal and entodermal. The more complete
the constituent elements, the more solid the consistency of this tumor. Dermoid cysts rarely
reach a large size, but sometimes mix with kistadenoma ovarii musinosum so that the
diameter gets bigger. The tumor constituent consists of mature cells so that the cyst is also
referred to as mature teratoma. Dermoid cysts have white walls and are relatively thick,
because the tumor walls contain many sebaceous glands and ectodermal derivatives (most
are hairs). In small size, dermoid cysts do not cause any complaints and the discovery of
tumors is generally only through routine gynecological examinations. The full and heavy
feeling in the stomach is only felt when the tumor size is large enough. Dermoid cyst
complications can be torsion, rupture, bleeding, and malignant transformation. The therapy
is laparotomy and cystectomy.4

B. Epidemiology

The incidence of cysts often occurs in women of productive age. Rarely under the age of
20 or over 50 years. Ovarian cysts are found in almost all premenopausal women and in
18% of postmenopausal women. Incidents that often occur in women aged 30-54 years and
the highest are women with white skin. In Indonesia, around 25-50% of women of
childbearing age are caused by problems related to pregnancy, childbirth, and diseases of
the reproductive system such as ovarian cysts. In the H. Adam Malik General Hospital in
Medan there were a total of 47 people with ovarian cysts in 2008. At Dr. Hospital Pirngadi
Medan from January 2010 to October 2010 ovarian cyst patients in women of childbearing
age were recorded as many as 34 cases. Then at ST Hospital. Elisabeth Medan, ovarian

17
 cyst patients from 2008-2012 were recorded as many as 116 cases. For the number of
incidents of the Neoplasm ovarian Cyst alone no data collection was conducted.

C. Clinical Symptoms

Cystic ovarian neoplasms are often asymptomatic, especially if the size of the cyst is still
small. A new benign cyst provides an uncomfortable feeling when the cyst is getting
bigger, whereas in malignant cysts it sometimes gives a complaint as a result of
surrounding tissue infiltration or metastasis. Ascertainment of the disease cannot be seen
from symptoms only because the symptoms may be similar to other conditions such as
endometriosis, pelvic inflammation, ectopic pregnancy (outside the uterus) or ovarian
cancer. However, it is important to pay attention to any symptoms or changes in the body
to find out which symptoms are serious. Symptoms include: stomach, feeling full, heavy
and bloated, pressure in the rectum and bladder (difficulty urinating), irregular menstrual
cycles and frequent pain, persistent or recurrent pelvic pain that can spread to the lower
back and thighs , dysuria, coitus pain, nausea, vomiting, or hardening of the breast similar
to during pregnancy, the surface area of the endometrial wall is thickened, and swelling of
the lower limbs is not accompanied by pain. Sometimes the cyst can rotate at its base,
experience infarction and tear, causing pain in the acute lower abdomen that requires
immediate medical treatment.

D. Pathophysiology
Every day, the normal ovary will form several small cysts called Follicles de Graff. At mid-
cycle, the dominant follicle with a diameter of more than 2.8 cm will release mature
oocytes. Ruptured follicles will become the corpus luteum, which when ripe has a structure
of 1.5 - 2 cm with a cyst in the middle. If fertilization does not occur in the oocyte, the
corpus luteum will experience progressive fibrosis and shrinkage. But if fertilization
occurs, the corpus luteum will initially enlarge and gradually will shrink during pregnancy.
Ovarian cysts originating from the normal ovulation process are called functional and
always benign cysts. Cysts can be follicular and luteal which are sometimes called theca-
lutein cysts. These cysts can be stimulated by gonadotropins, including FSH and HCG.

18
Multiple functional cysts can form due to gonadotropin stimulation or excessive sensitivity
to gonadotropin. In gestational tropoblastic neoplasia (hydatidiform mole and
choriocarcinoma) and sometimes in multiple pregnancies with diabetes, HCG causes a
condition called lutein hyperreactive. Patients in infertility therapy, ovulation induction
using gonadotropin (FSH and LH) or sometimes clomiphene citrate, can cause the ovarian
hyperstimulation syndrome, especially if accompanied by HCG administration. Neoplasia
cysts can grow from excessive and uncontrolled cell proliferation in the ovary and can be
malignant or benign. Malignant neoplasia can originate from all types of ovarian cells and
tissues.

So far, malignancy most often originates from the surface epithelium (mesothelium)
and most partial cystic lesions. A type of benign cyst similar to this malignancy is serous
and mucinous cistadenoma. Other malignant ovarian tumors can consist of cystic areas,
including this type are granulosa cell tumors from sex cord cells and germ cel tumors from
primordial germ cells. Many tumors show no symptoms and signs, especially small ovarian
tumors. Most of the symptoms and signs are a result of growth, endocrine activity and
tumor complications.

1. As a result of growth

The presence of a tumor in the lower abdomen can cause stomach ulcers. Pressure on
the tools around it is caused by the size of the tumor or its position in the stomach. If the
tumor urges the bladder and can cause interference with the micturition, while the cyst is
larger but is located freely in the abdominal cavity - sometimes it only causes a feeling of
heaviness in the stomach and can also cause obstipasi edema in the limbs

2. Due to hormonal activity

Ovarian tumors do not change the menstrual pattern unless the tumor itself secretes
hormones.

19
3. Due to Complications

a. Bleeding into the cyst

It usually occurs little by little so that it gradually causes enlargement of the wound
and only causes minimal clinical symptoms. However, if bleeding occurs in large amounts
it will cause pain in the stomach.

b. Stalk Round

Occurs in stemmed tumors with a diameter of 5 cm or more. The rotation of the stem
causes a pull through the infundibulopelvicum ligament to the parietal peritoneum and this
causes pain.

c. Infection of the tumor

Occurs if near the tumor there is a source of pathogenic germs. Dermoid cysts tend
to experience inflammation followed by restraint.

d. Torn the cyst wall

Occurs in the torque of the shaft, but can also be a result of trauma, such as a fall or
blow to the abdomen and more often during intercourse. If the cyst tears accompanied by
hemorrhage that arises acutely, then free bleeding takes place into the uterus into the
peritoneal cavity and causes continuous pain accompanied by signs of acute abdomen.

e. Changes in malignancy

After the tumor is removed, a careful microscopic examination of the possibility of

malignant changes is necessary. The presence of ascites in this case is suspicious. 6.7
Dermoid cysts are tumors that are thought to originate from the part of the ovum that
normally disappears during maturation. Its origin is not identified and consists of

20
 undifferentiated embryonal cells. These cysts grow slowly and are found during surgery
containing thick yellow sebaceous material, which arises from the skin layer. Dermoid
cysts are only one type of lesion that can occur. Many other types can occur and treatment
depends on the type.

E. Supporting Investigation

1. Laparoscopy

This examination is very useful to find out whether a tumor originates from the ovary
or not, and to determine the characteristics of the tumor

2. Ultrasonography

This examination can determine the location and extent of the tumor whether the tumor
originates from the uterus, ovary, or bladder, whether the tumor is cystic or solid, and
can it be distinguished between the fluid in the abdominal cavity that is free and that is
not.

Figure 1. Ultrasound results in mucosal cystadenoma

21
 3. X-rays

This examination is useful for determining the presence of hydrothorax. Furthermore,

in dermoid cysts the teeth can sometimes be seen in the tumor.

4. Parentesis
It has been mentioned that the function of ascites is useful in determining the cause of
ascites. It should be reminded that this action can contaminate the peritoneal cavity
with the contents of the cyst if the cyst wall is punctured

F. Complications
One of the most feared things about this disease is that the cyst becomes malignant and
many complications occur. Complications from ovarian cysts that can occur are:

1. Bleeding into the cyst

It usually occurs little by little until it causes the cyst to enlarge, enlargement of the wound
and only causes minimal clinical symptoms, but if bleeding occurs in large amounts there
will be rapid distention of the cyst that causes stomach pain. The cyst has the potential to
rupture, there is no standard regarding the size of the cyst that has the potential to rupture.
Rupture of a cyst can cause blood vessels to tear and cause bleeding

2. Infection of the cyst

If it occurs near the tumor there is a source of pathogenic germs

3. Torque (Stalk Turn)

Torsio or stem rotation occurs in stalked tumors with a diameter of 5 cm or more, torsion
includes the ovaries, fallopian tubes or ligamentum roduntum in the uterus. If this torque

22
is maintained it can develop into peritonitis infarction and death. The torque is usually
unilateral and associated with cysts, TOA carcinoma, a period that is not attached or that
can appear in women reproductive age includes sudden pain and severe lower abdomen,
nausea and vomiting can occur fever leukocytosis

4. Changes in malignancy

After the tumor is removed it is necessary to do a careful microscopic examination of the

possible changes in its health, the presence of ascites in this case is suspicious the period
of ovarian cysts develops after menopause so that it can possibly turn into cancer.

5. Tear the cyst wall

Occurs in the torque of the stalk, but can also occur due to trauma, such as falls or blows
to the abdomen, and more often during intercourse, if the cyst tears accompanied by
hemorrhage that arises acutely, then free bleeding takes place into the peritoneal cavity and
creates a feeling persistent pain including acute signs

G. Management

Management of ovarian cysts depends on the size of cysts. Most of the cysts having
diameter of less than 6 cm and which have benign looking picture on ultrasonography
(USG) can be managed conservatively and careful follow up can be done as most of them
resolve spontaneously over time. Cysts which measure more than 10cm are generally
resected due to fear of complications like torsion, rupture and increase chances of
malignancy. Management of cysts with diameter between 6-10 cm is controversial. If they
have USG picture of solid components, papillary excrescences, if the cysts contain septae
and nodules, than its better to resects them because of increase in risk of malignancy. If the
cyst has picture as that of simple cyst, than it can be followed up by serial ultrasonography.
However it is to be kept in mind that even these cysts may necessitate emergency
laparotomy and exploration if complications like torsion, rupture or necrosis arise as seen

23
in as many as 50% cases. These days due to advent of modern techniques such as MRI,
trans vaginal colour Doppler, high resolution ultrasound, conservative management has
become quite easy.

If the cyst has already grown and is diagnosed as a dangerous cystic ovarian
neoplasm, medical treatment is usually needed. Surgical removal will usually be done to
prevent the ovarian cyst from growing bigger. Healing from the cyst also depends on the
type of each. Neoplastic ovarian cysts require surgery and no non-neoplastic cysts. If you
face a cyst that does not give symptoms or complaints to the patient and the large cyst does
not exceed the lime with a diameter of less than 5 cm, most likely the cyst is a follicular
cyst or corpus luteum cyst, so it is a non-neoplastic cyst. Not infrequently these cysts
experience shrinkage spontaneously and disappear, so that on a repeat examination after a
few weeks the ovary can be found which is about the normal size. Therefore, in this case
it needs to wait for 2 to 3 months, while carrying out repeated gynecologic examinations.
If during the observation period there is an increase in the growth of the cyst, it can be
concluded that it is likely that the cyst is neoplastic, and one operative treatment can be
considered.

Therapy depends on the size and consistency of the cyst and its appearance on
ultrasound examination. It may be observed that ovarian cysts are less than 80 mm in
diameter, and the skeleton is repeated to see if the cyst is enlarged. If it is decided to do
therapy, aspiration of a cyst or ovarian cystectomy can be done. Cysts found in pregnant
women, those measuring > 80 mm with thick or semisolid walls require surgery, after the
12th week of pregnancy. Cysts detected after the 30th week of pregnancy may be difficult
to remove through surgery and preterm labor can occur. The decision to carry out surgery
can only be made after getting careful consideration by involving the patient and partner.
If the cyst causes birth canal obstruction and cannot be moved digitally, cesarean section
and ovarian cystectomy should be performed. In women over the age of 40 the main choice
is histectomy and bilateral salophingoectomy even if there are no signs of malignancy.

24
 H. LAPAROSCHOPY

Performing the surgery during the early second trimester has a higher success rate for
laparoscopic surgery while minimizing the risk for both the patient and the fetus. Laparoscopy
performed during the later stages of the second trimester or beyond carries greater technical and
surgical difficulties due to the size of the uterus becoming larger in volume and filling up a bigger
portion of the abdominal cavity. Moreover, pneumoperitoneum within the larger uterus which
could cause the uterine to contract and threatened preterm labor. Laparoscopic surgery done during
the first trimester of pregnancy may pose a greater danger to the fetus due to the early stages of
fetus formation and development, even though the first trimester offers a lower risk for surgical
and technical difficulties.

When comparing the surgery performed during organogenesis and the other performed
during the early second trimester, there were not any significant differences in terms of the surgery
time,insufflation time, and blood loss, indicating that the technical difficulties of performing
laparoscopic surgery during the first trimester and those performed during early second trimester
showed little differences. No fetal distress, complications, or fetal malformations were observed
in any of the cases. Therefore, we recommend that the best time to do elective laparoscopic surgery
is during the early stages of the second trimester when the fetus is more developed and the timing
for a spontaneous resolution and the risk of abortion is over. However, the stage of the pregnancy
should not be considered for performing the surgery in emergency cases. Only one emergency case
was performed at our institution wherein the patient was in the middle of the second trimester at
20 weeks,and tocolysis was administered surgery as a preliminary caution to help prevent uterine
contractions up until thedischarge date. However, no tocolysis was required to be administered
between the date of discharge and the delivery.Performing laparoscopic surgeries at the lowest
insufflation level possible can minimize fetal risk. The concern is that high insufflation levels over
a prolonged period of time could bring the fetus into acidosis. Some studies suggest that 10–15
mmHg of carbon dioxide insufflation is primarily safe for the fetus. Other studies have reported
that insufflation of <12 mmHg may not provide adequate visualization of the intra‑abdominal
cavity. In our institute, we set CO2 insufflation levels at 10 mmHg for nonpregnant patients.

For all pregnant patients in our case study, we used insufflation of 7–8 mmHg, which is
much lower than the suggested insufflation levels to ensure adequate venous return, which helps

25
minimize pressure on the inferior vena cava and prevent fetal acidosis.[8] No surgical difficulties
were reported, not even for the patient whose surgery was performed at 20 weeks of gestation.
Thus, we believe that insufflation levels at 7–8 mmHg is capable of performing surgeries without

any difficulties, thereby reducing the risk even more to the fetus. Laparoscopic surgery was found

to be a very safe surgical approach for pregnant patients. However, that being said, thesuccess rate
of laparoscopic surgery during pregnancy can be further enhanced while the risk of fetus
complications can effectively be reduced with the suggested approaches and ideas.

I. SALPHINGO OOPHORECTOMY

Oophorectomy is the surgical removal of the ovary or ovary. The operation is also
called ovariectomy, but this term has been used traditionally in basic science research
which describes the surgical removal of ovaries in laboratory animals. Removal of the
ovaries in women is the same as the biological castration in men, but the term castration is
only occasionally used in the medical literature to refer to oophorectomy in humans. In
veterinary science, complete removal of the ovaries, oviducts, horns of the uterus, and
uterus is called spaying and is a form of sterilization.

Partial oophorectomy is a term sometimes used to describe various types of surgery

such as removal of ovarian cysts or resection of parts of the ovary. Such surgery is
maintaining fertility even though ovarian damage may be relatively common. Most of the
long-term risks and consequences of oophorectomy are not or only partially present with
partial oophorectomy.

Removal of the ovary together with the fallopian tube is called unilateral salpingo-
oophorectomy or salpingo-oophorectomy (USO). When both the ovary and the second
oviduct are removed, the bilateral salpingo-oophorectomy term (BSO) is used.
Oophorectomy and salpingo-oophorectomy are not common forms of contraception in
humans, more commonly is tubal ligation, where the oviduct is blocked but the ovary

26
remains intact. In many cases, surgical removal of the ovary is carried out in conjunction
with hysterectomy. A formal medical name for eliminating the entire female reproductive
system (ovary, oviduct, uterus) is "Total abdominal hysterectomy with Bilateral salpingo-
oophorectomy (TAH-BSO), a more casual term for such surgery is" ovariohysterectomy
"The term" hysterectomy " often used to refer to the removal of any part of the female
reproductive system, including only the ovary, however, the correct definition of
"hysterectomy" is the removal of the without ovary removal egg or oviduct.

A bilateral salpingo-oophorectomy is an operation in which a woman's ovaries are

either removed, along with the fallopian tubes. This operation is used primarily to treat
gynecological cancers such as ovaries, tuba, and uterine cancer, although it is used in the
treatment of several other gynecological conditions as well.

Cysts, endometriosis, benign tumors, inflammation, etc., and less frequently

together with hysterectomy (61%). Specific indications include several groups of women
with a substantial risk of increased ovarian cancer, such as high risk carriers of BRCA
mutations and women with endometriosis who also suffer from frequent ovarian cysts.

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 CHAPTER IV

CONCLUSION

Ovarian cysts are excessive / abnormal cell growth in the ovary that forms like a bag.
Neoplasm ovarian Cyst (NOK) is divided into 3 types, namely cystadenoma ovarii serosum,
cystadenoma ovarii mucinosum, and dermoid cyst. Judging from the incidence of ovarian cysts,
the results showed quite high results. Therefore a quick intervention is needed, in addition to
preventing the occurrence of continuing complications. To make a diagnosis requires several
examinations, namely gynecological clinical examination, ultrasound examination, tumor marker
examination, CT scan / MRI examination. Management of ovarian cysts depends on the size of
cysts. Most of the cysts having diameter of less than 6 cm and which have benign looking picture
on ultrasonography (USG) can be managed conservatively and careful follow up can be done as
most of them resolve spontaneously over time. The best management for patients with neoplasm
ovarian cyst is to do an operation that is excision of the cyst, then monitor whether the cyst will
grow again or not.

Management of ovarian cysts can also be done according to period of gestation. Most
common ovarian cysts encountered during pregnancy are corpus luteal cysts. They usually resolve
up to 12-16 weeks so follow up can be done till then. There is an additional advantage of waiting
till 16 weeks as by this time implantation of pregnancy is more secure and there are less chances
of abortion. Persisting ovarian cysts beyond this gestation are managed by simple cystectomy or
ovariotomy as indicated till 28 weeks. Beyond this gestation, risk of preterm labour is there if
surgical option is considered. Emergency laparotomy is taken up whenever complications arise
such as torsion, rupture, hemorrhage, necrosis or features of malignancy, whatever may be the
period of gestation.

Ovarian cysts or masses during pregnancy should be accurately evaluated to decide the
most appropriate treatment option. Ultrasound and MRI are safe and allow distinguishing between

28
benign and malignant lesions. A wait-and-see strategy is advised for an ovarian cyst with benign
features. Masses with septa, solid components, papillae or nodules, or when persisting after 16
weeks of pregnancy should be further investigated. Treatment options including surgical
procedures should be discussed for each patient individually. Both open surgery and laparoscopy
can be performed considering the tumour diameter, gestational age and surgical expertise. When
advanced stage invasive ovarian cancer is diagnosed, termination of pregnancy may be considered
in early pregnancy, otherwise chemotherapy can be administered during second and third
trimester. When there is high suspicion of malignancy, a multidisciplinary approach is necessary,
and preferably patients should be referred to centres with specialized experience.

DAFTAR PUSTAKA

1. Cunningham F. Gary, Leveno Kenneth J, Bloom Steven L, Hauth John C, Rouse Dwight
J, Spong Catherine Y. Reproductive tract abnormalities. In: Cunningham F. Gary, Leveno
Kenneth J, Bloom Steven L, Hauth John C, Rouse Dwight J, Spong Catherine Y, eds.
William Obstetrics. 23rd ed. New York: McGraw-Hill; 2010: 912-925.
2. Beckmann, C. R. B. M., MHPE, FACOG; Frank W. Ling, M., FACOG; William N.P.
Herbert, M., FACOG, Contraception, Family Planning In Obstetrics and Gynecology, 8
ed.; china, 2018; Vol. 8, p 1142.
3. Pushpa Dahiya, Latika. Ovarian mass in pregnancy: a case report; International Journal of
Reproduction, Contraception, Obstetrics and Gynecology. Dahiya P et al. Int J Reprod
Contracept Obstet Gynecol. 2015 ; p 915-917
4. Frequently Asked Questions Faq075 Gynecologic Problems. Ovarian Cysts. the American
College of Obstetricians and Gynecologists. 2017.

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5. Mancari R, Tomasi-Cont N, Sarno MA et al. Treatment options for pregnant women
with ovarian tumors. Int J Gynecol Cancer. 2014;24:967-72.
6. Amant F, Halaska MJ, Fumagalli M et al. Gynecologic cancers in pregnancy: guidelines of a
second international consensus meeting. Int J Gynecol Cancer. 2014;24:394-403
7. Kurihara Koki, Mari Minagawa, Masamune Masuda, Mari Fukuyama, Keiko Tanigaki.
The Evaluation of Laparoscopic Surgery on Pregnant Patients with Ovarian Cysts and Its
Effects on Pregnancy over the Past 5 Years; Laparoscopic surgery during pregnancy. Gynecology
and Minimally Invasive Therapy .2018. ¦ Volume 7. p 1-5

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