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Ruptured/Bleeding Ovarian Cysts/Tumors in Pregnancy

Chapter · March 2014

DOI: 10.1007/978-3-319-05422-3_14

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14.4 Treatment
pelvis are found only upon pelvic examinations
in labor [1]. On the contrary, the diagnosis was
made during pregnancy in 77 % of Caverly’s 83
cases. The absence of symptoms in one-fourth of
cases shows the necessity of most careful ante-
partum routine examinations. The physical find-
ings are often misleading. Hard semisolid
dermoids or cystic tumors made tense by pres-
sure may be mistaken for fibroids or vice versa.
The abdominal distention with large flaccid cysts
and fat abdomen may be most confusing. Ascites
is common with cysts, but rarely occurs with
fibroids.
Pelvic examination usually reveals diffuse
pelvic tenderness, often lateralized to the side of
the cyst, and a mass may be palpated. If hemor-
rhage is severe, it may produce abdominal disten-
tion and shock.
14.3 Diagnosis
14.3.1 Laboratory Findings
Diagnosis between hemorrhagic ovarian cyst
and ectopic pregnancy is sometimes difficult.
The distinction between these entities largely
depends on the serum βHCG level. Assuming no
intrauterine pregnancy is seen in an elevated
serum βHCG level makes these findings strongly
suggestive of the adnexal ring heralding an ecto-
pic gestation, whereas a negative serum βHCG
level makes a hemorrhagic ovarian cyst more
likely [14].
14.3.2 Abdominal Ultrasound
If the patient is hemodynamically stable, pelvic
and abdominal sonography is valuable. The diag-
nosis is easy if the cyst is in the pelvis, but it is
often missed if the tumor is small and behind the
uterus, when its presence may not be revealed
until after labor. The hemorrhagic ovarian cyst
exhibits a myriad of sonographic appearances.
Most commonly it is depicted as a rounded
hypoechoic mass containing low-level echoes,
fine strands, or septations; however, other patterns
467
are seen so frequently that the hemorrhagic
ovarian cyst has been termed “the great imitator”
[12, 13]. Occasionally, a hemorrhagic ovarian
cyst presents as a thick echogenic wall surround-
ing a central rounded echolucent area – a pattern
remarkably similar to that of the adnexal ring
sign of an ectopic pregnancy. The identification
of an intrauterine gestational sac essentially
excludes the diagnosis of ectopic pregnancy and
may permit expectant management even when
intraperitoneal bleeding has occurred [11].
14.4 Treatment
14.4.1 Introduction
Because complications of abdominal surgery are
increased in pregnancy, surgical management of
ovarian cysts in pregnancy has been reconsidered
[15]. Historically, pregnant women with persis-
tent adnexal masses underwent elective removal
of the masses in the second trimester [16]; this is
no longer an acceptable practice in asymptomatic
women, as surgical intervention, as either an
emergency or after 24 weeks’ gestation, is associ-
ated with a poorer obstetric outcome [17].
Complications include spontaneous miscarriage
or preterm premature rupture of membranes [15].
Growing understanding of the natural history
of borderline ovarian tumors has allowed us to
be more conservative in their surgical manage-
ment, preserving fertility in many young women
[18]. However, the natural history of such tumors
is still unclear. In one study, three women were
thought to have borderline lesions. This was
based on the sonographic appearance and the
presence of papillary projections that were non-
vascular on color Doppler. Only one of these was
confirmed histologically; the others were a
benign cystic teratoma and a benign hemorrhagic
ovarian cyst that had undergone torsion [18].
This highlights the difficulty in classifying
some ovarian masses, and it is well accepted
that 10 % of adnexal masses are extremely dif-
ficult to classify [19]. Despite the fact that the
borderline lesions in the study by Crispens were
managed surgically, there is evidence to suggest
468
that expectant management of such ovarian
cysts is an option [18]. In recent studies, this
approach to such lesions was shown to be safe.
After the pregnancy, these patients underwent
surgery [5, 19].
14.4.2 Conservative Treatment
14.4.2.1 Observation
As only 0.13 % of women with an ovarian cyst
required acute intervention during pregnancy,
conclusion is that examining the ovaries at the
time of a first trimester scan is of limited value.
Those women requiring intervention will present
with pain, while prior knowledge of the presence
of a cyst may only increase anxiety even though
the risk of complication is very low. If an appar-
ently nonmalignant ovarian cyst is noted at the
time of a first trimester ultrasound examination,
the woman should be offered a follow-up scan
6 weeks after the pregnancy has concluded.
Although there are no randomized clinical trials
to determine the optimal management of an
adnexal mass in pregnancy, experience suggests
that expectant management is safe and without
serious adverse outcome for both mother and
fetus [4, 5].
In emergent settings, if a provisional diagno-
sis of hemorrhagic corpus luteum cyst with mini-
mal hemoperitoneum can be made, most such
cases may be best served by expectant manage-
ment with serial clinical examination and hemo-
globin measurements [9].
14.4.2.2 Aspiration
Aspiration of simple ovarian cysts during preg-
nancy is safe and may prevent the need for surgi-
cal intervention; in some cases, this will be the
definitive treatment [20]. Neither anesthesia nor
analgesia is required for such intervention.
Ultrasound-guided aspiration for the relief of
pain generated by simple ovarian cysts in non-
pregnant women can be performed either trans-
vaginally or transabdominally depending on the
location of the cyst [21]. After 14 weeks’ gesta-
tion, the uterus is an abdominal organ, and as a
14 Ruptured/Bleeding Ovarian Cysts/Tumors
result the ovaries are more easily targeted
transabdominally. If the pain persists after the
procedure without other symptoms or complica-
tions, a laparoscopic ovarian cystectomy after
delivery is indicated [5]. Fine-needle aspiration is
not appropriate if the cyst has any suspicious
morphological features. It is not a common diag-
nostic problem because the frequency of ovarian
cancer in pregnancy is reported to be 1/15,000–
1/32,000 pregnancies [3].
14.4.3 Operative Treatment
If the patient is hemodynamically unstable or the
diagnosis is in question, exploratory surgery is
required. In hemodynamically unstable patient,
emergency laparotomy, not laparoscopy, is indi-
cated because definitive surgery is mandatory in
the shortest possible time period. If rupture and
bleeding do occur, diagnostic and therapeutic
laparoscopy is appropriate.
If a provisional diagnosis of hemorrhagic cor-
pus luteum cyst with minimal hemoperitoneum
can be made, most such cases may be best served
by expectant management [9]. However, once
massive hemorrhage from ruptured corpus
luteum cysts occurs, it can be a life-threatening
condition that requires emergent surgical inter-
vention [10]. With advances in laparoscopic sur-
gical procedures and the development of surgical
equipment, laparoscopic treatment of a ruptured
corpus luteum cyst with hemoperitoneum is
highly desirable [22–25]. Further, utilizing intra-
operative autologous blood transfusion, transfu-
sion of bank blood can be avoided even in cases
of massive hemoperitoneum due to ruptured cor-
pus luteum cyst in patients with ectopic preg-
nancy [23, 25].
14.4.3.1 Laparoscopy
Introduction
Laparoscopic cystectomy in pregnancy was first
reported in 1991 by Nezhat et al. [26] and then a
second case in 1994 by Howard and Vill [27].
Since then, for various reasons, laparoscopic sur-
gery in pregnancy has rapidly increased as
14.4 Treatment
surgeons realized the safety of the technique in
general as well as in pregnancy. Pregnancy is no
longer considered as an absolute contraindication
for laparoscopic procedures. There is evidence to
suggest that laparoscopy and laparotomy do not
differ with regard to fetal outcome, that is, fetal
weight, gestational age, growth restriction, infant
survival, and fetal malformations [31]. However,
the major advantages of laparoscopy are magnifi-
cation and panoramic view of the pelvis resulting
in reduced intraoperative uterine manipulation
which may lead to decreased postoperative uter-
ine irritability, miscarriage rate, and preterm
labor which is seen in 50 % of third trimester
cases with an open approach. In addition, the cos-
metic results are much better, and the discomfort
of stretching and distension of the laparotomy
scar due to the rapidly growing uterus is avoided.
Very few case series provide long-term follow-
up. Only one series with 11 cases of 1–8 years of
follow-up has reported no evidence of develop-
mental or physical abnormalities in the resultant
children after acute non-obstetrical surgery dur-
ing pregnancy [32].
With increasing gestational age, the uterus
rises out of the pelvis, and there is an increasing
chance of injury while inserting the Veress nee-
dle. Generally, open cannulation laparoscopy or
Palmer’s point entry is recommended for laparos-
copy during pregnancy. This avoids the risk of
penetrating injury to the pregnant uterus by either
the Veress needle or the trocar cannula [28].
Cystectomy
After confirmation that the bleeding is secondary
to a cyst, conservative therapy consisting of
removing the cyst and coagulating its base is
standard therapy. If it is necessary to remove a
corpus luteum of early pregnancy (prior to
12 weeks), progesterone replacement is advis-
able following surgery.
Large cystic masses may require decompres-
sion to fit though a small incision. By decom-
pressing a cyst into a laparoscopic bag, spillage
can be minimal or nonexistent. Copious irriga-
tion also helps to keep the residual content to a
minimum [29]. After cystectomy, the ovarian
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469
incision can be left open or approximated by
three techniques:
• Fine monofilament suture of the edges
• Tissue glue
• Coagulation of the ovarian cortex adjacent to
the surface, which will in some instances evert
the edges
Stitching is necessary to avoid adhesions
between the raw ovarian surface and the raw peri-
toneal surface left after bowel adhesiolysis in the
left adnexa [29].
Furthermore, the risk of obstruction of labor
by ovarian cyst or tumor is calculated to be
17–21 % [30]. Antenatal operative procedures
ranging from aspiration of the cyst to oophorec-
tomy are described in the literature to prevent the
risk of obstruction of labor.
14.4.3.2 Bilateral Ovariectomy/
Adnexectomy
There are many reported cases where both ova-
ries have been removed and the pregnancy has
normally continued. It is usually stated that the
corpus luteum is indispensable to pregnancy for
the first two months and removal during that time
precipitates abortion. Waldstein, however,
recently removed bilateral dermoids at the sec-
ond month without interrupting the pregnancy.
Caverly reports two abortions following eight
single ovariotomies before the third month of
pregnancy. Another two patients continued early
pregnancy to term after bilateral ovariectomy.
Both women, however, had many children [33].
14.4.3.3 Ovarian Teratoma
Elective
Treatment of suspected ovarian teratoma is surgi-
cal removal as soon as possible after diagnosis to
avoid complications. They may be responsible
for torsion, rupture, and obstruction during labor.
Rupture is rare, but once it has occurred, it can
cause complications such as chemical or granulo-
matous peritonitis mimicking advanced ovarian
malignancy [37, 44, 45].
All efforts should be made to avoid rupture or
leakage of cyst fluid during the operation. If it
happens before or during the operation, copious