INTERESTING

CASE GYNE
Patient identification
▪ !"วยห&งอา* 22 +
▪ อา,พ .บ0าง
▪ 123เนา จ.กาฬ9น:
▪ แห<ง=อ>ล !"วยและเวชระเCยน
Chief complaint
▪ มาฝากครรGคHงแรก
Management

1 ANC
st
Management 1st ANC
▪ Complete history and physical examination
▪ Correct GA
▪ LAB I
▪ Diet
▪ Activity modification
▪ Sexual activity
▪ Medication : Fe, Folic acid, Calcium supplement
▪ Vaccination : dT, Tdap, Influenza
Present illness
▪ G1P0 GA 14+5 weeks by LMP
▪ !"วยมาฝากครรGคHงแรก ไJKอาการปวดNอง
▪ ไJKเOอดออกทางQองคลอด
▪ ไJKคRนไSอาเTยน UนไVปกW XกYงไJZน ไJK
ตกขาว]ดปกW
▪ ^สสาวะและ`จจาระปกW
Past history
▪No underlying disease
▪No food or drug allergy
▪No family history of diabetic mellitus/
hypertension/heart disease
▪No smoking
▪No alcohol drinking
▪No previous surgery
▪Unknown history of tetanus toxoid
OB-GYN history
▪ Para 0
▪ LMP 16/3/61, PMP 12/2/61
▪ Interval 30-60 days, Duration 3 days, Amount
1 pad/day
▪ Irregular cycle
▪ Contraception : OCPs ห*ด ต.ค. 60
 Physical
Examination
Physical examination
▪ Vital sign : BT 37.2 C, BP 123/75 mmHg
HR 102 /min, RR 20/min
▪ Measurement : BW 52 kg, HT 159 cm
▪ General appearance : A Thai pregnant woman,
good consciousness
▪ HEENT : not pale conjunctiva, anicteric sclera, no
thyroid gland enlargement
▪ Breast : no mass, normal nipple
▪ Lung : clear and equal breath sound
Physical examination
▪ Heart : normal S1S2, no murmur
▪ Abdomen : fundal height 20 week size,
soft, not tender, active bowel sound, fetal
heart sound 150 bpm
▪ Extremities : no edema
▪ Lymph node : can’t be palpated
Obstetric History
LAB I
Hemoglo
11.8 g/dL
bin
Hematoc
32.6 %
rit
MCV 84 fL
Platelet 285,00 Cell/cumm
OF/DCIP negative/negative
Hb
Obstetric History
LAB I
Anti-HIV Negative
HBsAg Negative
RPR Non-reactive
Blood group B
Rh Positive
Problem List
Problem list
▪ G1P0 GA 14+5 weeks by LMP
▪ Size>date
Differential
Diagnosis
Differential diagnosis
▪ Wrong date
▪ Twins
▪ Myoma uteri
▪ Adnexal mass
▪ Molar pregnancy
▪ Full bladder
Investigation
Transabdominal ultrasound
▪ Single viable fetus
▪ Cephalic presentation
▪ GA 14+2 weeks by USG
▪ Placenta posterior middle
▪ AFI- adequate
▪ Right ovarian cyst 73 x 71 mm, inhomogeneous hypoechoic
content, thin wall, no solid part, no septate, no free fluids
Diagnosis
Diagnosis
▪G1P0 GA 14+5 weeks by LMP with
right adnexal mass
Differential
Diagnosis
Differential diagnosis
▪ Endometrioma
▪ Dermoid cyst
▪ Serous cystadenoma
▪ Mucinous cystadenoma
 How to approach

Pregnancy with adnexal mass?
 Causes of adnexal mass 

in pregnancy
Ovarian
• Simple cyst
• Haemorrhagic cyst
• Hyperstimulation ovary
• Luteoma
• Endometrioma
• Brenner tumor
• Epithelial tumor : serous and mucinous; endometrioid and clear cell carcinoma
• Germ cell tumor : mature and immature teratoma, dysgerminoma, endodermal
sinus tumor, embryonal carcinoma
• Sex cord - stromal tumors : fibrothecoma; granulosa cell, sclerosing stromal and
Sertoli - Leydig cell tumor
• Metastatic (Secondary) tumor; Krukenberg
• Lymphoma
Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. The Obstetrician & Gynaecologist 2006;8:1
 Causes of adnexal mass 

in pregnancy
Fallopian tube
• Hydrosalpinx
• Paratubal cyst
• Heterotopic pregnancy
Leiomyoma
Non-gynaecological
• Mesenteric cyst
• Appendix mass
• Diverticular disease
• Pelvic kidney
• Urachal cyst
Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. The Obstetrician & Gynaecologist 2006;8:1
 Adnexal
Adnexal massininpregnancy
mass pregnancy
• Most frequent types of ovarian masses
• corpus luteum cysts
• Endometriomas
• benign cystadenomas
• mature cystic teratomas

Williams Obstetrics, 25th edition

How should adnexal mass 

be managed in pregnancy?
Management of
Management of an
an Adnexal
Adnexal Mass
Mass
Tumors between 5 and 10 cm
▪ Evaluated by sonography along with color Doppler and possibly MR

imaging.

▪ Simple cystic appearance : managed expectantly with sonographic

surveillance

Williams Obstetrics, 25th edition

 Surgery management
Tumors between 5 and 10 cm
▪Resection
▪ cysts grow and begin to display malignant qualities
▪ becomes symptomatic.
▪ sonographic characteristics that suggest a cancer
▪ thick septa
▪ nodules
▪ papillary excrescences
▪ solid components

Williams Obstetrics, 25th edition

 Surgery management
Surgery management
▪ Resection at 14 to 20 weeks (1)

▪ Classic findings of endometrioma or mature cystic

teratoma may be resected postpartum or during cesarean
for obstetrical indications (not present in Williams
Obstetrics, 25th edition)
▪ Prefer Laparoscopic surgery(2)
▪ Complication : decrease uterine blood flow, carbondioxide
absorption , fetal hypotension

1. Williams Obstetrics, 25th edition

2. Koo J, Lee J, Lim K, et al. A 10-year experience of laparoscopic surgery for adnexal masses during
pregnancy. Int J Gynaecol Obstet 2011; 113:36–39.
 Surgery management
Surgery management
ACOG committee opinions 2011
recommendation
▪ No currently used anesthetic agents have been shown to have any

teratogenic effects in humans when using standard concentrations at

any gestational age.

▪ Fetal heart rate monitoring may assist in maternal positioning and

cardiorespiratory management, and may influence a decision to
deliver the fetus.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery management
Surgery management
ACOG committee opinions 2011
recommendation
▪ A pregnant woman should never be denied indicated surgery,

regardless of trimester.

▪ Elective surgery should be postponed until after delivery

▪ Non-urgent surgery should be performed in the second trimester

when preterm contractions and spontaneous abortion are least likely.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery
Surgery management
management
ACOG committee opinions 2011
recommendation
▪ Surgery should be done at an institution with neonatal and pediatric

services.

▪ A qualified individual should be readily available to interpret the fetal

heart rate patterns.

▪ An obstetric care provider with cesarean delivery privileges should be

readily available.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery
Surgery management
management
ACOG committee opinions 2011
recommendation
▪ Fetus is considered previable: the fetal heart rate by Doppler before

and after the procedure.

▪ Fetus is considered to be viable : electronic fetal heart rate and

contraction

▪ Monitoring should be performed before and after the procedure

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery
Surgery management
management
ACOG committee opinions 2011
recommendation
▪ When possible, the woman has given informed consent to emergency

cesarean delivery.

▪ The nature of the planned surgery will allow the safe interruption or

alteration of the procedure to provide access to perform emergency

delivery.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
Operative note
Operative note
▪ Pre-op diagnosis : G1P0 16 weeks with right
ovarian tumor
▪ Post-op diagnosis : G1P0 16 weeks with right
ovarian tumor
▪ Operation : Right salpingo-oophorectomy
Operative note
▪ Position : Supine
▪ Incision : Pfannenstiel incision
▪ Finding : Uterus 16 weeks size pregnancy,
no ascites
Right ovarian cyst 8 x 7 cm, mucin
content, thin wall,
no solid part, no septate
Operative note
▪ Procedure : Right salpingo-oophoractomy
was done
Double ligated stump c vicryl no.0
No intraoperative complications
▪ EBL : 20 ml
Patho
Right SO

▪ Open uniloculated ovarian cyst

with fallopian tube
▪ Ovarian cyst 8.0x5.0x3.5 cm
▪ Gray brown and smooth outer
surface
▪ Gray brown and irregular inner
surface
▪ Wall range 0.1-0.4 cm thickness
▪ Fallopian tube with fimbria 6.0
cm in length, 0.5-0.7 cm in
diameter
Histo
Right ovary
▪ Benign mucinous cystadenoma
▪ Unilocular cyst
▪ Epithelium : single layer of
uniform tall columnar cell with
clear homogenous cytoplasm and
small basal hyperchromatic nuclei
Adnexal mass in
pregnancy
Topic review
 Adnexal mass in pregnancy
• Relatively common
• Incidence of ovarian mass : 1 in 100 to 2000
pregnancies (1)
• Incidences vary depending on the frequency of
prenatal sonography
• Incidence of adnexal mass : 2.3%(2)
• Incidnece of simple cyst : 5.3% (3)
• Incidnece of Ovarian cancer =1 % (1)(2)

1.Williams Obstetrics, 25th edition

2. Bernhard LM, Klebba PK, Gray DL, Mutch DG. Predictors of persistence of adnexal masses in pregnancy. Obstet
Gynecol 2011;93(4):585-589
 Adnexal
Adnexal massininpregnancy
mass pregnancy
• Most frequent types of ovarian masses
• corpus luteum cysts
• Endometriomas

3 • benign cystadenomas
• mature cystic teratomas
y

Williams Obstetrics, 25th edition

 Incidence of most common ovarian
masses in pregnancy
Type of mass Percent
(%)
Dermoid 25
Corpus luteal cyst, functional cyst, parovarian 17
cyst 
Serous cystadenoma 14
Mucinous cystadenoma   11
Endometrioma   8
Carcinoma 2.8
Low malignant potential  3
Ovarian Leiomyoma  2
Hoover. Evaluation and management of adnexal mass in pregnancy. Am J Obstet Gynecol 2011.;2 :1-6.
 Adnexal mass in pregnancy
• Most ovarian masses are asymptomatic in
pregnant women.
• Complication
- Torsion
- Rupture
- Hemorrhage
• blood loss significant enough to cause
hypovolemia.
• Symptom : pressure or chronic pain and acute
abdominal pain
Williams Obstetrics, 25th edition
 Diagnosis
• Many ovarian masses are detected during routine
prenatal sonography or during imaging done for
other
indications, including evaluation of symptoms.

• MRI can be used to evaluate complicated

anatomy.

Williams Obstetrics, 25th edition

A simple anechoic cyst Cystic structure with diffuse
with smooth walls internal low-level echoes

Physiological corpus Endometrioma or hemorrhagic

luteum cyst or benign corpus luteum
cystadenoma

Williams Obstetrics, 25th edition

 Mature cystic teratoma
• Adnexal cyst (marked by calipers) with
accentuated lines and dots that represent hair in
both longitudinal and transverse planes.
• At the central inferior aspect of this cyst, a mural
nodule—Rokitansky protuberance—is seen.
Williams Obstetrics, 25th edition
 Diagnosis
Tumor marker
• CA 125
• Normally elevated in early pregnancy and early
puerperium (possibly from the decidua)
• From 2nd trimester until term, levels are not
normally
higher than those in the nonpregnant woman

• Other tumor markers that have not been

proven for diagnosis or posttreatment
surveillance in pregnancy including hCG, AFP,
inhibin A and B, OVA1 test.
Williams Obstetrics, 25th edition
 Complication

• two most common complications of

any ovarian mass

Torsion and Hemorrhage.

Williams Obstetrics, 25th edition

 Complication…Torsion
• Incident 0.2-15%

• Related with size of ovarian mass ; 6-10

cm.

• 60 % in 1st and 2nd trimester (10-17 week)

Naqvi M1, Kaimal A. Adnexal masses in pregnancy. Clin Obstet Gynecol. 2015 Ma
 Complication…Torsion
• Symptoms
• acute constant or episodic lower abdominal pain
with nausea and vomiting

• Sonography
• TAS with color Doppler, presence of an ovarian
mass with absent flow
• minimal or early twisting may compromise only
venous flow, thus leaving arterial supply intact

Williams Obstetrics, 25th edition

 Complication…Torsion
• Laparoscopy or laparotomy is warranted.

• Adnexectomy is generally unnecessary to avoid clot

release, thus, most recommend attempts at
untwisting

• With a salvageable ovary, within minutes,

congestion is relieved, and ovarian volume and
cyanosis diminish.
• If cyanosis persists!removal of the infarcted adnexa
Williams Obstetrics, 25th edition
 Complication…Torsion
Unilateral or bilateral oophoropexy
• minimize the risk of repeated torsion

• techniques
• shortening of the uteroovarian ligament
• fixing the uteroovarian ligament to the posterior
uterus, the lateral pelvic wall, or the round ligament

Williams Obstetrics, 25th edition

 utero-ovarian
ligament at the
ovarian insertion is
attached to the
ipsilateral
uterosacral
ligament thus
immobilizing the
ovary in the pelvis

: Pediatric & Adolescent Gynecology, 6th ed, Emans SJ, Laufer MR, Goldstein DP (Eds), Lippincott
Williams & Wilkins, Philadelphia 2011
Djavadian. Oophoropexy and adnexal torsion. Fertil Steril 2004
 Complication…Hemorrhage
• most common cause of ovarian hemorrhage !
follows rupture of a corpus luteum cyst

• the diagnosis is certain and symptoms abate !

observation and surveillance is usually sufficient

• Concern for ongoing bleeding ! prompt surgical

evaluation

Williams Obstetrics, 25th edition

If corpus luteum is removed before 10
weeks’ gestation
Progestational support is recommended
1. Micronized progesterone (Prometrium) 200 or 300
mg
orally once daily;
2. 8-percent progesterone vaginal gel (Crinone)
one premeasured applicator vaginally daily plus
micronized progesterone 100 or 200 mg orally once
daily
3. Intramuscular 17-hydroxyprogesterone caproate
150 mg. Williams Obstetrics, 25th edition
If corpus luteum is removed before 10
weeks’ gestation
• The first two regimens are given until 10
completed weeks
• between 8 and 10 weeks’ gestation, only one
injection is required immediately after
surgery.
• between 6 and 8 weeks’ gestation, then two
additional doses should be given 1 and 2 weeks
after the first
Williams Obstetrics, 25th edition
Management of an Adnexal Mass
Cystic benign-appearing mass that is < 5 cm

• no additional antepartum surveillance.

• Early in pregnancy, this is likely a corpus luteum cyst,

which typically resolves by the early second trimester.

For cysts ≥ 10 cm

• substantial risk of malignancy, torsion, or labor

obstruction

• surgical removal is reasonable.

Williams Obstetrics, 25th edition
Managementof
Management ofan
anAdnexal
AdnexalMass
Mass
Tumors between 5 and 10 cm
• Evaluated by sonography along with color Doppler
and possibly MR imaging.

• Simple cystic appearance : managed expectantly

with sonographic surveillance

Williams Obstetrics, 25th edition

 Surgery management
Tumors between 5 and 10 cm
• Resection
• cysts grow and begin to display malignant
qualities
• becomes symptomatic.
• sonographic characteristics that suggest a cancer
• thick septa
• nodules
• papillary excrescences
• solid components

Williams Obstetrics, 25th edition

 Surgery management
Surgery management
• Resection at 14 to 20 weeks (1)
• Classic findings of endometrioma or mature cystic
teratoma may be resected postpartum or during cesarean
for obstetrical indications (not present in Williams
Obstetrics, 25th edition)
• Prefer Laparoscopic surgery(2)
• Complication : decrease uterine blood flow, carbondioxide absorption ,
fetal hypotension

1. Williams Obstetrics, 25th edition

2. Koo J, Lee J, Lim K, et al. A 10-year experience of laparoscopic surgery for adnexal masses during
pregnancy. Int J Gynaecol Obstet 2011; 113:36–39.
 Surgery management
Surgery management
ACOG committee opinions 2011
recommendation
• No currently used anesthetic agents have been shown
to have any teratogenic effects in humans when using
standard concentrations at any gestational age.

• Fetal heart rate monitoring may assist in maternal

positioning and cardiorespiratory management, and
may influence a decision to deliver the fetus.
ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery management
Surgery management
ACOG committee opinions 2011 recommendation
• A pregnant woman should never be denied indicated
surgery, regardless of trimester.

• Elective surgery should be postponed until after delivery

• Non-urgent surgery should be performed in the second

trimester when preterm contractions and spontaneous
abortion are least likely.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery
Surgery management
management
ACOG committee opinions 2011 recommendation

• Surgery should be done at an institution with

neonatal and pediatric services.

• A qualified individual should be readily available to

interpret the fetal heart rate patterns.

• An obstetric care provider with cesarean delivery

privileges should be readily available.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery
Surgery management
management
ACOG committee opinions 2011 recommendation

• fetus is considered previable: the fetal heart rate by

Doppler before and after the procedure.

• fetus is considered to be viable : electronic fetal

heart rate and contraction

• monitoring should be performed before and after the

procedure

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Surgery
Surgery management
management
ACOG committee opinions 2011
recommendation
• When possible, the woman has given informed
consent to emergency cesarean delivery.

• The nature of the planned surgery will allow the

safe interruption or alteration of the procedure to
provide access to perform emergency delivery.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery du
 Thank you 

for your attention
 Pregnancy-Related Ovarian
Tumors
• Stimulating effects of various pregnancy
hormones on ovarian stroma.
• Pregnancy luteoma
• Hyperreactio luteinalis
• Ovarian hyperstimulation syndrome

Williams Obstetrics, 25th edition

 Pregnancy Luteoma.
• Rare

• Benign

• Arise from luteinized stromal cells

• Elevated testosterone levels

• 25% of affected women will be virilized

Williams Obstetrics, 25th edition

 Pregnancy Luteoma.

• Affected women, approximately half of their

female fetuses will have some degree of
virilization
• Most mothers and their fetuses are
unaffected by the hyperandrogenemia :
Placenta rapidly converts androgens to
estrogens
Williams Obstetrics, 25th edition
 Pregnancy Luteoma.

• Range in size from microscopic to greater than 20

cm

• Appear as solid tumors, may be multiple or bilateral,

and may be complex because of hemorrhagic areas

• Not require surgical intervention unless there is

torsion, rupture, or hemorrhage

Williams Obstetrics, 25th edition

 Pregnancy Luteoma.

Differential diagnosis
• Granulosa cell tumors
• Thecomas
• Sertoli-Leydig cell tumors
• Stromal hyperthecosis
• Hyperreactio luteinalis

Williams Obstetrics, 25th edition

 Pregnancy Luteoma

• Spontaneously regress during the first few months

postpartum
• Androgen levels drop precipitously during the
first
2 weeks following delivery
• Lactation may be delayed a week or so by
hyperandrogenemia
• Recurrence in subsequent pregnancies is rare
Williams Obstetrics, 25th edition
 Hyperreactio Luteinalis

• one or both ovaries develop multiple large

theca-lutein cysts after the first trimester

• Caused by luteinization of the follicular

theca interna layer

• Response to stimulation by exceptionally

high hCG levels
Williams Obstetrics, 25th edition
 Hyperreactio Luteinalis

• Maternal virilization develops, but no

reports of fetal virilization

• unless complicated by torsion or

hemorrhage

• masses resolve after delivery

Williams Obstetrics, 25th edition

 Hyperreactio Luteinalis

“Spoke wheel” pattern

 Ovarian Hyperstimulation
Syndrome (OHSS)
• Complication of ovulation-induction therapy for
infertility

• Multiple ovarian follicular cysts

• Clinical spectrum with symptoms

• abdominal distention, rapid weight gain, dyspnea,
and progressive hypovolemia

Williams Obstetrics, 25th edition

 Ovarian Hyperstimulation
Syndrome (OHSS)
• Serious complications are renal dysfunction,
adult respiratory distress syndrome, ovarian
rupture with hemorrhage, and
thromboembolism.

• Treatment is primarily supportive with attention

to maintaining vascular volume and
thromboprophylaxis.
• In severe case, Paracentesis can be helpful
Williams Obstetrics, 25th edition
 tion of
Ovarian Hyperstimulation
Ovarian Hyperstimulation
vascula
Syndrome
Syndrome
(OHSS) (OHSS)
r
endoth
elial
growth
increas
factor
ed
hypovol
(VEGF)
vascul
emia
expressi
arin
with
on
ascites,
perme
granulos
pleural
ability
a-lutein
or
cells
pericard
acute
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kidney
effusion
injury
,
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bility. th
 Ovarian Cancer in pregnancy

• incidence ranges from 1 in 20,000 to 1 in 50,000

births

• 75 % are early-stage cancers

• 5-year survival rate between 70 and 90 %

• Pregnancy does not alter the prognosis of most

ovarian malignancies

Williams Obstetrics, 25th edition

 Ovarian Cancer
Ovarian Cancer in
in pregnancy
pregnancy
• Management is similar to that for non-
pregnant women
• If frozen section histopathological analysis
verifies malignancy !surgical staging is done
with careful inspection of all accessible
peritoneal and visceral surfaces
• Management depend on staging and type of
histopathology

Williams Obstetrics, 25th edition

 Ovarian Cancer
Ovarian Cancer in
in pregnancy
pregnancy
Management is similar to that for non-
pregnant women
• advanced disease: bilateral adnexectomy and
omentectomy will decrease most tumor burden.
• Chemotherapy = Pregnancy category D
• Fetal growth restriction, preterm labor, side effect of
each chemotherapy
• can be given during pregnancy while awaiting
pulmonary maturation

Williams Obstetrics, 25th edition

 Adnexal Cysts in pregnancy

• Paratubal and Par-ovarian cysts

• remnants of the paramesonephric ducts or are
mesothelial inclusion cysts
• most are ≤ 3 cm in size
• most common paramesonephric cyst = hydatid
of Morgagni (pedunculated and typically
dangles from one of the fimbria.)
Williams Obstetrics, 25th edition
 Adnexal Cysts in pregnancy

• Paratubal and Par-ovarian cysts

• Neoplastic paraovarian cysts are rare,
histologically resemble tumors of ovarian
origin

Williams Obstetrics, 25th edition

 Adnexal Cysts in
pregnancy
• Hydatid of Morgagni
• cause complications such as torsion/twisted
• commonly identified at the time of cesarean
delivery or puerperal sterilization
• an simply be drained or excised

Williams Obstetrics, 25th edition