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Conservative management of ovarian cystic teratoma during pregnancy and labor
Conservative management of ovarian cystic teratoma during pregnancy and labor Benjamin Caspi, MD, a Roni Levi, MD,a Zvi Appelman, MID, a David Rabinerson, MD, b Gil G o l d , - a n , MD,b a n d Zion Hagay, MD~ Rehovot and Tel Aviv, Israel OBJECTIVE: Our goal was to evaluate the adequacy of conservative management during pregnancy and tabor in women with an ultrasonographically diagnosed ovarian cystic teratoma. STUDY DESIGN: Forty-nine women with ultrasonographically diagnosed ovarian cystic teratoma <6 cm were followed for detection of possible complications through pregnancy and labor. Serial ultrasenographic examinations before pregnancy, during pregnancy, and after delivery were performed to detect changes in the size of the cystic teratoma. RESULTS: In a group of 49 women with dermoid cysts (mean age, 30 years), 68 pregnancies resulted. Of the 68 pregnancies, 4 ended in miscarriages, 1 was electively terminated, and in the remaining 63 pregnancies, a total of 64 healthy infants were delivered. Five patients needed treatment with assisted reproductive techniques. Fifty-five pregnancies ended in normal vaginal deliveries and 8 were delivered by cesarean (cesarean delivery rate of 16%). None of the classical complications attributed to dermoid cysts such as torsion, dystocia, or rupture occurred in the study group. In a follow-up of 56 dermoid cysts throughout pregnancy, cyst size remained unchanged. CONCLUSIONS: Ovarian dermoid cysts <6 cm are not expected to grow during pregnancy or to cause complications in pregnancy and labor. (Am J Obstet Gyneco12000;182:503-5.)
Key word.~ Ovarian tumors, dermoid cysts, pregnancy complications, labor
B e n i g n cystic teratoma is the most common ovarian t u m o r found in pregnancy, composing 24% to 40% of all ovarian tumors, t, 2 Ultrasonography can detect ovarian dermoid cysts with an accuracy rate of 97.5% to 100%. s, 4 In Our recent prospective study it was shown that women in their reproductive years with an ovarian dermoid cyst <6 cm diagnosed ultrasonographically can be followed safely.5 These data relate to cysts having a minimal diameter of 0.5 cm, for which the pathognomonic signs of dermoid cysts are conclusive. Complications associated with dermoid cysts may include torsion, rupture, and malignant transformarion. Pregnancy is a special state in which the rate of complications such as torsion and rupture may increase because of the increasing size of the uterus during pregnancy. Moreover, dermoid cysts may complicate labor by obstructing the birth canal. We report here the fertility characteristics of 49 women with an ovarian dermoid cyst
From the Department of Obstetrics and Ccynecology,Kaplan Medical Centeg, Rehovot (affiliated to the Hebrew University, Hadassah Medical Schoo~ Jerusalem),a and the Oepartn~mt of Obstetrics and Ceyne¢olog3, Rabin Medical Centeg,Beilinson Campus, Petach Tiqva, SacMerSchool of Medidne, TelAviv University) Received for publication June 4, 1999; mAsed S~Otember3, 1999; accepted October20, 1999. Reprints not availablefrom the authors. Copyright © 2000 by Mosby, Inc. 0002-9378/2000 ~1Z00 + 0 6/1/103768 doi:l O.1067/mob.2000.103768
<6 era in diameter diagnosed ulmasonographicallyand the outcome of 68 pregnancies in this group of women. Patients a n d m e t h o d s
Between 1985 a n d 1997, 49 w o m e n with ultrasonographically diagnosed dermoid cysts were followed u p during pregnancy and delivery. In 42 of these patients the d e r m o i d cyst was diagnosed before c o n c e p t i o n whereas in 7 women the dermoid cyst was diagnosed during pregnancy. T h e expectant m a n a g e m e n t p r o g r a m had been approved by the Institutional Review Board at the Kaplan Medical Center. Only women with cysts <6 cm (mean diameter) were eligible. Before enrolling in this program, each patient signed an informed consent form in which the risks and benefits of the nonsurgical conservative m a n a g e m e n t were discussed in detail. In those women who conceived, follow-up i n c l u d e d two ultrasonographic examinations of the cyst size during first and second halves of pregnancy. The cysts were measured in three right-angle planes, and the m e a n diameter of the largest cysts was recorded. Mean diameter was calculated as the sum of three diameters divided by 3. The size of the cysts during pregnancy was compared with the size before pregnancy and after delivery. Oneway analysis of variance for repeated measurements was performed to find changes i n cyst size throughout pregnancy. A t test was performed to compare the mean di503
504 Caspi et al
March 2000 AmJ Obstet Gynecol
18 16 14 JB 12 le,,
o d z
10 8 6 4 2 0 <20
21-30
31-40
41-50
51-60
Cysts size (mean diameter in mm) Fig 1. Size distribution of 56 cystic teratomas.
a m e t e r of the cysts. All statistical analyses were perf o r m e d with SPSS (Statistical Package for the Social Sciences, Windows 6.1 version). A value of P < .05 was considered significant. Ultrasonographic examinations were performed with transabdominal and transvaginal transducers of 3.5 MHz and 5 MHz, respectively (GeneralElectric RT 3000; General Electric, Tokyo, Japan; or LTltmmark IV Plus and HD13000; Advanced Technology Laboratories, BotheR, WA).
Results I n the group of 49 women with dermoid cysts, 68 pregnancies occurred. The mean age was 30 years (range, 1944). Forty-four women conceived spontaneously whereas 5 n e e d e d assisted reproductive techniques. O f the 68 pregnancies, 4 ended with miscarriages, I woman elected to have termination of pregnancy, and in 63 pregnancies, a total of 64 healthy infants were delivered. Fifty-five pregnancies e n d e d in normal vaginal deliveries and 8 were delivered by cesarean (16%). Seven women in the cesarean delivery group underwent operation for obstetric indications. In 1 case cesarean delivery was performed because of the couple's demand. None of the women were operated o n as a result of complications attributed to cystic teratomas, such as torsion, rupture, or dystocia. In this group cystectomy was performed during cesarean delivery. Another 6 patients underwent cystectomy after pregnancy because of the demand of the patients. Benign cystic teratoma was histologically confirmed in all cases. In 12 patients the cyst was bilateral; thus a total of 75 d e r m o i d cysts were followed through pregnancy. O f those 75, we had complete follow-up of 56 cysts. The size distribution of the cysts is illustrated in Fig 1. The m e a n interval between the first examination before pregnancy and the examination in the first half of pregnancy was 4 months (range, 2-9), and the mean interval between the examination in the second half of pregnancy and the examination after pregnancy was 3.7 months (range, 2-6).
The m e a n cyst diameter was 3.53 cm (range, 1.6-6.0) before pregnancy, 3.58 cm (range, 1.5-5.8) in the first half of pregnancy, 3.54 cm (range, 1.6-5.9) in the second half of pregnancy, and 3.52 cm (range, 1.7-5.9) after pregnancy. Analysis of variance revealed n o significant change in the size o f cysts t h r o u g h o u t pregnancy compared with the size before pregnancy a n d after delivery. No significant difference was f o u n d in the mean diameter of the dermoid cysts in the follow-up groups during and after pregnancy (Fig 1). In the other women in whom there was no complete follow-up, no obvious change in cyst size was encountered and n o n e of the tumors grew to a mean diameter of >6 cm during pregnancy.
Comment Traditional m a n a g e m e n t of persistent ovarian cysts in pregnancy is exploratory laparotomy at 16 to 20 weeks of gestation and resection of the tumor. This approach has b e e n a c o m m o n practice because of several possible associated complications. T h e major fear was of ovarian mal i g n a n c y with its grave prognosis; however, a m o n g w o m e n with cystic teratomas these complications typically occur in those who are older and who have large tumors.6 Other justifications for elective laparotomy during the second trimester of pregnancy were an effort to prevent an urgent operative procedure because of rupture, hemorrhage, or torsion of a cyst or to prevent dystocia o f labor when the t u m o r lies low in the pelvis.7 B e n i g n cystic teratoma is the most c o m m o n ovarian n e o p l a s m diagnosed in pregnancy. ~ Previous series reported a higher rate of complications of these tumors in pregnancy. In a clinicopathologic study of 1007 cases of b e n i g n cystic teratoma Petersen et all reported that pregn a n c y increases the complication rate associated with d e r m o i d cysts; torsion occurred in 19.3%, r u p t u r e in 17%, a n d malignancy in up to 5% of these cysts. In their study, in 87% of the cases the size of the cystic teratomas was >5 cm. In a more recent study Caruso et al8 reported that the complication rate of dermoid cysts did n o t increase during pregnancy. In their study 31 pregnancies occurred in 295 cases of benign cystic teratomas, a n d the torsion rate d u r i n g pregnancy was 6.5%, as compared with 9.3% in n o n p r e g n a n t patients. Likewise, they did n o t find any evidence of an increased incidence of infection, rupture, or malignancy complicating these ovarian neoplasms. The size of the majority of benign cystic teraromas fell in the range of 5 to 9 cm; the average tumor measured 7.7 cm in diameter, with approximately 80% measuring ___10cm. However, these figures for complication rate cannot be applied to our study because they are drawn from older series of larger-sized tumors. In our study we report conservative foUow-up t h r o u g h pregn a n c y a n d labor in 49 women with 63 pregnancies (bilateral cysts were p r e s e n t in 12 w o m e n ) ; n o cyst-related complications occurred. Although cesarean delivery was
Caspi et
Volume 182, Number 3 AmJ Obstet Gynecol
p e r f o r m e d in 2 cases because o f failure to progress in labor, obstruction o f the birth canal by the cyst did n o t o c c u r in any of them. T h e absence of c o m p l i c a t i o n s may be attributed to the smaller m e a n d i a m e t e r ($.53 cm) o f the cysts c o m p a r e d with those described in previous publications. Controversies exist as to w h e t h e r surgery a n d g e n e r a l anesthesia e n d a n g e r pregnancy. At least o n e study rep o r t e d an increased risk o f s p o n t a n e o u s a b o r t i o n a m o n g w o m e n who were subjected to g e n e r a l anesthesia a n d gyn e c o l o g i c e x a m i n a t i o n d u r i n g t h e first a n d s e c o n d trimesters. 9 P r e t e r m l a b o r a n d fetal growth restriction, as well as neonatal death, were also r e p o r t e d to increase significantly in w o m e n who were subjected to surgery duri n g pregnancy. 10 Cystic teratomas in p r e g n a n c y can b e r e m o v e d by l a p a r o t o m y o r laparoscopy. 11, 12 P a r k e r et a119 r e p o r t e d o n 12 p r e g n a n t w o m e n in w h o m laparoscopic removal o f d e r m o i d cysts h a d b e e n p e r f o r m e d . A l t h o u g h n o m a t e r n a l o r fetal c o m p l i c a t i o n s w e r e reported, in 10 w o m e n intraoperative r u p t u r e o f the cyst occurred. These potential adverse effects d u r i n g surgery may justify a conservative a p p r o a c h to small, n o n g r o w i n g cystic teratomas d u r i n g pregnancy. T h e growth rate o f d e r m o i d cysts may be i n f l u e n c e d by h o r m o n a l changes d u r i n g pregnancy. A f t e r puberty, derm o i d cysts may increase in size, presumably because o f h o r m o n a l stimulation of the sebaceous glands. Is We rep o r t e d a significantly h i g h e r growth rate o f d e r m o i d cysts in p r e m e n o p a u s a l w o m e n c o m p a r e d with postm e n o p a u s a l w o m e n . 5 A l t h o u g h we e x p e c t e d a h i g h e r growth rate in p r e g n a n t w o m e n because o f the h i g h h o r m o n a l levels in pregnancy, n o growth was observed. In conclusion, o u r data indicate that p r e g n a n c y does n o t affect the growth rate o f d e r m o i d cysts <6 c m in diameter. F u r t h e r m o r e , n o complications o f the d e r m o i d cysts have b e e n observed, within the limits o f u n c e r t a i n t y related to the small size o f o u r study g r o u p . T h e s e data are, however, s u p p o r t i v e o f c o u n s e l i n g gravid w o m e n with small d e r m o i d cysts to u n d e r g o conservative m a n a g e m e n t d u r i n g p r e g n a n c y a n d labor. As yet, t h e r e are
al 505
n o data supportive o f conservative m a n a g e m e n t in patients with d e r m o i d cysts >6 cm. By p o s t p o n i n g surgery to r e m o v e d e r m o i d cysts <6 cm, we may avoid possible adverse effects o f anesthesia and abdominal surgery o n the fetus. F u r t h e r m o r e , in w o m e n who are delivered by cesarean, cystectomy can b e c a r d e d out, thus additional surgical i n t e r v e n t i o n will be avoided. REFERENCES
I. Petersen WF, Prevost EC, EHmunds FT, HundleyJM, Morriss F~. Benign cystic teratomas of the ovary. Am J Obstet Oynecol 1955;70:368-82. 2. Taws K. Ovarian tumors in pregnancy. Am j obstet Gynecol 1964;90:511-6. 3. Caspi B, Appelman Z, Rabinerson D, Elchalal U, Zalel Y, Katz Z. Pathognomonic echo patterns of benign cystic teratomas of the ovary: classification, incidence and accuracy rate of sonographic diagnosis.J Ulmasound Obstet Gynecol 1996;7:275-9. 4. Bronstein M, Yoffe N, Brandes JM. Hair as a sonographic marker of ovarian teratomas: improved identification using transvaginal sonography and simulation model. J Clin Ultrasound 1991,19:351-5. 5. Caspi B, Appelman Z, Rabiner~on D, Zalel Y,Tulandi T, Shoham Z. The growth pattern of ovarian dermoid cysts: a prospective study in premenopansal and postmenopausal women. Fertil Steri11997;68:501-5. 6. Talerman A, Path F. Germ cell tumors of the ovary. In: Knrman RJ, editor. Blaustein's pathology of the female genital tract. 3rd ed. New York: Springer-Verlag; 1987. p. 654727. 7. Hess LW, Peaceman A, O'Brien WF, Winkel CA, Crnikshank DP, Morrison JC. Adnexal mass occurring with intrauterine pregnancy: report of fifty-four patients requiring laparotomy for definitive management. Am J Obstet Gynecol 1988;158:1029-34. 8. Caruso PA, Marsh MR, Minkowitz S, Karten G. An intense clinicopathologic study of 305 teratomas of the ovary. Cancer 1971;27:343-8. 9. Duncan P, Pope WDB, Cohen MM, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986;64:790-4. 10. Mazze RI, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Ob~tet Gyne¢ol 1989;161:1178-85. 11. Platek DN, Henderson CE, Goldberg GL. The management of a persistent acinexai mass in pregnancy. Am J Obstet Gyaecol 1995;173:1236-40. 12. Parker WH, Childers JM, Canis M, Phillips DR, Tope1 H. Laparoscopic management of benign cystic teratomas during pregnancy. AmJ Obstet Gynecol 1996;174:1499-501. 13. Blackwell wJ, Dockerty MB, Masson JC, Mussey RD. Dermoid cysts of the ovary;,their clinical and pathologic significance. Am .] Obstet Gyneco11946;51:151-72.
Key word.~ Ovarian tumors, dermoid cysts, pregnancy complications, labor
B e n i g n cystic teratoma is the most common ovarian t u m o r found in pregnancy, composing 24% to 40% of all ovarian tumors, t, 2 Ultrasonography can detect ovarian dermoid cysts with an accuracy rate of 97.5% to 100%. s, 4 In Our recent prospective study it was shown that women in their reproductive years with an ovarian dermoid cyst <6 cm diagnosed ultrasonographically can be followed safely.5 These data relate to cysts having a minimal diameter of 0.5 cm, for which the pathognomonic signs of dermoid cysts are conclusive. Complications associated with dermoid cysts may include torsion, rupture, and malignant transformarion. Pregnancy is a special state in which the rate of complications such as torsion and rupture may increase because of the increasing size of the uterus during pregnancy. Moreover, dermoid cysts may complicate labor by obstructing the birth canal. We report here the fertility characteristics of 49 women with an ovarian dermoid cyst
From the Department of Obstetrics and Ccynecology,Kaplan Medical Centeg, Rehovot (affiliated to the Hebrew University, Hadassah Medical Schoo~ Jerusalem),a and the Oepartn~mt of Obstetrics and Ceyne¢olog3, Rabin Medical Centeg,Beilinson Campus, Petach Tiqva, SacMerSchool of Medidne, TelAviv University) Received for publication June 4, 1999; mAsed S~Otember3, 1999; accepted October20, 1999. Reprints not availablefrom the authors. Copyright © 2000 by Mosby, Inc. 0002-9378/2000 ~1Z00 + 0 6/1/103768 doi:l O.1067/mob.2000.103768
<6 era in diameter diagnosed ulmasonographicallyand the outcome of 68 pregnancies in this group of women. Patients a n d m e t h o d s
Between 1985 a n d 1997, 49 w o m e n with ultrasonographically diagnosed dermoid cysts were followed u p during pregnancy and delivery. In 42 of these patients the d e r m o i d cyst was diagnosed before c o n c e p t i o n whereas in 7 women the dermoid cyst was diagnosed during pregnancy. T h e expectant m a n a g e m e n t p r o g r a m had been approved by the Institutional Review Board at the Kaplan Medical Center. Only women with cysts <6 cm (mean diameter) were eligible. Before enrolling in this program, each patient signed an informed consent form in which the risks and benefits of the nonsurgical conservative m a n a g e m e n t were discussed in detail. In those women who conceived, follow-up i n c l u d e d two ultrasonographic examinations of the cyst size during first and second halves of pregnancy. The cysts were measured in three right-angle planes, and the m e a n diameter of the largest cysts was recorded. Mean diameter was calculated as the sum of three diameters divided by 3. The size of the cysts during pregnancy was compared with the size before pregnancy and after delivery. Oneway analysis of variance for repeated measurements was performed to find changes i n cyst size throughout pregnancy. A t test was performed to compare the mean di503
504 Caspi et al
March 2000 AmJ Obstet Gynecol
18 16 14 JB 12 le,,
o d z
10 8 6 4 2 0 <20
21-30
31-40
41-50
51-60
Cysts size (mean diameter in mm) Fig 1. Size distribution of 56 cystic teratomas.
a m e t e r of the cysts. All statistical analyses were perf o r m e d with SPSS (Statistical Package for the Social Sciences, Windows 6.1 version). A value of P < .05 was considered significant. Ultrasonographic examinations were performed with transabdominal and transvaginal transducers of 3.5 MHz and 5 MHz, respectively (GeneralElectric RT 3000; General Electric, Tokyo, Japan; or LTltmmark IV Plus and HD13000; Advanced Technology Laboratories, BotheR, WA).
Results I n the group of 49 women with dermoid cysts, 68 pregnancies occurred. The mean age was 30 years (range, 1944). Forty-four women conceived spontaneously whereas 5 n e e d e d assisted reproductive techniques. O f the 68 pregnancies, 4 ended with miscarriages, I woman elected to have termination of pregnancy, and in 63 pregnancies, a total of 64 healthy infants were delivered. Fifty-five pregnancies e n d e d in normal vaginal deliveries and 8 were delivered by cesarean (16%). Seven women in the cesarean delivery group underwent operation for obstetric indications. In 1 case cesarean delivery was performed because of the couple's demand. None of the women were operated o n as a result of complications attributed to cystic teratomas, such as torsion, rupture, or dystocia. In this group cystectomy was performed during cesarean delivery. Another 6 patients underwent cystectomy after pregnancy because of the demand of the patients. Benign cystic teratoma was histologically confirmed in all cases. In 12 patients the cyst was bilateral; thus a total of 75 d e r m o i d cysts were followed through pregnancy. O f those 75, we had complete follow-up of 56 cysts. The size distribution of the cysts is illustrated in Fig 1. The m e a n interval between the first examination before pregnancy and the examination in the first half of pregnancy was 4 months (range, 2-9), and the mean interval between the examination in the second half of pregnancy and the examination after pregnancy was 3.7 months (range, 2-6).
The m e a n cyst diameter was 3.53 cm (range, 1.6-6.0) before pregnancy, 3.58 cm (range, 1.5-5.8) in the first half of pregnancy, 3.54 cm (range, 1.6-5.9) in the second half of pregnancy, and 3.52 cm (range, 1.7-5.9) after pregnancy. Analysis of variance revealed n o significant change in the size o f cysts t h r o u g h o u t pregnancy compared with the size before pregnancy a n d after delivery. No significant difference was f o u n d in the mean diameter of the dermoid cysts in the follow-up groups during and after pregnancy (Fig 1). In the other women in whom there was no complete follow-up, no obvious change in cyst size was encountered and n o n e of the tumors grew to a mean diameter of >6 cm during pregnancy.
Comment Traditional m a n a g e m e n t of persistent ovarian cysts in pregnancy is exploratory laparotomy at 16 to 20 weeks of gestation and resection of the tumor. This approach has b e e n a c o m m o n practice because of several possible associated complications. T h e major fear was of ovarian mal i g n a n c y with its grave prognosis; however, a m o n g w o m e n with cystic teratomas these complications typically occur in those who are older and who have large tumors.6 Other justifications for elective laparotomy during the second trimester of pregnancy were an effort to prevent an urgent operative procedure because of rupture, hemorrhage, or torsion of a cyst or to prevent dystocia o f labor when the t u m o r lies low in the pelvis.7 B e n i g n cystic teratoma is the most c o m m o n ovarian n e o p l a s m diagnosed in pregnancy. ~ Previous series reported a higher rate of complications of these tumors in pregnancy. In a clinicopathologic study of 1007 cases of b e n i g n cystic teratoma Petersen et all reported that pregn a n c y increases the complication rate associated with d e r m o i d cysts; torsion occurred in 19.3%, r u p t u r e in 17%, a n d malignancy in up to 5% of these cysts. In their study, in 87% of the cases the size of the cystic teratomas was >5 cm. In a more recent study Caruso et al8 reported that the complication rate of dermoid cysts did n o t increase during pregnancy. In their study 31 pregnancies occurred in 295 cases of benign cystic teratomas, a n d the torsion rate d u r i n g pregnancy was 6.5%, as compared with 9.3% in n o n p r e g n a n t patients. Likewise, they did n o t find any evidence of an increased incidence of infection, rupture, or malignancy complicating these ovarian neoplasms. The size of the majority of benign cystic teraromas fell in the range of 5 to 9 cm; the average tumor measured 7.7 cm in diameter, with approximately 80% measuring ___10cm. However, these figures for complication rate cannot be applied to our study because they are drawn from older series of larger-sized tumors. In our study we report conservative foUow-up t h r o u g h pregn a n c y a n d labor in 49 women with 63 pregnancies (bilateral cysts were p r e s e n t in 12 w o m e n ) ; n o cyst-related complications occurred. Although cesarean delivery was
Caspi et
Volume 182, Number 3 AmJ Obstet Gynecol
p e r f o r m e d in 2 cases because o f failure to progress in labor, obstruction o f the birth canal by the cyst did n o t o c c u r in any of them. T h e absence of c o m p l i c a t i o n s may be attributed to the smaller m e a n d i a m e t e r ($.53 cm) o f the cysts c o m p a r e d with those described in previous publications. Controversies exist as to w h e t h e r surgery a n d g e n e r a l anesthesia e n d a n g e r pregnancy. At least o n e study rep o r t e d an increased risk o f s p o n t a n e o u s a b o r t i o n a m o n g w o m e n who were subjected to g e n e r a l anesthesia a n d gyn e c o l o g i c e x a m i n a t i o n d u r i n g t h e first a n d s e c o n d trimesters. 9 P r e t e r m l a b o r a n d fetal growth restriction, as well as neonatal death, were also r e p o r t e d to increase significantly in w o m e n who were subjected to surgery duri n g pregnancy. 10 Cystic teratomas in p r e g n a n c y can b e r e m o v e d by l a p a r o t o m y o r laparoscopy. 11, 12 P a r k e r et a119 r e p o r t e d o n 12 p r e g n a n t w o m e n in w h o m laparoscopic removal o f d e r m o i d cysts h a d b e e n p e r f o r m e d . A l t h o u g h n o m a t e r n a l o r fetal c o m p l i c a t i o n s w e r e reported, in 10 w o m e n intraoperative r u p t u r e o f the cyst occurred. These potential adverse effects d u r i n g surgery may justify a conservative a p p r o a c h to small, n o n g r o w i n g cystic teratomas d u r i n g pregnancy. T h e growth rate o f d e r m o i d cysts may be i n f l u e n c e d by h o r m o n a l changes d u r i n g pregnancy. A f t e r puberty, derm o i d cysts may increase in size, presumably because o f h o r m o n a l stimulation of the sebaceous glands. Is We rep o r t e d a significantly h i g h e r growth rate o f d e r m o i d cysts in p r e m e n o p a u s a l w o m e n c o m p a r e d with postm e n o p a u s a l w o m e n . 5 A l t h o u g h we e x p e c t e d a h i g h e r growth rate in p r e g n a n t w o m e n because o f the h i g h h o r m o n a l levels in pregnancy, n o growth was observed. In conclusion, o u r data indicate that p r e g n a n c y does n o t affect the growth rate o f d e r m o i d cysts <6 c m in diameter. F u r t h e r m o r e , n o complications o f the d e r m o i d cysts have b e e n observed, within the limits o f u n c e r t a i n t y related to the small size o f o u r study g r o u p . T h e s e data are, however, s u p p o r t i v e o f c o u n s e l i n g gravid w o m e n with small d e r m o i d cysts to u n d e r g o conservative m a n a g e m e n t d u r i n g p r e g n a n c y a n d labor. As yet, t h e r e are
al 505
n o data supportive o f conservative m a n a g e m e n t in patients with d e r m o i d cysts >6 cm. By p o s t p o n i n g surgery to r e m o v e d e r m o i d cysts <6 cm, we may avoid possible adverse effects o f anesthesia and abdominal surgery o n the fetus. F u r t h e r m o r e , in w o m e n who are delivered by cesarean, cystectomy can b e c a r d e d out, thus additional surgical i n t e r v e n t i o n will be avoided. REFERENCES
I. Petersen WF, Prevost EC, EHmunds FT, HundleyJM, Morriss F~. Benign cystic teratomas of the ovary. Am J Obstet Oynecol 1955;70:368-82. 2. Taws K. Ovarian tumors in pregnancy. Am j obstet Gynecol 1964;90:511-6. 3. Caspi B, Appelman Z, Rabinerson D, Elchalal U, Zalel Y, Katz Z. Pathognomonic echo patterns of benign cystic teratomas of the ovary: classification, incidence and accuracy rate of sonographic diagnosis.J Ulmasound Obstet Gynecol 1996;7:275-9. 4. Bronstein M, Yoffe N, Brandes JM. Hair as a sonographic marker of ovarian teratomas: improved identification using transvaginal sonography and simulation model. J Clin Ultrasound 1991,19:351-5. 5. Caspi B, Appelman Z, Rabiner~on D, Zalel Y,Tulandi T, Shoham Z. The growth pattern of ovarian dermoid cysts: a prospective study in premenopansal and postmenopausal women. Fertil Steri11997;68:501-5. 6. Talerman A, Path F. Germ cell tumors of the ovary. In: Knrman RJ, editor. Blaustein's pathology of the female genital tract. 3rd ed. New York: Springer-Verlag; 1987. p. 654727. 7. Hess LW, Peaceman A, O'Brien WF, Winkel CA, Crnikshank DP, Morrison JC. Adnexal mass occurring with intrauterine pregnancy: report of fifty-four patients requiring laparotomy for definitive management. Am J Obstet Gynecol 1988;158:1029-34. 8. Caruso PA, Marsh MR, Minkowitz S, Karten G. An intense clinicopathologic study of 305 teratomas of the ovary. Cancer 1971;27:343-8. 9. Duncan P, Pope WDB, Cohen MM, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986;64:790-4. 10. Mazze RI, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Ob~tet Gyne¢ol 1989;161:1178-85. 11. Platek DN, Henderson CE, Goldberg GL. The management of a persistent acinexai mass in pregnancy. Am J Obstet Gyaecol 1995;173:1236-40. 12. Parker WH, Childers JM, Canis M, Phillips DR, Tope1 H. Laparoscopic management of benign cystic teratomas during pregnancy. AmJ Obstet Gynecol 1996;174:1499-501. 13. Blackwell wJ, Dockerty MB, Masson JC, Mussey RD. Dermoid cysts of the ovary;,their clinical and pathologic significance. Am .] Obstet Gyneco11946;51:151-72.