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Elective vs. conservative management of ovarian tumors in pregnancy
International Journal of Gynecology and Obstetrics 85 (2004) 250–254
Article
Elective vs. conservative management of ovarian tumors in pregnancy G.S.R. Lee, S.Y. Hur, J.C. Shin, S.P. Kim, S.J. Kim* Department of Obstetrics and Gynecology, Holy Family Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea Received 26 May 2003; received in revised form 16 December 2003; accepted 17 December 2003
Abstract Objectives: To determine optimal management of the ovarian tumors in pregnancy. Methods: This study included 89 cases of the ovarian tumor in pregnancy that required surgery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001. Among 89 cases, 36 and 53 were emergency and elective surgery, respectively. Student’s t-test and the x2-test were used for statistical analysis and a P-value of -0.05 was considered statistically significant. Results: The most common size of torsion of ovarian tumors during pregnancy was 6–10 cm and the incidence was the most frequent during the first trimester of pregnancy. The incidence of preterm delivery (-37 weeks) was higher in emergency surgery, but there was no difference in the gestational age at delivery, also no difference in the birth weight or the method of delivery. Conclusions: Although surgery for ovarian tumors in pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with that after elective surgery. We propose that conservative management would be used in optimal management of pregnant women with ovarian tumors. 䊚 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Keywords: Ovarian tumor; Pregnancy; Elective management; Conservative management
1. Introduction The reported incidence of ovarian tumor is 1 in 200 pregnancies w1x, or 1 in 1300–1312 live births w2,3x. Koonings et al. w4x reported finding one adnexal neoplasm for every 197 cesarean sections. The ovarian tumors during pregnancy may result in serious complications such as torsion and infarc*Corresponding author. Tel.: q82-32-340-2262; fax: q8232-340-2255. E-mail address: [email protected] (S.J. Kim).
tion, and the tumor can obstruct vaginal delivery if it fills the pelvic cavity. Proper evaluation and management of ovarian tumor during pregnancy is important for the health of pregnant woman and the continuance of pregnancy. In the past, ovarian tumors in pregnancy were managed by elective operation, preferably in the second trimester, because of decreasing the risk of complications as torsion, rupture, and ruling out ovarian malignancy, but any abdominal surgery in pregnancy causes significant physical and emotional stress to both the mother and fetus w5x.
0020-7292/04/$30.00 䊚 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2003.12.008
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
Therefore, our purpose in this study is to compare emergency surgery followed by conservative management to elective surgery performed due to ovarian mass in pregnancy, and then it is to determine optimal management of the ovarian tumors in pregnancy. 2. Patients and method This study includes 36 cases followed up among 48 pregnant women that underwent emergency operation due to torsion of ovarian tumor during pregnancy (Group A) (12 cases were failed to follow up) and 53 cases that underwent elective operation within the second trimester (Group B) on the basis of the histologic finding and clinical records retrospectively among 310 cases that received the operation during pregnancy and delivery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001. This study excluded the emergency operation of ovarian tumor associated with hemorrhage, rupture, or appendicitis and the ovarian tumors that resected incidentally by misdiagnosis or at the time of cesarean section. Student’s t-test and the x2-test were used for statistical analysis. 3. Results 3.1. Demographic characteristics There was no significant difference in maternal age (mean age; 27.8 years and 28.4 years, respectively) or parity between patients undergoing emergency surgery (Group A) and those having elective surgery (Group B). There was no significant difference in the gestational age at surgery between the two groups. The median gestational age at surgery was 12.6 weeks in Group A and 15.0 weeks in Group B, respectively. Emergency surgery was performed in 22 cases (61.1%) during the first trimester, in five cases (13.9%) during the second trimester and in nine cases (25%) during the third trimester. Elective surgery was done in 35 cases (66%) during second trimester and in 18 cases (34%) during the first trimester. There was no difference in mean gestational age at delivery (Group A: 38.82"1.76 weeks, Group B:
251
39.12"1.97 weeks) and mean birth weight (Group A:3.08"0.36 kg, Group B: 3.17"0.52 kg). However, the incidence of preterm birth (-37 weeks) was significantly higher in 22.2% of Group A than 3.77% of Group B (P-0.005), but there was no difference in the gestational age at preterm delivery (Group A: 35.78"0.85 weeks; Group B: 34.28"0.81 weeks) (Table 1). 3.2. Location and diameters of ovarian tumor removed at surgery There was no difference in location at operation and the average size of the ovarian tumors between the two groups. Three patients (8.3%) of Group A and five patients (9.4%) of Group B had bilateral ovarian tumors. The average size of the ovarian tumors was 7.63"2.44 cm in Group A and 9.14"3.23 cm in Group B. The most common size of the ovarian tumor was 6–10 cm in both groups (Table 2). 3.3. Histologic diagnosis of ovarian tumor Dermoid cyst was the most common histologic finding in both groups. The incidence of dermoid cyst was 36.1% and 45.0%, respectively, in Group A and Group B. No malignant tumor was found in Group B, but two cases, an immature teratoma and a mucinous adenocarcinoma, were diagnosed at 9 weeks and 17q6 weeks, respectively, in Group A (Table 3). 4. Discussion The frequency of ovarian tumor found on ultrasonography during pregnancy is 1.14%, with most of these tumors being either corpus luteum or theca lutein cysts. Most, however, disappear spontaneously before the 16th week of pregnancy w6x. It is difficult to determine a therapeutic plan for those that persist or are large-sized ovarian tumors with solid components and septa on ultrasonography. The most common histological finding of ovarian tumors operated during pregnancy is that of a benign cystic teratoma w7x. For this, Whitecar et
252
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
Table 1 Demographic characteristics and outcome data of study groups
Maternal age (years) Mean"S.D. Range Parity (no.) Primipara Multipara Gestational age at surgery Median (weeks) 1st trimester No. (%) Mean"S.D. (weeks) 2nd trimester No. (%) Mean"S.D. (weeks) 3rd trimester No. (%) Mean"S.D. (weeks) Gestational age at delivery Mean"S.D. (weeks) Preterm delivery (-37weeks) No. (%) Mean"S.D. (weeks) Term delivery (G37weeks) No. (%) Mean"S.D. (weeks) Birth weight (kg) Neonatal mortality (%) Methods of delivery NSD (No. (%)) CyS (No. (%))
Group A (ns36)
Group B (ns53)
27.81"3.07 25–36
28.42"3.22 21–37
21 15
14 39
12.6
15
22 (61.1%) 10.11"2.55
18 (34%) 13.02"1.52
5 (13.9%) 22.91"4.65
35 (66%) 16.45"1.32
9 (25%) 32.59"2.87
0 0
38.82"1.76
39.12"1.97
NS
8 (22.2%) 35.78"0.85
2 (3.77%) 34.28"0.81
P-0.005 NS
28 (77.8%) 39.68"0.93 3.08"0.36 0
51 (96.23%) 39.31"1.32 3.17"0.52 0
NS NS NS
12 (33.3%) 24 (66.7%)
27 (50.94%) 26 (49.06%)
NS NS
NS NS
NS, non-significant.
al. w2x have reported 30% of benign ovarian tumors and Ueda et al. w8x have reported 45.3%. The most frequent and most serious complication of benign ovarian tumors during pregnancy is
torsion, which frequently occurs in the first trimester of pregnancy, and may result in cyst rupture with spillage into the peritoneal cavity. Whitecar et al. w2x stated that torsion was responsible for
Table 2 Location and diameters of ovarian tumors removed operation
Location Right Left Bilateral Diameter of masses Mean cystic size (cm) -6 cm 6–10 cm 11–15 cm )15 cm
Group A (ns36)
Group B (ns53)
23 10 3
24 24 5
NS
7.63"2.44 3 26 6 1
9.14"3.23 5 30 16 2
NS
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
253
Table 3 Histologic findings of ovarian tumors Type
Group A (ns36)
Tumor-like lesion Hemorrhagic corpus luteum Simple cyst Endometrial cyst Parovarian cyst
4 10 0 0
Benign tumor Dermoid cyst Serous cystadenoma Mucinous adenoma Malignant tumor Mucinous adenocarcinoma Immature teratoma
(11.1%) (27.9%) (0%) (0%)
13 (36.1%) 3 (8.4%) 4 (11.1%)
seven cases (43.8%) of 17 cases of emergency surgery for adnexal tumors during pregnancy. Novak et al. w9x recommended surgery for ovarian tumors that persist until the second trimester of pregnancy to reduce fetal loss. Whitecar et al. w2x reported a significant increase in preterm birth, cesarean section, and perinatal mortality when surgery was done after 23 weeks’ gestation. Hess et al. w3x stated that the risk of abortion or preterm birth was higher in the group that received emergency operation for ovarian tumor torsion than the group that received elective operation. Ueda et al. w8x reported ovarian surgery in the first trimester for persistent or enlarging masses is important to obtain a correct diagnosis and rule out malignancy. However, operative intervention might have significant physical and emotional effects on the fetus or the mother, increasing the risk of preterm delivery w5,10,11x, and Platek et al. w12x evaluated the outcomes of pregnancy complicated by a persistent adnexal mass that was managed conservatively or with surgical intervention and in conclusion they reported that there are no differences in pregnancy outcomes, respectively. Because complications of abdominal surgery are increased in pregnancy, surgical management needs to be reassessed. Thornton et al. w13x suggested a policy of selective conservative management of ovarian cysts during pregnancy on the basis of the ultrasound appearance. Caspi et al. w14x suggested that ovarian dermoid cysts -6 cm are not expected
1 (2.7%) 1 (2.7%)
Group B (ns53) 5 6 5 1
(9.1%) (11.1%) (9.1%) (1.6%)
24 (45.0%) 7 (13.0%) 6 (11.1%) 0 (0%) 0 (0%)
to grow during pregnancy or to cause complications in pregnancy and labor. In this study, women who had emergency surgery because of ovarian torsion showed a higher frequency of preterm birth compared to those with elective operation, but there was not different in the gestational age at preterm delivery and there was no perinatal mortality, nor there was any difference in the vaginal delivery, cesarean section and birth weight between both groups. What was unique, was that although the emergency surgery for torsion of ovarian tumor was done even in the third trimester of pregnancy, there was no difference in the average gestational age at the emergency operation compared to the elective operation. It is considered that torsion of ovarian tumor frequently occur during the first trimester of pregnancy, in this study also, 61.1% of torsion of ovarian tumor occurred in the first trimester of pregnancy. The most common size of ovarian tumor during pregnancy ranged from 6 to 10 cm, and there was no difference in the average size of the tumor and its location between the two groups. In the histological comparisons, there was no malignant tumor in the group that received the elective operation, but there were two cases including the immature teratoma and mucinous adenocarcinoma in the group that received the emergency surgery. The former was managed with a unilateral adnexectomy and delivered a health baby at 38 weeks’ gestation, the latter had received
254
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
six cycles of chemotherapy after cesarean hysterectomy and left adnexectomy at 35.5 weeks’ gestation. In conclusion, it seems likely that the conservative management of the low risk level of malignancy is better than the operative intervention during the second trimester of gestation, even though there is a possibility of emergency surgery later, and the emergency surgery during pregnancy may not result in higher adverse pregnancy outcome compared with elective surgery. Although surgery for ovarian tumor in pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with that after elective surgery. We propose that conservative management would be used in optimal management of pregnant women with ovarian tumors. References w1x Katz VL, Watson WJ, Hansen WF, Washington JL. Massive ovarian tumor complicating pregnancy. A case report. J Reprod Med 1993;38:907 –909. w2x Whitecar P, Turner S, Higby K. Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol 1999;181:19 –24. w3x Hess LW, Peaceman A, O’Brien WF, Winkel GA, Cruikshank Morison JC. Adnexal mass occurring with intrauterine pregnancy: report of fifty four patients requiring laparotomy for definitive management. Am J Obstet Gynecol 1988;158:1029 –1034.
w4x Koonings PP, Platt LD, Wallace R. Incidental adnexal neoplasms at cesarean section. Obstet Gynecol 1988;73:767 –769. w5x Shnider SM, Webster GM. Maternal and fetal hazards of surgery during pregnancy. Am J Obstet Gynecol 1965;92:891 –900. w6x Nesson MJ, Cavalieri R, Graham D, sanders RC. Cysts in pregnancy discovered by sonography. J Clin Ultrasound 1986;14:509 –512. w7x Usui R, Minakmi H, Kosuge S, Iwasaki R, Ohwada M, Sato I. A retrospective survey of clinical, pathologic, and prognostic features of adnexal masses operated on during pregnancy. J Obstet Gynecol Res 2000;26:89 – 93. w8x Ueda M, Ueki M. Ovarian tumors associated with pregnancy. Int J Gynecol Obstet 1996;55:59 –65. w9x Novak ER, Lambrou CD, Woodruff JD. Ovarian tumors in pregnancy: an ovarian tumor registry review. Obstet Gynecol 1975;46:401 –406. w10x Buttery BW, Beischier NA, Fortune DW, Macafee CA. Ovarian tumors in pregnancy. Med J Aust 1973;1:345 – 349. w11x Caverly CE. Ovarian cyst complicating pregnancy. Am J Obstet Gynecol 1931;21:566 –574. w12x Platek DN, Henderson CE, Goldberg GL. The management of a persistent adnexal mass in pregnancy. Am J Obstet Gynecol 1995;173:1236–1240. w13x Thornton JG, Wells M. Ovarian cysts in pregnancy: does ultrasound make traditional management inappropriate? Obstet Gynecol 1987;69:717 –721. w14x Caspi B, Levi R, Appleman Z, Rabinerson D, Goldman G, Hagay Z. Conservative management of ovarian cystic teratoma during pregnancy and labor. Am J Obstet Gynecol 2000;182:503 –505.
Article
Elective vs. conservative management of ovarian tumors in pregnancy G.S.R. Lee, S.Y. Hur, J.C. Shin, S.P. Kim, S.J. Kim* Department of Obstetrics and Gynecology, Holy Family Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea Received 26 May 2003; received in revised form 16 December 2003; accepted 17 December 2003
Abstract Objectives: To determine optimal management of the ovarian tumors in pregnancy. Methods: This study included 89 cases of the ovarian tumor in pregnancy that required surgery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001. Among 89 cases, 36 and 53 were emergency and elective surgery, respectively. Student’s t-test and the x2-test were used for statistical analysis and a P-value of -0.05 was considered statistically significant. Results: The most common size of torsion of ovarian tumors during pregnancy was 6–10 cm and the incidence was the most frequent during the first trimester of pregnancy. The incidence of preterm delivery (-37 weeks) was higher in emergency surgery, but there was no difference in the gestational age at delivery, also no difference in the birth weight or the method of delivery. Conclusions: Although surgery for ovarian tumors in pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with that after elective surgery. We propose that conservative management would be used in optimal management of pregnant women with ovarian tumors. 䊚 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Keywords: Ovarian tumor; Pregnancy; Elective management; Conservative management
1. Introduction The reported incidence of ovarian tumor is 1 in 200 pregnancies w1x, or 1 in 1300–1312 live births w2,3x. Koonings et al. w4x reported finding one adnexal neoplasm for every 197 cesarean sections. The ovarian tumors during pregnancy may result in serious complications such as torsion and infarc*Corresponding author. Tel.: q82-32-340-2262; fax: q8232-340-2255. E-mail address: [email protected] (S.J. Kim).
tion, and the tumor can obstruct vaginal delivery if it fills the pelvic cavity. Proper evaluation and management of ovarian tumor during pregnancy is important for the health of pregnant woman and the continuance of pregnancy. In the past, ovarian tumors in pregnancy were managed by elective operation, preferably in the second trimester, because of decreasing the risk of complications as torsion, rupture, and ruling out ovarian malignancy, but any abdominal surgery in pregnancy causes significant physical and emotional stress to both the mother and fetus w5x.
0020-7292/04/$30.00 䊚 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2003.12.008
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
Therefore, our purpose in this study is to compare emergency surgery followed by conservative management to elective surgery performed due to ovarian mass in pregnancy, and then it is to determine optimal management of the ovarian tumors in pregnancy. 2. Patients and method This study includes 36 cases followed up among 48 pregnant women that underwent emergency operation due to torsion of ovarian tumor during pregnancy (Group A) (12 cases were failed to follow up) and 53 cases that underwent elective operation within the second trimester (Group B) on the basis of the histologic finding and clinical records retrospectively among 310 cases that received the operation during pregnancy and delivery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001. This study excluded the emergency operation of ovarian tumor associated with hemorrhage, rupture, or appendicitis and the ovarian tumors that resected incidentally by misdiagnosis or at the time of cesarean section. Student’s t-test and the x2-test were used for statistical analysis. 3. Results 3.1. Demographic characteristics There was no significant difference in maternal age (mean age; 27.8 years and 28.4 years, respectively) or parity between patients undergoing emergency surgery (Group A) and those having elective surgery (Group B). There was no significant difference in the gestational age at surgery between the two groups. The median gestational age at surgery was 12.6 weeks in Group A and 15.0 weeks in Group B, respectively. Emergency surgery was performed in 22 cases (61.1%) during the first trimester, in five cases (13.9%) during the second trimester and in nine cases (25%) during the third trimester. Elective surgery was done in 35 cases (66%) during second trimester and in 18 cases (34%) during the first trimester. There was no difference in mean gestational age at delivery (Group A: 38.82"1.76 weeks, Group B:
251
39.12"1.97 weeks) and mean birth weight (Group A:3.08"0.36 kg, Group B: 3.17"0.52 kg). However, the incidence of preterm birth (-37 weeks) was significantly higher in 22.2% of Group A than 3.77% of Group B (P-0.005), but there was no difference in the gestational age at preterm delivery (Group A: 35.78"0.85 weeks; Group B: 34.28"0.81 weeks) (Table 1). 3.2. Location and diameters of ovarian tumor removed at surgery There was no difference in location at operation and the average size of the ovarian tumors between the two groups. Three patients (8.3%) of Group A and five patients (9.4%) of Group B had bilateral ovarian tumors. The average size of the ovarian tumors was 7.63"2.44 cm in Group A and 9.14"3.23 cm in Group B. The most common size of the ovarian tumor was 6–10 cm in both groups (Table 2). 3.3. Histologic diagnosis of ovarian tumor Dermoid cyst was the most common histologic finding in both groups. The incidence of dermoid cyst was 36.1% and 45.0%, respectively, in Group A and Group B. No malignant tumor was found in Group B, but two cases, an immature teratoma and a mucinous adenocarcinoma, were diagnosed at 9 weeks and 17q6 weeks, respectively, in Group A (Table 3). 4. Discussion The frequency of ovarian tumor found on ultrasonography during pregnancy is 1.14%, with most of these tumors being either corpus luteum or theca lutein cysts. Most, however, disappear spontaneously before the 16th week of pregnancy w6x. It is difficult to determine a therapeutic plan for those that persist or are large-sized ovarian tumors with solid components and septa on ultrasonography. The most common histological finding of ovarian tumors operated during pregnancy is that of a benign cystic teratoma w7x. For this, Whitecar et
252
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
Table 1 Demographic characteristics and outcome data of study groups
Maternal age (years) Mean"S.D. Range Parity (no.) Primipara Multipara Gestational age at surgery Median (weeks) 1st trimester No. (%) Mean"S.D. (weeks) 2nd trimester No. (%) Mean"S.D. (weeks) 3rd trimester No. (%) Mean"S.D. (weeks) Gestational age at delivery Mean"S.D. (weeks) Preterm delivery (-37weeks) No. (%) Mean"S.D. (weeks) Term delivery (G37weeks) No. (%) Mean"S.D. (weeks) Birth weight (kg) Neonatal mortality (%) Methods of delivery NSD (No. (%)) CyS (No. (%))
Group A (ns36)
Group B (ns53)
27.81"3.07 25–36
28.42"3.22 21–37
21 15
14 39
12.6
15
22 (61.1%) 10.11"2.55
18 (34%) 13.02"1.52
5 (13.9%) 22.91"4.65
35 (66%) 16.45"1.32
9 (25%) 32.59"2.87
0 0
38.82"1.76
39.12"1.97
NS
8 (22.2%) 35.78"0.85
2 (3.77%) 34.28"0.81
P-0.005 NS
28 (77.8%) 39.68"0.93 3.08"0.36 0
51 (96.23%) 39.31"1.32 3.17"0.52 0
NS NS NS
12 (33.3%) 24 (66.7%)
27 (50.94%) 26 (49.06%)
NS NS
NS NS
NS, non-significant.
al. w2x have reported 30% of benign ovarian tumors and Ueda et al. w8x have reported 45.3%. The most frequent and most serious complication of benign ovarian tumors during pregnancy is
torsion, which frequently occurs in the first trimester of pregnancy, and may result in cyst rupture with spillage into the peritoneal cavity. Whitecar et al. w2x stated that torsion was responsible for
Table 2 Location and diameters of ovarian tumors removed operation
Location Right Left Bilateral Diameter of masses Mean cystic size (cm) -6 cm 6–10 cm 11–15 cm )15 cm
Group A (ns36)
Group B (ns53)
23 10 3
24 24 5
NS
7.63"2.44 3 26 6 1
9.14"3.23 5 30 16 2
NS
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
253
Table 3 Histologic findings of ovarian tumors Type
Group A (ns36)
Tumor-like lesion Hemorrhagic corpus luteum Simple cyst Endometrial cyst Parovarian cyst
4 10 0 0
Benign tumor Dermoid cyst Serous cystadenoma Mucinous adenoma Malignant tumor Mucinous adenocarcinoma Immature teratoma
(11.1%) (27.9%) (0%) (0%)
13 (36.1%) 3 (8.4%) 4 (11.1%)
seven cases (43.8%) of 17 cases of emergency surgery for adnexal tumors during pregnancy. Novak et al. w9x recommended surgery for ovarian tumors that persist until the second trimester of pregnancy to reduce fetal loss. Whitecar et al. w2x reported a significant increase in preterm birth, cesarean section, and perinatal mortality when surgery was done after 23 weeks’ gestation. Hess et al. w3x stated that the risk of abortion or preterm birth was higher in the group that received emergency operation for ovarian tumor torsion than the group that received elective operation. Ueda et al. w8x reported ovarian surgery in the first trimester for persistent or enlarging masses is important to obtain a correct diagnosis and rule out malignancy. However, operative intervention might have significant physical and emotional effects on the fetus or the mother, increasing the risk of preterm delivery w5,10,11x, and Platek et al. w12x evaluated the outcomes of pregnancy complicated by a persistent adnexal mass that was managed conservatively or with surgical intervention and in conclusion they reported that there are no differences in pregnancy outcomes, respectively. Because complications of abdominal surgery are increased in pregnancy, surgical management needs to be reassessed. Thornton et al. w13x suggested a policy of selective conservative management of ovarian cysts during pregnancy on the basis of the ultrasound appearance. Caspi et al. w14x suggested that ovarian dermoid cysts -6 cm are not expected
1 (2.7%) 1 (2.7%)
Group B (ns53) 5 6 5 1
(9.1%) (11.1%) (9.1%) (1.6%)
24 (45.0%) 7 (13.0%) 6 (11.1%) 0 (0%) 0 (0%)
to grow during pregnancy or to cause complications in pregnancy and labor. In this study, women who had emergency surgery because of ovarian torsion showed a higher frequency of preterm birth compared to those with elective operation, but there was not different in the gestational age at preterm delivery and there was no perinatal mortality, nor there was any difference in the vaginal delivery, cesarean section and birth weight between both groups. What was unique, was that although the emergency surgery for torsion of ovarian tumor was done even in the third trimester of pregnancy, there was no difference in the average gestational age at the emergency operation compared to the elective operation. It is considered that torsion of ovarian tumor frequently occur during the first trimester of pregnancy, in this study also, 61.1% of torsion of ovarian tumor occurred in the first trimester of pregnancy. The most common size of ovarian tumor during pregnancy ranged from 6 to 10 cm, and there was no difference in the average size of the tumor and its location between the two groups. In the histological comparisons, there was no malignant tumor in the group that received the elective operation, but there were two cases including the immature teratoma and mucinous adenocarcinoma in the group that received the emergency surgery. The former was managed with a unilateral adnexectomy and delivered a health baby at 38 weeks’ gestation, the latter had received
254
G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250–254
six cycles of chemotherapy after cesarean hysterectomy and left adnexectomy at 35.5 weeks’ gestation. In conclusion, it seems likely that the conservative management of the low risk level of malignancy is better than the operative intervention during the second trimester of gestation, even though there is a possibility of emergency surgery later, and the emergency surgery during pregnancy may not result in higher adverse pregnancy outcome compared with elective surgery. Although surgery for ovarian tumor in pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with that after elective surgery. We propose that conservative management would be used in optimal management of pregnant women with ovarian tumors. References w1x Katz VL, Watson WJ, Hansen WF, Washington JL. Massive ovarian tumor complicating pregnancy. A case report. J Reprod Med 1993;38:907 –909. w2x Whitecar P, Turner S, Higby K. Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol 1999;181:19 –24. w3x Hess LW, Peaceman A, O’Brien WF, Winkel GA, Cruikshank Morison JC. Adnexal mass occurring with intrauterine pregnancy: report of fifty four patients requiring laparotomy for definitive management. Am J Obstet Gynecol 1988;158:1029 –1034.
w4x Koonings PP, Platt LD, Wallace R. Incidental adnexal neoplasms at cesarean section. Obstet Gynecol 1988;73:767 –769. w5x Shnider SM, Webster GM. Maternal and fetal hazards of surgery during pregnancy. Am J Obstet Gynecol 1965;92:891 –900. w6x Nesson MJ, Cavalieri R, Graham D, sanders RC. Cysts in pregnancy discovered by sonography. J Clin Ultrasound 1986;14:509 –512. w7x Usui R, Minakmi H, Kosuge S, Iwasaki R, Ohwada M, Sato I. A retrospective survey of clinical, pathologic, and prognostic features of adnexal masses operated on during pregnancy. J Obstet Gynecol Res 2000;26:89 – 93. w8x Ueda M, Ueki M. Ovarian tumors associated with pregnancy. Int J Gynecol Obstet 1996;55:59 –65. w9x Novak ER, Lambrou CD, Woodruff JD. Ovarian tumors in pregnancy: an ovarian tumor registry review. Obstet Gynecol 1975;46:401 –406. w10x Buttery BW, Beischier NA, Fortune DW, Macafee CA. Ovarian tumors in pregnancy. Med J Aust 1973;1:345 – 349. w11x Caverly CE. Ovarian cyst complicating pregnancy. Am J Obstet Gynecol 1931;21:566 –574. w12x Platek DN, Henderson CE, Goldberg GL. The management of a persistent adnexal mass in pregnancy. Am J Obstet Gynecol 1995;173:1236–1240. w13x Thornton JG, Wells M. Ovarian cysts in pregnancy: does ultrasound make traditional management inappropriate? Obstet Gynecol 1987;69:717 –721. w14x Caspi B, Levi R, Appleman Z, Rabinerson D, Goldman G, Hagay Z. Conservative management of ovarian cystic teratoma during pregnancy and labor. Am J Obstet Gynecol 2000;182:503 –505.