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Giant ovarian cyst: Case report
Peripartum pelvic instability
Volume 166 Number 4
12. Vleeming A, Volkers ACW, Snijders Cj, Stoeckart R. Relation between form and function in the sacroiliac joint. I I. Biomechanical aspects. Spine 1990; 15: 133-6. 13. Snijders Cj. Snijder JGN, Hoedt HTE. Biomechanische Modellen in het bestek van rugklachten tijdens de zwangerschap. Tijdschr Soc Gezondheidsz 1984;62:141-7. 14. Kraubig H. Der Symphysenschaden der Schwangeren and Gebarenden. Med Klink 1962;20:883-6. 15. Lemberger F. Die Symphysenruptur and ihre Behandlung. Munch Med Wochenschr 1963;9:450-4. 16. Taylor RN, Sonson RD. Separation of the pubic symphysis, an underrecognized peripartum complication. J Reprod Med 1986;3 I :203-6. 17. Crim MW, Moss SW. Pelvic diastasis in pregnancy. Am Fam Phvsician 1987:35:185-6. 18. Vleemi~g A, Van Wingerden JP. Snijders Cj, Stoeckart R, Stijnen 1'. Load application to the sacrotuberous ligament: influences on sacroiliac joint mechanics. Clin Biomechanics 1989;4:204-9. 19. Struck H. Viell B. Metabolic responses to relaxin in the mouse svmphysis pubis. Horm Metab Res 1987;19:669.
20. Camiel R. Relaxin and the radiolucent fissure in the symphysis pubis during pregnancy: the gas phenomenon."AM J OBSTETGVNECOL 1986;154:1104-5. 21. Van Roosmalen J. Maternal health care in the southwestern highlands of Tanzania [Thesis]. Rotterdam, The Netherlands: Erasmus University. 1988. 22. Olerud S, Walheim GG. Symphysiodesis with a new compression plate. Acta Orthop Scand 1984;55:315-18. 23. Greenhill JP, Friedman EA. Biological principles and modern practice of obstetrics. Philadelphia: WB Saunders, 1974. 24. Moran JM. Stress fractures in pregnancy. AM J OBSTET GnlEcoL 1988;158:1274-6. 25. Vleeming A, Stoeckart R. Snijders Cj. The sacrotuberous ligament, a conceptual approach to its dynamic role in stabilizing the sacroiliac joint. Clin Biomechanics 1989;4:201-3. 26. Webb LX, Gristina AG. Wilson JR, Rhyne AL, Meredith JH, Hansen ST. Two-hole plate fixation for traumatic symphysis pubis diastasis. J Trauma 1988;28:813-16.
Giant ovarian cyst: Case report Miguel Zamora-Garza, MD, Joel Rizo, MD, and Alberto Dominguez, MD Mexico City, Mexico We present the case of a woman 22 years old with an ovarian cyst of 6 years' duration. The total weight of the tumor was 154 pounds (70 kg). She was treated surgically with good results. (AM J OBSTET GVNECOL 1992;166:1247-8.)
Key word: Giant ovarian cyst We describe a case of a 22-year-old woman with an ovarian cyst of 6 years' duration weighing 154 pounds.
Case report Clinical history. The patient was a 22-year-old woman
admitted to the Woman's Hospital (Health Department) on Nov. 21, 1988. She came from a town in the state of Oaxaca, Mexico. She presented with features of social deprivation. She was unmarried, with unknown parents and four brothers who died of unknown causes. At age 13 menstrual periods started; they occurred every 30 days and lasted 3 days. There had been no sexual activity. Her last menstruation was on April 12,
From the Division of Gynecology, Hospital de la Mujer. Receivedforpublicationjune 17.1990; revised December 12,1991; accepted December 30, 1991. Reprint requests: Miguel Zamora-Garza, MD, Circuito Navegantes No. 31, Cd. SaUlite, Naucalpan, Estado de Mexico, CP 53100, Mexico. 611 136034
1988. At the age of 16, she noticed that her abdomen was growing gradually, and it was painful. In 1985 she was hospitalized and nonspecific tests including an abdominal puncture were done. Results are unknown. The patient reported that since January 1988 the large abdominal volume had made her lose her equilibrium. She had also lost the use of muscles and was fatigued by small efforts. She had had amenorrhea for 17 months, and she had edema of the lower extremities. Physical examination. Weight on admission was 242 pounds, heart rate 88 beats/min, respiratory rate 24 breaths/min, temperature 36° C, and arterial pressure 110170 mm Hg. She appeared older than her age with bad conformation because of the large volume of the abdomen. She was pale, with normal breasts and a small amount of pubic hair. The abdomen demonstrated collateral venous trajectories. The measurement from the pubis to the top of cyst was 128 cm. No visceral growth was found. Peristalsis was present. A pelvic examination was not done. The sphincter tonus was normal, and we could not feel either the uterus or the adnexae by rectal 1247
1248 Zamora-Garza, Rizo, and Dominguez
April 1992 Am J Obstet Gynecol
Fig. 1. Appearance of the patient on admission.
examination. The lower extremities had bimalleolar edema, loss of muscular volume, and atrophic changes of the skin (Fig. 1). On Nov. 23, 1988, she had a cough with basal rales that made pulmonary ventilation very difficult. The cardiac rate increased to 110 beats/min. There was moderate obstruction and hypoxemia with a tendency to hyperventilation. The electrocardiogram showed a sinus tachycardia. Renal ultrasonography showed hydronephrosis of the right kidney and moderate cholestasis in the left kidney. The pulmonary surface was diminished on x-ray film. The right hemidiaphragm was at the level of the fourth space between the ribs and the left hemidiaphragm was at the seventh space. The cardiac shadow was horizontal. The abdominal x-ray films and the abdominal sonogram could not be interpreted. Treatment with digitalis and decompressive paracentesis was undertaken for 7 days with extraction of 28.8 L of fluid weighing 71.9 pounds. The fluid was negative for malignant cells. The patient's condition improved, and we decided to perform an exploratory laparotomy on Dec. 5, 1988, with a preoperative diagnosis of a giant ovarian tumor. Operative procedure. With the patient under general anesthesia, the abdomen was opened. A tumor of the right ovary was removed with an intraoperative diagnosis of serous cystadenoma. The rest of the structures were normal. The abdominal wall was dosed with the Mayo technique. During the operation the patient
received 400 ml of blood, 250 ml of plasma, and 200 ml of solutions. The postoperative course was satisfactory. The patient's preoperative admission weight was 242 pounds (110 kg). Her postoperative weight was 88 pounds (40 kg). The weight of the tumor was 154 pounds (70 kg). After 36 days of hospitalization, her weight was 105.6 pounds (48 kg). Comment
The patient was slowly decompressed because of the systemic effect of the tumor on the cardiovascular system. Fisher' reported dissemination after a puncture in the presence of a malignancy. In other reports it is suggested that the puncture is used to prevent rupture of the capsule and greater dissemination! There is little experience in cases of giant ovarian tumors. The participation of several specialties is necessary: gynecology, anesthesiology, critical care, rehabilitation, and histopathology. The more frequent complications mentioned in the literature are bleeding, supine hypotension, anesthesia complications, and splenic shock. REFERENCES 1. Fisher EL. Management of a large ovarian tumor: report of a case. J Obstet Gynecol 1965;26:417. 2. Hunter DJS. Management of a massive ovarian cyst. Obstet Gynecol 1980;56:254-5.
Volume 166 Number 4
12. Vleeming A, Volkers ACW, Snijders Cj, Stoeckart R. Relation between form and function in the sacroiliac joint. I I. Biomechanical aspects. Spine 1990; 15: 133-6. 13. Snijders Cj. Snijder JGN, Hoedt HTE. Biomechanische Modellen in het bestek van rugklachten tijdens de zwangerschap. Tijdschr Soc Gezondheidsz 1984;62:141-7. 14. Kraubig H. Der Symphysenschaden der Schwangeren and Gebarenden. Med Klink 1962;20:883-6. 15. Lemberger F. Die Symphysenruptur and ihre Behandlung. Munch Med Wochenschr 1963;9:450-4. 16. Taylor RN, Sonson RD. Separation of the pubic symphysis, an underrecognized peripartum complication. J Reprod Med 1986;3 I :203-6. 17. Crim MW, Moss SW. Pelvic diastasis in pregnancy. Am Fam Phvsician 1987:35:185-6. 18. Vleemi~g A, Van Wingerden JP. Snijders Cj, Stoeckart R, Stijnen 1'. Load application to the sacrotuberous ligament: influences on sacroiliac joint mechanics. Clin Biomechanics 1989;4:204-9. 19. Struck H. Viell B. Metabolic responses to relaxin in the mouse svmphysis pubis. Horm Metab Res 1987;19:669.
20. Camiel R. Relaxin and the radiolucent fissure in the symphysis pubis during pregnancy: the gas phenomenon."AM J OBSTETGVNECOL 1986;154:1104-5. 21. Van Roosmalen J. Maternal health care in the southwestern highlands of Tanzania [Thesis]. Rotterdam, The Netherlands: Erasmus University. 1988. 22. Olerud S, Walheim GG. Symphysiodesis with a new compression plate. Acta Orthop Scand 1984;55:315-18. 23. Greenhill JP, Friedman EA. Biological principles and modern practice of obstetrics. Philadelphia: WB Saunders, 1974. 24. Moran JM. Stress fractures in pregnancy. AM J OBSTET GnlEcoL 1988;158:1274-6. 25. Vleeming A, Stoeckart R. Snijders Cj. The sacrotuberous ligament, a conceptual approach to its dynamic role in stabilizing the sacroiliac joint. Clin Biomechanics 1989;4:201-3. 26. Webb LX, Gristina AG. Wilson JR, Rhyne AL, Meredith JH, Hansen ST. Two-hole plate fixation for traumatic symphysis pubis diastasis. J Trauma 1988;28:813-16.
Giant ovarian cyst: Case report Miguel Zamora-Garza, MD, Joel Rizo, MD, and Alberto Dominguez, MD Mexico City, Mexico We present the case of a woman 22 years old with an ovarian cyst of 6 years' duration. The total weight of the tumor was 154 pounds (70 kg). She was treated surgically with good results. (AM J OBSTET GVNECOL 1992;166:1247-8.)
Key word: Giant ovarian cyst We describe a case of a 22-year-old woman with an ovarian cyst of 6 years' duration weighing 154 pounds.
Case report Clinical history. The patient was a 22-year-old woman
admitted to the Woman's Hospital (Health Department) on Nov. 21, 1988. She came from a town in the state of Oaxaca, Mexico. She presented with features of social deprivation. She was unmarried, with unknown parents and four brothers who died of unknown causes. At age 13 menstrual periods started; they occurred every 30 days and lasted 3 days. There had been no sexual activity. Her last menstruation was on April 12,
From the Division of Gynecology, Hospital de la Mujer. Receivedforpublicationjune 17.1990; revised December 12,1991; accepted December 30, 1991. Reprint requests: Miguel Zamora-Garza, MD, Circuito Navegantes No. 31, Cd. SaUlite, Naucalpan, Estado de Mexico, CP 53100, Mexico. 611 136034
1988. At the age of 16, she noticed that her abdomen was growing gradually, and it was painful. In 1985 she was hospitalized and nonspecific tests including an abdominal puncture were done. Results are unknown. The patient reported that since January 1988 the large abdominal volume had made her lose her equilibrium. She had also lost the use of muscles and was fatigued by small efforts. She had had amenorrhea for 17 months, and she had edema of the lower extremities. Physical examination. Weight on admission was 242 pounds, heart rate 88 beats/min, respiratory rate 24 breaths/min, temperature 36° C, and arterial pressure 110170 mm Hg. She appeared older than her age with bad conformation because of the large volume of the abdomen. She was pale, with normal breasts and a small amount of pubic hair. The abdomen demonstrated collateral venous trajectories. The measurement from the pubis to the top of cyst was 128 cm. No visceral growth was found. Peristalsis was present. A pelvic examination was not done. The sphincter tonus was normal, and we could not feel either the uterus or the adnexae by rectal 1247
1248 Zamora-Garza, Rizo, and Dominguez
April 1992 Am J Obstet Gynecol
Fig. 1. Appearance of the patient on admission.
examination. The lower extremities had bimalleolar edema, loss of muscular volume, and atrophic changes of the skin (Fig. 1). On Nov. 23, 1988, she had a cough with basal rales that made pulmonary ventilation very difficult. The cardiac rate increased to 110 beats/min. There was moderate obstruction and hypoxemia with a tendency to hyperventilation. The electrocardiogram showed a sinus tachycardia. Renal ultrasonography showed hydronephrosis of the right kidney and moderate cholestasis in the left kidney. The pulmonary surface was diminished on x-ray film. The right hemidiaphragm was at the level of the fourth space between the ribs and the left hemidiaphragm was at the seventh space. The cardiac shadow was horizontal. The abdominal x-ray films and the abdominal sonogram could not be interpreted. Treatment with digitalis and decompressive paracentesis was undertaken for 7 days with extraction of 28.8 L of fluid weighing 71.9 pounds. The fluid was negative for malignant cells. The patient's condition improved, and we decided to perform an exploratory laparotomy on Dec. 5, 1988, with a preoperative diagnosis of a giant ovarian tumor. Operative procedure. With the patient under general anesthesia, the abdomen was opened. A tumor of the right ovary was removed with an intraoperative diagnosis of serous cystadenoma. The rest of the structures were normal. The abdominal wall was dosed with the Mayo technique. During the operation the patient
received 400 ml of blood, 250 ml of plasma, and 200 ml of solutions. The postoperative course was satisfactory. The patient's preoperative admission weight was 242 pounds (110 kg). Her postoperative weight was 88 pounds (40 kg). The weight of the tumor was 154 pounds (70 kg). After 36 days of hospitalization, her weight was 105.6 pounds (48 kg). Comment
The patient was slowly decompressed because of the systemic effect of the tumor on the cardiovascular system. Fisher' reported dissemination after a puncture in the presence of a malignancy. In other reports it is suggested that the puncture is used to prevent rupture of the capsule and greater dissemination! There is little experience in cases of giant ovarian tumors. The participation of several specialties is necessary: gynecology, anesthesiology, critical care, rehabilitation, and histopathology. The more frequent complications mentioned in the literature are bleeding, supine hypotension, anesthesia complications, and splenic shock. REFERENCES 1. Fisher EL. Management of a large ovarian tumor: report of a case. J Obstet Gynecol 1965;26:417. 2. Hunter DJS. Management of a massive ovarian cyst. Obstet Gynecol 1980;56:254-5.