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Ovarian surgery in pregnancy
Ovarian surgery in pregnancy LYNDON CARL
M. E.
HILL,
JOHNSON,
RAYMOND
A.
Rochester,
M.D. M.D.
LEE,
M.D.
Minnesota
A .reries of 57 cases of ovarian disease during pregnancy is presented; 10 of the patients were referred to the Mayo Clinic for treatment. Durkg the 17 year period under investigation (1955 through 1971), there were 25,189 deliveries in Rochester, Minnesota. Thus, the corrected incidence of operable ovarian disease in pregnancy was one case in every 536 deliveries. Simple ovarian cysts were the most common lesions found (38 of 57 cases). The over-all abortion rate was about 25 per cent (14 of 57 patients); six of the patients were threatening to abort prior to surgery. Therefore, the incidence of spontaneous abortion after surgery was 16 per cent (eight of 51 patients). Progestational agents given before and after operatzon
dzd
not
affect
the
abortion
rate.
Material
A B D o M I N A L surgery in pregnancy is associated with some uneasiness. The clinician and the surgeon suddenly may become unsure of their diagnosis and are hesitant to operate unless the signs and symptoms of a surgical condition are unmistakably present. Procrastination in order to obtain more information may be harmful to both the patient and her child. At the Mayo Clinic from 1955 through 1971, 112 abdominal surgical procedures were performed on the indigenous pregnant population-an incidence of 0.44 per cent (one per 225 deliveries). Ovarian disease is the one type of abdominal surgery in which the obstetrician has the primary role in diagnosis. The following study was undertaken to determine the Mayo Clinic’s experience with ovarian surgery during pregnancy in the 17 year period of 1955 through 1971. This time span was selected to ensure sufficient data for analysis and yet maintain continuity in surgical philosophy and technique. From
the
Mayo
Clinic
and
Mayo
During the 17 years under investigation, 25,189 deliveries were performed. A total of 57 gravid women had ovarian surgery; 10 of these were referred from other hospitals for diagnosis and definitive treatment. The incidence for our total series of 57 patients was one case for every 442 deliveries. The corrected incidence for the 47 cases indigenous to Rochester, Minnesota, was one case in every 536 deliveries. Results
At ovarian surgery in our series, four types of masses were found : benign cysts, endometriomas, dermoid cysts, and benign and malignant cystadenomas. Benign cysts. Of the 57 adnexal masses found, 38 were corpus luteal, simple follicular, or parovarian cysts (Table I) . Corpus luteal cysts are the most common adnexal iriasses palpable early in pregnancy, but they seldom exceed 6 cm. in diameter. Their average size in our series was 4.6 rm.. excluding a massive 25 cm. cyst. Follicular cysts are derived from blighted follicles that become overdistended with fluid. Like corpus luteal cysts, they usually are less than 6 cm. in diameter. In our series, there were 11 follicular cysts either aspirated or excised at surgery. Four other cysts had twisted on their pedicle, causing infarction and thereby requiring salpingo-oophorectomy.
Foundation.
Read at the District VI meeting of the American College of Obstetricians and Gynecologists, Omaha, Nebraska, October 23 to 26, 1974. Receiljed
for
publication
Revised
September
Accepted
October
April
2, 1974.
1 I 1 1974. 4, 1974.
Reprint address: Dr. L. M. Hill, c/o Section of Publications, Mayo Clinic, 200 First Street SW, Rochester. Minnesota 5.5901.
565
Table I. Pathologic diagnoses after ovarian surgery in pregnancy ( Mayo Clinic, 1955 through 1971) ~~ No.__ Series
Diapnosis Benign cysts corpus luteal Simple ovarian Parovarian Twisted ovarian Ovarian endometriomas cysts Ovarian dermoid Benign and malignant cystadenomas Serous cystadenoma Mutinous cystadenoma Serous cystadenocarcinoma Mutinous cystadenocarcinoma
of
patients
38
6 19 11 4 4
66.6 2 9 0 2
4 7
33.3 19.3 7.0 7.0
0 3
8
7.0 12.3
1
14.1
4
0
7.0
1
0
1.8
1
1
1.8
2
Total
Percentage of total
1Referred
0
57
3.5
10
100
Table II. Comparison of preoperative and pathologic diagnoses in 38 cases of benign cysts noted at ovarian surgery in pregnancy (Mayo Clinic, 1955 through 1971)
diagnosis
1 cyst
Ectopic pregnancy Ovarian cvst Pelvic ma& Appendicitis Abdominal uain
8 8* 0 2 1
/
cyst
1 cyst
1’ cyst
1 Total
5 3* 3” 0
2 0 2* 0
0 1” ‘7 *
15 12 7 2
0
0
0
1
‘I
I
Total *Correct
Is
11
a
e
38
diagnosis.
The average gestational length at surgery for this group was 9.1 weeks, with a range of 4 to 24 weeks. There were two indications for surgery in the 38 cases of benign cysts: presence of symptoms and large tumor size. Lower abdominal pain, either acute or chronic, was present in 26 patients; rebound tenderness was an associated finding in seven of the 26. Of the remaining 12 patients, seven were asymptomatic, one complained of abdominal enlargement, one discovered an abdominal mass, and three had only mild vaginal spotting. These 12 patients, however, all had palpable adnexal masses of 7 cm. or greater. Nausea and vomiting as a symptom complex were
found only in patients who had infarcted c,vari;in cysts. A temperature higher than 37.7” C. ( 100” I: ) was found in two patients, both of whom h:lti herrtorrhagic corpus luteal cysts. Only one patient in our series had a Irukoc\te count greater than 13,000 per cubic millimeter, and 12 patients had counts between 10,000 and 13.000. (Pregnancy normally can be associated wit11 counts as high as 15,500.) ‘L‘he following preoperative diagnoses were made : ectopic pregnancy 15, ovarian cyst 12, pelvic mass seven, appendicitis two, and abdominal pain two (Table II). Only 19 of the 38 diagnoses (50 per cent) were correct. Fetal outcome after surgery in patients with benign cysts in pregnancy was poor. There were 10 abortions in the 38 cases (26 per cent). Endometriomas. In our series, four patients with endometriomas in pregnancy were found (7 per cent) ; nonr had bilateral disease. The average size of the four endonletriomas was 9.8 cm. (range 8 to 10 cm.). All four patients had an asymptomatic pelvic mass. All four patients were observed for 2 to 6 weeks before surgery to detect any change in tumor size. Average gestation at surgery was 16 weeks (range 8 to 20 weeks). The diagnosis was made correctly preoperatively in one of the four cases. Fetal outcome was excellent, with four normal deliveries occurring at term. Dermoid cysts. Seven of the 57 lesions (12.3 per cent) in our series were dermoid cysts. Five of the seven patients with dermoid lesions were asymptomatic. Consequently, pelvic examination was the primary means of diagnosis prior to the onset of symptoms of torsion or rupture. One patient complained of mild lower abdominal discomfort, and another had a ruptured dermoid with abdominal pain and rebound tenderness. The average size of the dermoid tumors in our series was 8.5 cm., with a range of 6 to 12 cm. Surgery was performed between the eighth and the thirty-sixth weeks of gestation, with a mean of 16 weeks. A preoperative diagnosis of ovarian dermoid was made in two of the seven cases; in both, roentgenograms
of
the
abdomen
revealed
“teeth”
in
the
re-
of the ovary. Four of the preoperative diagnoses were categorized as ovarian masses. The one patient with a ruptured dermoid had a preoperative diagnosis of acute appendicitis. In our series, fetal outcome after excision of an gion
ovarian
dermoid
included
four
normal
deliveries,
V”lum,~
122
Numbrr
5
one spontaneous abortion, one therapeutic abortion, and one delivery after premature labor at 36 weeks of gestation, following chemical peritonitis from the ruptured dermoid. Benign and malignant cystadenomas. In our series, there were one mutinous cystadenoma and four serous cystadenomas. Of the five patients, two had asymptomatic pelvic masses, whereas three had lower abdominal pain that ranged from mild to severe. The sizes of the tumors varied from 6 to 10 cm., with a mean of 8.4 cm. Preoperative diagnoses included one ectopic pregnancy, one twisted ovarian cyst, and three ovarian masses. Surgery consisted of one salpingooophorectomy (for the mutinous cystadenoma) and four ovarian cystectomies. In our series, three cystadenocarcinomas were found: two were mutinous and one was serous. The two patients with mutinous cystadenocarcinoma were 25 years old (gravida 2, para 1) and 32 years old (gravida 5, para 4)) respectively, and both presented with crampy abdominal pain of 2 tc 3 weeks’ duration. Both patients were at 16 weeks of gestation. On examination, a 10 cm. pelvic mass was found in one patient, and a 30 cm. abdominal mass was found in the other. Each patient, with a pathologic diagnosis of grade 1 intracystic papillary mutinous adenocarcinoma, underwent a temporizing oophorectomy, followed by the removal of the remaining pelvic organs after delivery. Both patients were alive and well in August, 1973 (11 and 14 years after operation). The only patient with a serous cystadenocarcinema was a 23-year-old white woman (gravida 1, para 0)) who was 8 weeks pregnant at her first prenatal visit. Although she was asymptomatic, an 8 cm. ovarian mass was palpated. At surgery, an intracystic serous papillary, grade 1 cystadenocarcinoma was found. For religious reasons, the patient had refused to have a therapeutic abortion should it be necessary. Consequently, a salpingo-oophorectomy was performed. She did well and was delivered of a normal child at term. She is still free of recurrence 15 years after surgery. Comment
Review of the literature reveals much variability in the reported incidence of ovarian disease during pregnancy. In 1954, Grimes and associates1 reported an incidence of one ovarian cyst for every 81 deliveries; however, 70 per cent of their patients had cysts of less than 5 cm. in diameter. Tawa,? in
Ovarian
Table III. pregnancy
surgery
Fetal outcome (Mayo Clinic,
after ovarian 1955 through Gestation
O-9 No. of cases Normal delivery Abortion Threatened O-7 days 7+ days Actual O-7 days 7+ days *Includes delivered at ?IncIudes mild vaginal $Includes one therapeutic BIncludes
in pregnancy
surgery 197 1)
in
(wk.)
1 lo-20
33 22
567
1 21-40
22 10
Total
2 2
57 42s
2 ‘I
2 ‘)
4 4
4 31
4t 45
8 7
eight patients with threatened abortions term. two patients: one with heavy and one bleeding before surgery. three patients: two with mild spotting abortion. two patients with mild spotting.
who with and
a review of the literature to 1964, found that the incidence of ovarian tumors in pregnancy ranged from 1 : 273 to 1 : 2,489, depending on the author and the institution. An important factor in determining incidence is the time at which the patient presents herself for prenatal care. Most authors’-” emphasized that the first prenatal examination is the optimal time to palpate an ovarian mass. After the third trimester, the ovaries are drawn up out of the pelvis with the enlarging uterus, making palpation more difficult. The incidence given for various ovarian pathologic entities in pregnancy likewise varies widely. This is in part due to the different sizes of the studies reported. Grimes and associates,l for example, reported an incidence of 2 per cent for endometriomas (one of 50 cases) in their study of ovarian cysts in pregnancy, whereas Sinnathuray+ in 1971 found an incidence of 10.5 per cent (two of 19 cases). As a further example, only 12.3 per cent of the ovarian masses in the present study of 57 cases were dermoids. In 1955, Peterson and associates,” however, stated that 22 to 40 per cent of ovarian tumors in pregnancy were dermoids. In our series, the incidence of spontaneous abortion was 24.5 per cent (14 of 57 cases, Table III). There was one therapeutic abortion. Eight patients threatened to abort after surgery (Table III). This was defined as vaginal spotting with or without lower abdominal cramping at any time after surgery. The onset of these symptoms after surgery has been divided into two time groups: before and after the seventh postoperative day.
5@
;Giii,
;ohnson,
and
Lee Am.
Table IV. Progestational agents used after ovarian surgery in pregnancy (Mayo Clinic, 1955 through 1971) ( z
1
;;ieltut’s
Agent Hydroxyprogesterone caproate
250 500 750 1,000 1 250 “1875 5,750 8,000
Medroxyprogesterone acetate Progesterone
7* 4t 2 1 1 1 1X 13
50 140
1 1
Total
!o
*Two patients also received progesterone, 100 mg. intramuscularly, on the first 2 postoperative days. tone patient also received progesterone, 100 mg. intramuscularly, on the first 6 postoperative days. jTota1 dosage received from surgery until delivery.
Table V. Use of morphine sulfate after ovarian surgery in pregnancy (Mayo Clinic, 1955 through 1971) Dosage 10 10 10 15
mg. every mg. every mg. every mg. every
4 6 4 4
No. of patients
(intramuscular) hours hours hours hours
for for for for
2 2 4 3
days days days days
-
7 2 1 1
Of the 15 patients who had actual abortions, seven had mild to heavy vaginal bleeding prior to surgery (see footnote, Table III). Because ectopic pregnancy was a primary preoperative diagnosis, this was not unexpected. Evans and Beischer” in 1970 found that 81 per cent of pregnant women with heavy vaginal bleeding who required hospitalization subsequently aborted, while 60 per cent of those with only mild bleeding aborted. If the seven patients who threatened to abort before the additional stress of surgery are excluded from our series, the percentage of spontaneous abortion is reduced from 26 to 16 per cent (eight of 51 patients). A search of the literature revealed wide variation in fetal loss after ovarian surgery in pregnancy. In 1954, Gustafson, Gardiner and Stout’ reported an over-all fetal loss of 18 per cent, whereas, in 1964, Tawa’ reported 9.7 per cent. Most authors observe their patients who have
July 1, 19% J. Ohstrt. Gynccol.
asymptomatic ovarian cysts of less than 5 or 6 cm. in diameter carefully until the sixteenth to eighteenth week of pregnancy. By that time, corpus luteal size and function will have diminished and the first trimester, in which most abortions occur, will have been passed.’ In the present investigation, only 23 of 57 patients had asymptomatic masses. The remaining 34 gravid females had symptoms of lower abdominal pain or vaginal spotting (or both) associated with an ovarian mass. Particularly when these symptoms and signs arise in combination, ectopic gestation must be strongly considered in the differential diagnosis, and one therefore does not have the luxury of waiting prior to abdominal exploration. Culdoscopy and, more recently, laparoscopy can afford direct visualization without initial laparotomy. In our series, culdotomy was the surgical procedure in eight of the 38 cases (2 1 per cent) of benign cysts. This permitted both diagnosis and treatment
without
celiotomy.
our series, postoperative prevention of abortion was attempted through the use of progestational or both. The selection of agents, heavy sedation, drug, the dosage, and the duration of treatment were more dependent on the preference of the obIn
stetrician
than
gesterone
caproate
nant
on
progestational
dosage
varied
operation
in
from seven
any
other
factor.
(Delalutin)
was
agent
(Table
used
Hydroxypro-
the
predomiIV).
250 mg. intramuscularly cases
to
a
total
of
The
before 8,000
mg.
divided over the remaining weeks of pregnancy in one case. Morphine sulfate was the only drug utilized for postoperative sedation (Table V). The dosage of morphine also varied widely. although all patients were on a given schedule for at least 2 days. Of our 57 patients with ovarian surgery during pregnancy, 20 received progestational compounds, 11 had heavy postoperative sedation, and 26 received no specific treatment directed at inhibiting uterine contractility. Consequently, 31 patients were actively treated and 26 were not. Gestational age at the time of surgery was comparable in the treated ( 10.4 weeks) and the untreated group (10 vveeks) There was no difference in the abortion rate between these two groups. The type of anesthetic used in the 57 cases in our series depended on the preference of the anesthesiologist. Kegional anesthesia was not used for any of the patients. Of the 57 patients, 22 received halothane, 18 a nitrous oxide-ether combination, and
eight
nine
primarily
patients,
nitrous
four
oxide.
received
Of
the
remaining
methoxyflurane
and
Volume. 122 Number 5
four had fentanyl. No anesthetic agent was associated with a higher rate of abortion than another. Conclusions
A review of 17 years of experience (57 cases) in ovarian surgery during pregnancy at the Mayo Clinic revealed the following. 1. One ovarian surgical procedure was performed for every 536 deliveries in Rochester, Minnesota. 2. Most procedures involved simple ovarian cysts (38 of the 57 cases) ; these included corpus luteal, follicular, and parovarian cysts.
REFERENCES
1.
2. 3. 4.
Grimes, W. H., Jr., Bartholomew, R. A., C&in, E. D., Fish, J. S., and Lester, W. M.: AM. J. OBSTET. GYNECOL. 68: 594, 19%. Tawa, K.: AM. J. OBSTET. GYNECOL. 90: 511, 1964. Wilson, R. B., and Mussey, R. D.: Surg. Clin. North Am. 1949, p. 1119. Sinnathuray, T. A.: Int. Surg. 55: 422, 1971.
Ovarian
surgery
in pregnancy
569
3. Lower abdominal pain and tumor size greater than 6 cm. were the primary indications for surgery. 4. Examination of fetal outcome revealed eight abortions in 51 cases (16 per cent fetal loss) in which vaginal spotting prior to surgery had not occurred. 5. Active treatment with progestational agents before and after operation did not affect the abortion rate.
5.
6. 7. 8.
Peterson, W. F., Prevost, E. C., Edmunds, F. T., Hundley, J. M., and Morris, F. K.: AM. J. OBSTET. GYNECOL. 70: 368, 1955. Evans, J. H., and Beischer, N. A.: Med. J. Aust. 2: 165, 1970. Gustafson, G. W., Gardiner, S. H., and Stout, F. E.: AM. J. OBSTET. GYNECOL. 67: 1210, 1954. Munnell, E. W.: Clin. Obstet. Gynecol. 6: 983, 1963.
M. E.
HILL,
JOHNSON,
RAYMOND
A.
Rochester,
M.D. M.D.
LEE,
M.D.
Minnesota
A .reries of 57 cases of ovarian disease during pregnancy is presented; 10 of the patients were referred to the Mayo Clinic for treatment. Durkg the 17 year period under investigation (1955 through 1971), there were 25,189 deliveries in Rochester, Minnesota. Thus, the corrected incidence of operable ovarian disease in pregnancy was one case in every 536 deliveries. Simple ovarian cysts were the most common lesions found (38 of 57 cases). The over-all abortion rate was about 25 per cent (14 of 57 patients); six of the patients were threatening to abort prior to surgery. Therefore, the incidence of spontaneous abortion after surgery was 16 per cent (eight of 51 patients). Progestational agents given before and after operatzon
dzd
not
affect
the
abortion
rate.
Material
A B D o M I N A L surgery in pregnancy is associated with some uneasiness. The clinician and the surgeon suddenly may become unsure of their diagnosis and are hesitant to operate unless the signs and symptoms of a surgical condition are unmistakably present. Procrastination in order to obtain more information may be harmful to both the patient and her child. At the Mayo Clinic from 1955 through 1971, 112 abdominal surgical procedures were performed on the indigenous pregnant population-an incidence of 0.44 per cent (one per 225 deliveries). Ovarian disease is the one type of abdominal surgery in which the obstetrician has the primary role in diagnosis. The following study was undertaken to determine the Mayo Clinic’s experience with ovarian surgery during pregnancy in the 17 year period of 1955 through 1971. This time span was selected to ensure sufficient data for analysis and yet maintain continuity in surgical philosophy and technique. From
the
Mayo
Clinic
and
Mayo
During the 17 years under investigation, 25,189 deliveries were performed. A total of 57 gravid women had ovarian surgery; 10 of these were referred from other hospitals for diagnosis and definitive treatment. The incidence for our total series of 57 patients was one case for every 442 deliveries. The corrected incidence for the 47 cases indigenous to Rochester, Minnesota, was one case in every 536 deliveries. Results
At ovarian surgery in our series, four types of masses were found : benign cysts, endometriomas, dermoid cysts, and benign and malignant cystadenomas. Benign cysts. Of the 57 adnexal masses found, 38 were corpus luteal, simple follicular, or parovarian cysts (Table I) . Corpus luteal cysts are the most common adnexal iriasses palpable early in pregnancy, but they seldom exceed 6 cm. in diameter. Their average size in our series was 4.6 rm.. excluding a massive 25 cm. cyst. Follicular cysts are derived from blighted follicles that become overdistended with fluid. Like corpus luteal cysts, they usually are less than 6 cm. in diameter. In our series, there were 11 follicular cysts either aspirated or excised at surgery. Four other cysts had twisted on their pedicle, causing infarction and thereby requiring salpingo-oophorectomy.
Foundation.
Read at the District VI meeting of the American College of Obstetricians and Gynecologists, Omaha, Nebraska, October 23 to 26, 1974. Receiljed
for
publication
Revised
September
Accepted
October
April
2, 1974.
1 I 1 1974. 4, 1974.
Reprint address: Dr. L. M. Hill, c/o Section of Publications, Mayo Clinic, 200 First Street SW, Rochester. Minnesota 5.5901.
565
Table I. Pathologic diagnoses after ovarian surgery in pregnancy ( Mayo Clinic, 1955 through 1971) ~~ No.__ Series
Diapnosis Benign cysts corpus luteal Simple ovarian Parovarian Twisted ovarian Ovarian endometriomas cysts Ovarian dermoid Benign and malignant cystadenomas Serous cystadenoma Mutinous cystadenoma Serous cystadenocarcinoma Mutinous cystadenocarcinoma
of
patients
38
6 19 11 4 4
66.6 2 9 0 2
4 7
33.3 19.3 7.0 7.0
0 3
8
7.0 12.3
1
14.1
4
0
7.0
1
0
1.8
1
1
1.8
2
Total
Percentage of total
1Referred
0
57
3.5
10
100
Table II. Comparison of preoperative and pathologic diagnoses in 38 cases of benign cysts noted at ovarian surgery in pregnancy (Mayo Clinic, 1955 through 1971)
diagnosis
1 cyst
Ectopic pregnancy Ovarian cvst Pelvic ma& Appendicitis Abdominal uain
8 8* 0 2 1
/
cyst
1 cyst
1’ cyst
1 Total
5 3* 3” 0
2 0 2* 0
0 1” ‘7 *
15 12 7 2
0
0
0
1
‘I
I
Total *Correct
Is
11
a
e
38
diagnosis.
The average gestational length at surgery for this group was 9.1 weeks, with a range of 4 to 24 weeks. There were two indications for surgery in the 38 cases of benign cysts: presence of symptoms and large tumor size. Lower abdominal pain, either acute or chronic, was present in 26 patients; rebound tenderness was an associated finding in seven of the 26. Of the remaining 12 patients, seven were asymptomatic, one complained of abdominal enlargement, one discovered an abdominal mass, and three had only mild vaginal spotting. These 12 patients, however, all had palpable adnexal masses of 7 cm. or greater. Nausea and vomiting as a symptom complex were
found only in patients who had infarcted c,vari;in cysts. A temperature higher than 37.7” C. ( 100” I: ) was found in two patients, both of whom h:lti herrtorrhagic corpus luteal cysts. Only one patient in our series had a Irukoc\te count greater than 13,000 per cubic millimeter, and 12 patients had counts between 10,000 and 13.000. (Pregnancy normally can be associated wit11 counts as high as 15,500.) ‘L‘he following preoperative diagnoses were made : ectopic pregnancy 15, ovarian cyst 12, pelvic mass seven, appendicitis two, and abdominal pain two (Table II). Only 19 of the 38 diagnoses (50 per cent) were correct. Fetal outcome after surgery in patients with benign cysts in pregnancy was poor. There were 10 abortions in the 38 cases (26 per cent). Endometriomas. In our series, four patients with endometriomas in pregnancy were found (7 per cent) ; nonr had bilateral disease. The average size of the four endonletriomas was 9.8 cm. (range 8 to 10 cm.). All four patients had an asymptomatic pelvic mass. All four patients were observed for 2 to 6 weeks before surgery to detect any change in tumor size. Average gestation at surgery was 16 weeks (range 8 to 20 weeks). The diagnosis was made correctly preoperatively in one of the four cases. Fetal outcome was excellent, with four normal deliveries occurring at term. Dermoid cysts. Seven of the 57 lesions (12.3 per cent) in our series were dermoid cysts. Five of the seven patients with dermoid lesions were asymptomatic. Consequently, pelvic examination was the primary means of diagnosis prior to the onset of symptoms of torsion or rupture. One patient complained of mild lower abdominal discomfort, and another had a ruptured dermoid with abdominal pain and rebound tenderness. The average size of the dermoid tumors in our series was 8.5 cm., with a range of 6 to 12 cm. Surgery was performed between the eighth and the thirty-sixth weeks of gestation, with a mean of 16 weeks. A preoperative diagnosis of ovarian dermoid was made in two of the seven cases; in both, roentgenograms
of
the
abdomen
revealed
“teeth”
in
the
re-
of the ovary. Four of the preoperative diagnoses were categorized as ovarian masses. The one patient with a ruptured dermoid had a preoperative diagnosis of acute appendicitis. In our series, fetal outcome after excision of an gion
ovarian
dermoid
included
four
normal
deliveries,
V”lum,~
122
Numbrr
5
one spontaneous abortion, one therapeutic abortion, and one delivery after premature labor at 36 weeks of gestation, following chemical peritonitis from the ruptured dermoid. Benign and malignant cystadenomas. In our series, there were one mutinous cystadenoma and four serous cystadenomas. Of the five patients, two had asymptomatic pelvic masses, whereas three had lower abdominal pain that ranged from mild to severe. The sizes of the tumors varied from 6 to 10 cm., with a mean of 8.4 cm. Preoperative diagnoses included one ectopic pregnancy, one twisted ovarian cyst, and three ovarian masses. Surgery consisted of one salpingooophorectomy (for the mutinous cystadenoma) and four ovarian cystectomies. In our series, three cystadenocarcinomas were found: two were mutinous and one was serous. The two patients with mutinous cystadenocarcinoma were 25 years old (gravida 2, para 1) and 32 years old (gravida 5, para 4)) respectively, and both presented with crampy abdominal pain of 2 tc 3 weeks’ duration. Both patients were at 16 weeks of gestation. On examination, a 10 cm. pelvic mass was found in one patient, and a 30 cm. abdominal mass was found in the other. Each patient, with a pathologic diagnosis of grade 1 intracystic papillary mutinous adenocarcinoma, underwent a temporizing oophorectomy, followed by the removal of the remaining pelvic organs after delivery. Both patients were alive and well in August, 1973 (11 and 14 years after operation). The only patient with a serous cystadenocarcinema was a 23-year-old white woman (gravida 1, para 0)) who was 8 weeks pregnant at her first prenatal visit. Although she was asymptomatic, an 8 cm. ovarian mass was palpated. At surgery, an intracystic serous papillary, grade 1 cystadenocarcinoma was found. For religious reasons, the patient had refused to have a therapeutic abortion should it be necessary. Consequently, a salpingo-oophorectomy was performed. She did well and was delivered of a normal child at term. She is still free of recurrence 15 years after surgery. Comment
Review of the literature reveals much variability in the reported incidence of ovarian disease during pregnancy. In 1954, Grimes and associates1 reported an incidence of one ovarian cyst for every 81 deliveries; however, 70 per cent of their patients had cysts of less than 5 cm. in diameter. Tawa,? in
Ovarian
Table III. pregnancy
surgery
Fetal outcome (Mayo Clinic,
after ovarian 1955 through Gestation
O-9 No. of cases Normal delivery Abortion Threatened O-7 days 7+ days Actual O-7 days 7+ days *Includes delivered at ?IncIudes mild vaginal $Includes one therapeutic BIncludes
in pregnancy
surgery 197 1)
in
(wk.)
1 lo-20
33 22
567
1 21-40
22 10
Total
2 2
57 42s
2 ‘I
2 ‘)
4 4
4 31
4t 45
8 7
eight patients with threatened abortions term. two patients: one with heavy and one bleeding before surgery. three patients: two with mild spotting abortion. two patients with mild spotting.
who with and
a review of the literature to 1964, found that the incidence of ovarian tumors in pregnancy ranged from 1 : 273 to 1 : 2,489, depending on the author and the institution. An important factor in determining incidence is the time at which the patient presents herself for prenatal care. Most authors’-” emphasized that the first prenatal examination is the optimal time to palpate an ovarian mass. After the third trimester, the ovaries are drawn up out of the pelvis with the enlarging uterus, making palpation more difficult. The incidence given for various ovarian pathologic entities in pregnancy likewise varies widely. This is in part due to the different sizes of the studies reported. Grimes and associates,l for example, reported an incidence of 2 per cent for endometriomas (one of 50 cases) in their study of ovarian cysts in pregnancy, whereas Sinnathuray+ in 1971 found an incidence of 10.5 per cent (two of 19 cases). As a further example, only 12.3 per cent of the ovarian masses in the present study of 57 cases were dermoids. In 1955, Peterson and associates,” however, stated that 22 to 40 per cent of ovarian tumors in pregnancy were dermoids. In our series, the incidence of spontaneous abortion was 24.5 per cent (14 of 57 cases, Table III). There was one therapeutic abortion. Eight patients threatened to abort after surgery (Table III). This was defined as vaginal spotting with or without lower abdominal cramping at any time after surgery. The onset of these symptoms after surgery has been divided into two time groups: before and after the seventh postoperative day.
5@
;Giii,
;ohnson,
and
Lee Am.
Table IV. Progestational agents used after ovarian surgery in pregnancy (Mayo Clinic, 1955 through 1971) ( z
1
;;ieltut’s
Agent Hydroxyprogesterone caproate
250 500 750 1,000 1 250 “1875 5,750 8,000
Medroxyprogesterone acetate Progesterone
7* 4t 2 1 1 1 1X 13
50 140
1 1
Total
!o
*Two patients also received progesterone, 100 mg. intramuscularly, on the first 2 postoperative days. tone patient also received progesterone, 100 mg. intramuscularly, on the first 6 postoperative days. jTota1 dosage received from surgery until delivery.
Table V. Use of morphine sulfate after ovarian surgery in pregnancy (Mayo Clinic, 1955 through 1971) Dosage 10 10 10 15
mg. every mg. every mg. every mg. every
4 6 4 4
No. of patients
(intramuscular) hours hours hours hours
for for for for
2 2 4 3
days days days days
-
7 2 1 1
Of the 15 patients who had actual abortions, seven had mild to heavy vaginal bleeding prior to surgery (see footnote, Table III). Because ectopic pregnancy was a primary preoperative diagnosis, this was not unexpected. Evans and Beischer” in 1970 found that 81 per cent of pregnant women with heavy vaginal bleeding who required hospitalization subsequently aborted, while 60 per cent of those with only mild bleeding aborted. If the seven patients who threatened to abort before the additional stress of surgery are excluded from our series, the percentage of spontaneous abortion is reduced from 26 to 16 per cent (eight of 51 patients). A search of the literature revealed wide variation in fetal loss after ovarian surgery in pregnancy. In 1954, Gustafson, Gardiner and Stout’ reported an over-all fetal loss of 18 per cent, whereas, in 1964, Tawa’ reported 9.7 per cent. Most authors observe their patients who have
July 1, 19% J. Ohstrt. Gynccol.
asymptomatic ovarian cysts of less than 5 or 6 cm. in diameter carefully until the sixteenth to eighteenth week of pregnancy. By that time, corpus luteal size and function will have diminished and the first trimester, in which most abortions occur, will have been passed.’ In the present investigation, only 23 of 57 patients had asymptomatic masses. The remaining 34 gravid females had symptoms of lower abdominal pain or vaginal spotting (or both) associated with an ovarian mass. Particularly when these symptoms and signs arise in combination, ectopic gestation must be strongly considered in the differential diagnosis, and one therefore does not have the luxury of waiting prior to abdominal exploration. Culdoscopy and, more recently, laparoscopy can afford direct visualization without initial laparotomy. In our series, culdotomy was the surgical procedure in eight of the 38 cases (2 1 per cent) of benign cysts. This permitted both diagnosis and treatment
without
celiotomy.
our series, postoperative prevention of abortion was attempted through the use of progestational or both. The selection of agents, heavy sedation, drug, the dosage, and the duration of treatment were more dependent on the preference of the obIn
stetrician
than
gesterone
caproate
nant
on
progestational
dosage
varied
operation
in
from seven
any
other
factor.
(Delalutin)
was
agent
(Table
used
Hydroxypro-
the
predomiIV).
250 mg. intramuscularly cases
to
a
total
of
The
before 8,000
mg.
divided over the remaining weeks of pregnancy in one case. Morphine sulfate was the only drug utilized for postoperative sedation (Table V). The dosage of morphine also varied widely. although all patients were on a given schedule for at least 2 days. Of our 57 patients with ovarian surgery during pregnancy, 20 received progestational compounds, 11 had heavy postoperative sedation, and 26 received no specific treatment directed at inhibiting uterine contractility. Consequently, 31 patients were actively treated and 26 were not. Gestational age at the time of surgery was comparable in the treated ( 10.4 weeks) and the untreated group (10 vveeks) There was no difference in the abortion rate between these two groups. The type of anesthetic used in the 57 cases in our series depended on the preference of the anesthesiologist. Kegional anesthesia was not used for any of the patients. Of the 57 patients, 22 received halothane, 18 a nitrous oxide-ether combination, and
eight
nine
primarily
patients,
nitrous
four
oxide.
received
Of
the
remaining
methoxyflurane
and
Volume. 122 Number 5
four had fentanyl. No anesthetic agent was associated with a higher rate of abortion than another. Conclusions
A review of 17 years of experience (57 cases) in ovarian surgery during pregnancy at the Mayo Clinic revealed the following. 1. One ovarian surgical procedure was performed for every 536 deliveries in Rochester, Minnesota. 2. Most procedures involved simple ovarian cysts (38 of the 57 cases) ; these included corpus luteal, follicular, and parovarian cysts.
REFERENCES
1.
2. 3. 4.
Grimes, W. H., Jr., Bartholomew, R. A., C&in, E. D., Fish, J. S., and Lester, W. M.: AM. J. OBSTET. GYNECOL. 68: 594, 19%. Tawa, K.: AM. J. OBSTET. GYNECOL. 90: 511, 1964. Wilson, R. B., and Mussey, R. D.: Surg. Clin. North Am. 1949, p. 1119. Sinnathuray, T. A.: Int. Surg. 55: 422, 1971.
Ovarian
surgery
in pregnancy
569
3. Lower abdominal pain and tumor size greater than 6 cm. were the primary indications for surgery. 4. Examination of fetal outcome revealed eight abortions in 51 cases (16 per cent fetal loss) in which vaginal spotting prior to surgery had not occurred. 5. Active treatment with progestational agents before and after operation did not affect the abortion rate.
5.
6. 7. 8.
Peterson, W. F., Prevost, E. C., Edmunds, F. T., Hundley, J. M., and Morris, F. K.: AM. J. OBSTET. GYNECOL. 70: 368, 1955. Evans, J. H., and Beischer, N. A.: Med. J. Aust. 2: 165, 1970. Gustafson, G. W., Gardiner, S. H., and Stout, F. E.: AM. J. OBSTET. GYNECOL. 67: 1210, 1954. Munnell, E. W.: Clin. Obstet. Gynecol. 6: 983, 1963.