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Ovarian tumors complicating pregnancy
Int. J. Gymecol. Obstet., 1983, 21: 219-282 International Federation of Gynaecology & Obstetrics
OVARIAN
ADNAN
HASANa,
‘Department (Received (Accepted
TUMORS COMPLICATING
SAMIR AMRb, ABDULLA
of Obstetrics and Gvnecologjj
PREGNANCY
ISSAa and MAJED BATAa
and bDepartment
of Pathology,
liniversit,v of Jordan,
Amman.
Jordan
July 12th, 1982) August lOth, 1982)
Abstract
Materials and methods
Hasan A, Amr S, Issa A, Bata M (Dept of Obstetrics and Gynecology and Dept of Pathology, University of Jordan, Amman, Jordan). Ovarian tumors complicating pregnancy. Int J Gynaecol Obstet 21 279-282, 1983 Between the years I9 77 and 1981, 9037 patients gave birth at Jordan University Hospital (JUH). Among these ten patients were found to have an associated ovarian tumor, an incidence of one in 900 deliveries. Benign cystic teratomas were the most common ovarian tumors found, followed by mutinous cystadenomas. All of the tumors were benign except one case of Burkitt’s lymphoma.
The records of all the patients with ovarian tumors managed at JUH during the 5-year period (1977- 198 1) were reviewed. Functional non-neoplastic cysts were excluded from this study. The records of the Department of Obstetrics and Gynecology showed that 9037 deliveries took place during the same period of time. Review of the patient records included age, parity, time of tumor detection, clinical presentation, treatment, pregnancy outcome and pathologic findings.
Key words: Ovarian tumors; Benign cystic teratomas; Mutinous cystadenomas; Analysis clinical experience; Comparison of findings; Functional non-neoplastic cysts excluded Introduction There is a wide variation in the incidence and pathologic characteristics of ovarian tumors complicating pregnancy throughout the world. This study was undertaken at JUH to analyze our clinical experience with this complication. Details related to clinical presentation, treatment, pregnancy outcome and pathologic findings are presented. Comparison of our findings with those from other parts of the world is discussed. 0020-7292/83/$03.00 0 1983 International Federation Printed and Published in Ireland
Results A summary of the data is presented in Table I. The age distribution was between 16 and 33 years, with a mean age of 24. All of the patients except one were multiparous. Four tumors were detected during pregnancy, during labor in two cases, and four tumors were found in the immediate postpartum period. All the tumors were benign except one, an unusual case of Burkitt’s lymphoma. There was no fetal death in utero but one abortion occurred. One patient died 5 months later from acute lymphoblastic leukemia. Discussion The incidence of ovarian tumors associated with pregnancy in this study is one in 900 deliveries. Reported incidences from other Int J Gynaecol
of Gynaecology
& Obstetrics
Obstet 21
280
Hasan et al.
Table I.
Summary of clinicopathologic
Case No.
Age
Gravida
Time of tumor detection
Clinical presentation
Treatment
Pregnancy outcome
Pathology report
1.
25
8
1st trimester
Acute abdomen
Aborted
2.
21
I
1st trimester
Acute abdomen
3.
20
3
2nd trimester
Acute abdomen
4.
24
4
2nd trimester
Benign cystic teratona Serous cystadenoma Benign cystic teratoma Papillary serous cystadenoma
5.
25
4
During labor
6.
22
2
During labor
Pelvic mass on routine examination Obstructed labor Incidental finding
Ovarian cystectomy Ovarian cystectomy Ovarian cystectomy Salpingooopherectomy Ovarian cystectomy Ovarian cystectomy
I.
22
5
Puerperium
Abdominal mass
8.
22
5
Puerperium
Abdominal mass
Cesarean section Cesarean section for placenta previa Normal delivery Normal delivery
Mutinous cystadenoma Burkitt’s lymphoma
9.
33
5
Puerperium
Abdominal mass
10.
16
1
Puerperium
Abdominal mass
Normal delivery Normal delivery
Mutinous cystadenoma (infected) Mutinous cystadenoma
aAcute lymphoblastic
data.
Benign cystic teratoma Benign cystic teratoma
leukemia was also found.
studies varied from as high as one in 273 deliveries [5] to as low as one in 6226 [ 1 l] (Table II). Benign cystic teratomas are the most common ovarian tumors found, followed by the cystadenomas [ 3,ll I. This is conTable II.
Salpingooopherectomy Salpingooopherectomy & resection of terminal ileum Salpingooopherectomy Salpingooopherectomy and liver biopsy
Normal delivery Normal delivery Normal delivery
sistent with the relative frequency of these types of tumors in the childbearing age and is not restricted to pregnancy. In the series reported by Buttery [3] from Australia, there were 45 dermoid cysts and 38 mutinous cystadenomas out of 164 tumors.
Incidence of ovarian tumors in pregnancy.
No.
Author
Country
No. of deliveries
Year
No. of ovarian tumors
Incidence
1. 2. 3. 4. 5. 6. 7. 8.
Sinnathuray Buttery Tawa Chung Booth Karpathios Grimes Present study
Malaysia Australia California (USA) New York (USA) London (UK) Greece Georgia (USA) Jordan
118,303 153,832 50,495 160,889 29,597 5,616 15,000 9,037
1964-66 1947-69 1953-62 1951-62 1950-59 1969-75 1918-53 1975-81
19 164 62 199 50 16 55 10
1:6226 1:938 1:815 1:800 1:519 1:351 1:273 1:900
Int J Gynaecol
Obstet 21
Ovarian tumors complicating pregnancy
It is of interest to find a case of Burkitt’s lymphoma in this series. Burkitt’s lymphoma was initially described as a sarcoma of the jaw occurring in East African children [2] . Although it is primarily a disease of children, Burkitt’s lymphoma occurs in women of areas, childbearing age. In non-endemic this disease most frequently presents as abdominal or pelvic masses [7 I . Our patient received chemotherapy and she is still alive and well. Diagnosis is generally facilitated if pelvic examination is done in the first trimester, at which time, the tumor is still in the pelvis and easily palpated [ 3,5 ] . Following delivery and involution of the uterus, the tumor becomes increasingly palpable. Ultrasound is helpful to outline the mass separate from the uterus and a roentgenogram is indicated in cases of obstructed labor to confirm any displacement of the presenting part and that in case of dermoid cyst will show an area of increased radio-translucency [ lo] (Fig. 1). The most common ovarian enlargement palpable in early pregnancy is the corpus luteum cyst, which usually disappears by the sixteenth week of gestation [6]. Operation during the first trimester has been found to be associated with high incidence of abortion [3] , but surgery is indicated if there is an acute abdominal condition or if malignancy is suspected. The second trimester is the ideal time to remove an ovarian tumor because the placenta has developed sufficient production of progesterone to maintain the pregnancy and the size of the uterus does not require undue manipulation [ 3,111 . In the series reported by Buttery [3], nine abortions occurred in the 26 patients who underwent first trimester surgery; however, second-trimester abortion occurred in only one of the 48 patients who underwent surgery. In our study, abortion occurred in one of the two patients who had surgery in the first 12 weeks of gestation. The problem of whether the patient should be allowed to deliver vaginally when the tumor
Fig. 1. Lateral radiotranslucent
pelvic roentgenogram showing tumor with focal calcification.
281
fetal head and
is diagnosed in the third trimester is controversial. If the tumor is found early in the third trimester, surgery should be done and the pregnancy allowed to continue, but if it is found near term or during labor, the uterus should be emptied by cesarean section and the tumor removed [9,10]. When the tumor is diagnosed during the puerperium, surgery should be done as early as possible. References 1 Booth RT: Ovarian tumors and pregnancy. Am J Obstet Gynecol91: 189,1963. 2 Burkitt DP: A sarcoma involving the jaws in African children. Br J Surg 46; 218, 1958.
Int J G.ynaecol Ohstet 21
282
Hasan et al.
3 Buttery BW, Be&her NA, Fortune DW and Macafee CAJ: Ovarian tumors in pregnancy. Med J Aust 1: 345, 1973. 4 Chung A, Birnbaum SJ: Ovarian cancer associated with pregnancy. Obstet Gynecol41: 211, 1973. 5 Grimes WH, Bartholomew RA, Colvin ED et al: Ovarian cyst complicating pregnancy. Am J Obstet Gynecol 68: 594,1954. 6 Hill LM, Johnson CE, Lee RA: Ovarian surgery in pregnancy. Am J Obstet Gynecol12.2: 565, 1974. 7 Jones DE, d’Avignon MB, Lawrence R, Latchaw RF: Burkitt’s lymphoma: obstetric and gynecologic aspects. Obstet Gynecol56: 533, 1980. 8 Karpathios S, Lolis D, Tzigounis B, Kaskarelia D: Ovarian neoplasms and pregnancy. lnt Surg 62: 80, 1977. 9 Marshal C: MCL, Ovariotomy or caesarean section? (Letter). Br Med J I: 421, 1945.
Int J Gynaecol Obstet 21
10 Moir JC, Myerscough PR: Tumors and extragenital infections complicating pregnancy, labour and puerpirum. In Operative Obstetrics (ed M Kerr), p 398. Williams and Wilkins Company, Baltimore, 197 1. 11 Sinnathuray TA: Ovarian tumors in pregnancy: a clinicopathological study of 19 surgically proven cases in a South East Asia Hospital. Int Surg 55: 422, 1971. 12 Tawa K: Ovarian tumors in pregnancy. Am J Obstet Gynecol90: 511, 1964.
Address for reprints: Adnan A. Hasan Jordan University Hospital Amman, Jordan
OVARIAN
ADNAN
HASANa,
‘Department (Received (Accepted
TUMORS COMPLICATING
SAMIR AMRb, ABDULLA
of Obstetrics and Gvnecologjj
PREGNANCY
ISSAa and MAJED BATAa
and bDepartment
of Pathology,
liniversit,v of Jordan,
Amman.
Jordan
July 12th, 1982) August lOth, 1982)
Abstract
Materials and methods
Hasan A, Amr S, Issa A, Bata M (Dept of Obstetrics and Gynecology and Dept of Pathology, University of Jordan, Amman, Jordan). Ovarian tumors complicating pregnancy. Int J Gynaecol Obstet 21 279-282, 1983 Between the years I9 77 and 1981, 9037 patients gave birth at Jordan University Hospital (JUH). Among these ten patients were found to have an associated ovarian tumor, an incidence of one in 900 deliveries. Benign cystic teratomas were the most common ovarian tumors found, followed by mutinous cystadenomas. All of the tumors were benign except one case of Burkitt’s lymphoma.
The records of all the patients with ovarian tumors managed at JUH during the 5-year period (1977- 198 1) were reviewed. Functional non-neoplastic cysts were excluded from this study. The records of the Department of Obstetrics and Gynecology showed that 9037 deliveries took place during the same period of time. Review of the patient records included age, parity, time of tumor detection, clinical presentation, treatment, pregnancy outcome and pathologic findings.
Key words: Ovarian tumors; Benign cystic teratomas; Mutinous cystadenomas; Analysis clinical experience; Comparison of findings; Functional non-neoplastic cysts excluded Introduction There is a wide variation in the incidence and pathologic characteristics of ovarian tumors complicating pregnancy throughout the world. This study was undertaken at JUH to analyze our clinical experience with this complication. Details related to clinical presentation, treatment, pregnancy outcome and pathologic findings are presented. Comparison of our findings with those from other parts of the world is discussed. 0020-7292/83/$03.00 0 1983 International Federation Printed and Published in Ireland
Results A summary of the data is presented in Table I. The age distribution was between 16 and 33 years, with a mean age of 24. All of the patients except one were multiparous. Four tumors were detected during pregnancy, during labor in two cases, and four tumors were found in the immediate postpartum period. All the tumors were benign except one, an unusual case of Burkitt’s lymphoma. There was no fetal death in utero but one abortion occurred. One patient died 5 months later from acute lymphoblastic leukemia. Discussion The incidence of ovarian tumors associated with pregnancy in this study is one in 900 deliveries. Reported incidences from other Int J Gynaecol
of Gynaecology
& Obstetrics
Obstet 21
280
Hasan et al.
Table I.
Summary of clinicopathologic
Case No.
Age
Gravida
Time of tumor detection
Clinical presentation
Treatment
Pregnancy outcome
Pathology report
1.
25
8
1st trimester
Acute abdomen
Aborted
2.
21
I
1st trimester
Acute abdomen
3.
20
3
2nd trimester
Acute abdomen
4.
24
4
2nd trimester
Benign cystic teratona Serous cystadenoma Benign cystic teratoma Papillary serous cystadenoma
5.
25
4
During labor
6.
22
2
During labor
Pelvic mass on routine examination Obstructed labor Incidental finding
Ovarian cystectomy Ovarian cystectomy Ovarian cystectomy Salpingooopherectomy Ovarian cystectomy Ovarian cystectomy
I.
22
5
Puerperium
Abdominal mass
8.
22
5
Puerperium
Abdominal mass
Cesarean section Cesarean section for placenta previa Normal delivery Normal delivery
Mutinous cystadenoma Burkitt’s lymphoma
9.
33
5
Puerperium
Abdominal mass
10.
16
1
Puerperium
Abdominal mass
Normal delivery Normal delivery
Mutinous cystadenoma (infected) Mutinous cystadenoma
aAcute lymphoblastic
data.
Benign cystic teratoma Benign cystic teratoma
leukemia was also found.
studies varied from as high as one in 273 deliveries [5] to as low as one in 6226 [ 1 l] (Table II). Benign cystic teratomas are the most common ovarian tumors found, followed by the cystadenomas [ 3,ll I. This is conTable II.
Salpingooopherectomy Salpingooopherectomy & resection of terminal ileum Salpingooopherectomy Salpingooopherectomy and liver biopsy
Normal delivery Normal delivery Normal delivery
sistent with the relative frequency of these types of tumors in the childbearing age and is not restricted to pregnancy. In the series reported by Buttery [3] from Australia, there were 45 dermoid cysts and 38 mutinous cystadenomas out of 164 tumors.
Incidence of ovarian tumors in pregnancy.
No.
Author
Country
No. of deliveries
Year
No. of ovarian tumors
Incidence
1. 2. 3. 4. 5. 6. 7. 8.
Sinnathuray Buttery Tawa Chung Booth Karpathios Grimes Present study
Malaysia Australia California (USA) New York (USA) London (UK) Greece Georgia (USA) Jordan
118,303 153,832 50,495 160,889 29,597 5,616 15,000 9,037
1964-66 1947-69 1953-62 1951-62 1950-59 1969-75 1918-53 1975-81
19 164 62 199 50 16 55 10
1:6226 1:938 1:815 1:800 1:519 1:351 1:273 1:900
Int J Gynaecol
Obstet 21
Ovarian tumors complicating pregnancy
It is of interest to find a case of Burkitt’s lymphoma in this series. Burkitt’s lymphoma was initially described as a sarcoma of the jaw occurring in East African children [2] . Although it is primarily a disease of children, Burkitt’s lymphoma occurs in women of areas, childbearing age. In non-endemic this disease most frequently presents as abdominal or pelvic masses [7 I . Our patient received chemotherapy and she is still alive and well. Diagnosis is generally facilitated if pelvic examination is done in the first trimester, at which time, the tumor is still in the pelvis and easily palpated [ 3,5 ] . Following delivery and involution of the uterus, the tumor becomes increasingly palpable. Ultrasound is helpful to outline the mass separate from the uterus and a roentgenogram is indicated in cases of obstructed labor to confirm any displacement of the presenting part and that in case of dermoid cyst will show an area of increased radio-translucency [ lo] (Fig. 1). The most common ovarian enlargement palpable in early pregnancy is the corpus luteum cyst, which usually disappears by the sixteenth week of gestation [6]. Operation during the first trimester has been found to be associated with high incidence of abortion [3] , but surgery is indicated if there is an acute abdominal condition or if malignancy is suspected. The second trimester is the ideal time to remove an ovarian tumor because the placenta has developed sufficient production of progesterone to maintain the pregnancy and the size of the uterus does not require undue manipulation [ 3,111 . In the series reported by Buttery [3], nine abortions occurred in the 26 patients who underwent first trimester surgery; however, second-trimester abortion occurred in only one of the 48 patients who underwent surgery. In our study, abortion occurred in one of the two patients who had surgery in the first 12 weeks of gestation. The problem of whether the patient should be allowed to deliver vaginally when the tumor
Fig. 1. Lateral radiotranslucent
pelvic roentgenogram showing tumor with focal calcification.
281
fetal head and
is diagnosed in the third trimester is controversial. If the tumor is found early in the third trimester, surgery should be done and the pregnancy allowed to continue, but if it is found near term or during labor, the uterus should be emptied by cesarean section and the tumor removed [9,10]. When the tumor is diagnosed during the puerperium, surgery should be done as early as possible. References 1 Booth RT: Ovarian tumors and pregnancy. Am J Obstet Gynecol91: 189,1963. 2 Burkitt DP: A sarcoma involving the jaws in African children. Br J Surg 46; 218, 1958.
Int J G.ynaecol Ohstet 21
282
Hasan et al.
3 Buttery BW, Be&her NA, Fortune DW and Macafee CAJ: Ovarian tumors in pregnancy. Med J Aust 1: 345, 1973. 4 Chung A, Birnbaum SJ: Ovarian cancer associated with pregnancy. Obstet Gynecol41: 211, 1973. 5 Grimes WH, Bartholomew RA, Colvin ED et al: Ovarian cyst complicating pregnancy. Am J Obstet Gynecol 68: 594,1954. 6 Hill LM, Johnson CE, Lee RA: Ovarian surgery in pregnancy. Am J Obstet Gynecol12.2: 565, 1974. 7 Jones DE, d’Avignon MB, Lawrence R, Latchaw RF: Burkitt’s lymphoma: obstetric and gynecologic aspects. Obstet Gynecol56: 533, 1980. 8 Karpathios S, Lolis D, Tzigounis B, Kaskarelia D: Ovarian neoplasms and pregnancy. lnt Surg 62: 80, 1977. 9 Marshal C: MCL, Ovariotomy or caesarean section? (Letter). Br Med J I: 421, 1945.
Int J Gynaecol Obstet 21
10 Moir JC, Myerscough PR: Tumors and extragenital infections complicating pregnancy, labour and puerpirum. In Operative Obstetrics (ed M Kerr), p 398. Williams and Wilkins Company, Baltimore, 197 1. 11 Sinnathuray TA: Ovarian tumors in pregnancy: a clinicopathological study of 19 surgically proven cases in a South East Asia Hospital. Int Surg 55: 422, 1971. 12 Tawa K: Ovarian tumors in pregnancy. Am J Obstet Gynecol90: 511, 1964.
Address for reprints: Adnan A. Hasan Jordan University Hospital Amman, Jordan