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Pregnancy and adnexal cysts
R. L. HAAS, M.D., ANN ARBOR, MICH. (From
the Department
of Obstetrics
and Gynecology,
University
Hospital)
N THE course of an obstetric practice one not infrequently encounters the problem of pregnancy and a coexisting adnexal cyst. The exact frequency of this combination is difficult to determine, since reports in the literature reveal variable flndings (Table I). This report is based upon 25 pregnancies with associated parametrial cysts (24 were ovarian, and one was parovarian). They occurred in 23 patients over a thirteen-year-period including 7,598 pregnancies. Therefore, our incidence is one adnexal cyst in 304 pregnancies, or, if we omit the one parovarian cyst, we have an incidence of true ovarian cysts of one in 316 pregnancies. I
TABLE I.
INCIDENCE OF OVARIAN CYSTS IN PREGNANCY INCIDENCE
AUTHOR
Litzenberg Mathieu and Holman Priest Falk & Bunkin (Average of reports
1: 1: 1: 1:
in literature)
1,500 102 1,085 2,500
pregnancies pregnancies pregnancies pregnancies
HlGM
(All adnexal cysts) (Ovarian cysts)
1: 1:
304 pregnancies 316 pregnancies
It is notsurprising that there is considerable variation in the reported rate of occurrence of cysts during pregnancy, since this would depend not only upon the size of cysts included, but also upon the stage of pregnancy at the time of first examination. Realizing the difficulties of precise estimation of the size of pelvic structures, we have decided upon a lower limit of about 5 cm. We recognize that cystic enlargements of the ovary of less than 5 cm. occur not infrequently, but these are often difficult to distinguish from the normal ovarian variations, and therefore they are not included. The duration of gestation at the time of initial examination influences the number of cysts reported because in early pregnancy functional cysts are more common. On the other hand, many cysts disappear spontaneously in the latter half of pregnancy and so will not be detected by late examinations. As will be seen in Table II, nearly two-thirds (64 per cent) of these cysts were discovered during the first trimester and approximately one quarter (23 per cent) during the second. The fact that most patients are first examined before the end of the third month undoubtedly is a large factor in the high One cyst was discovered during incidence noteda during the first trimester. labor, and one at the time of discharge examination 12 days post partum. and
*Presented Gynecologists,
at
the Sixteenth Denver, Colorado,
Annual Sept.
Meeting of the 23 to 25, 1948.
283
Central
Association
of
Obstetricians
-
..__
--___----._
-
._I_-~..^-._30.
.__ ..-_~-_ ot
i'P:li(
~I'~N'l'A(~
I',
srri\rli 1 , First
tlinlt?st~r-------‘---~
Aecond Third
trimester
LabOr Post
shown
trimester
?,artuJ!l
After microscopic in Table III.
examination
these cysts were
fonnd to bc dist,ributed
as
-.__GKOU~
Functional Neoplaatic Endometrial Parovarian Simple cysts Unknown (Not operated Total
Both neoplastic
____-._
upon
)
NI‘MBER
OF CYSTS
5, IO 2 I 1 $4
---.--..-.-
--__-.
___--
of the functional cysts were cysts are listed in Table IV.
Monolocular serous cystadenomxs Multilocular pseudomucinous cystadenoma Combined dermoid and multilocular r’?etJtlonluc,inou. Complex teratoma Dermoid tumors Papilliferous C~Stad~nOnlit with early carcinomatow
-_22
--
of t,he corpus
lnteum
-_-----.-_
type.
The ten
3 1 cptatlcnorwl
I
I 3 change
--
1 _I--I II
The exact nature of the cyst was unknown in nine pregnancies since thase were not removed and studied. In one pregnancy the cyst was 5 cm. in diameter when discovered, and remained unchanged and asymptomatic through a normal breech delivery. The patient was not examined again until the fourth month of her second pregnancy, two years later, when she had an 8 cm. cyst of the same ovary. When removed this revealed early careinomatous change in a papilliferous cystadenoma. Another cyst occurred in conjunction with a hydatid mole, and regressed after curettage. Still another was discovered dul’ing labor and was displaced out. of the pelvis allowing delivery to occur. This cyst was still present six weeks post partum, and until the sixth month of the It could not be identified by second pregnancy which followed prompt,ly. The remaining five careful examination immediately aft.er t.he last delivery. cysts likewise disappeared spontaneously in the fifth and sixth months. $ince seven of t,hese nine cysts disappeared spontaneously, they must be assumed to have been of the functional type. Adding these to the two known functional cysts it is apparent, t,hat nine (36 per cent ) of the total series of 25 were functional. Fifteen of the cyst,s in this series involved the right ovary, while nine arose on the left side, In one case it was not possible to determine th(l origin.
PREGNANCY
AND
ADNEXAL
CYSTS
2x5
Symptoms referable to the cyst were few, and usually of vague nature ((Table V). Thirteen of the patients with adnexal cysts had no important complaints. Of the twelve patients who did present symptoms, ten had discomfort of some kind. This was not well localized, and in no case was it Two patients had sypmptoms severe enough to inconvenience the patient. suggesting torsion of the cyst, and one, with a cul-de-sac cyst complained c)f dyspareunia. It is apparent that adnesal cysts seldom product symptoms until they become large. TABLE
V.
SYMPTOMS
REFERABLE
TO CYST
SYMPTOM None Discomfort Symptoms Dyspareunia
suggesting
NO. OF PREGNAKCIES 13 10 2 7
torsion
-- -
Among the 25 pregnancies making up this series, there were no spontaneous abortions, and only three patients had bleeding or cramps suggesting a threatened abortion (Table VI). This makes the threatened abortion rate 12 per cent-not much different, than would be found among pregnancies in general. It appears, therefore, that the presence of a cyst during pregnancy does not materially increase the risk of abortion. TABLE
VI.
ABORTIOK
IK PATIENTS
NO.OF
TYPE
None Threatened Actual
WITH
ADNEXAL
PREGNANCIES 2" 5 0 25
CYSTS PERCENTAGEOFTOTAL 88 12 0 100
One of the chief problems in connection with the management of adnexal cysts encountered during pregnancy is that of abortions produced by ovariotomy. Consequently, various medications have been recommended with the hope of preventing loss of the pregnancy. In general, these agents have fallen into one of two classes, sedatives and hormones. The sedatives may be either narcotics or smoooth muscle relaxers, such as Pavatrine. The hormone is usually some corpus luteum preparation, although recently stilbestrol has also been advocated. We have not been impressed with the value of any of these preparations in preventing spontaneous abortions, although there might be some logic in their use when the corpus luteum serum is removed or when the uterus must be manipulated unduly. As shown in Table VII, ten patients in this series were given no antiabortion therapy postoperatively, three patients received a corpus luteum preparation, and one received both corpus luteum and sedation. Eleven other patient,s either had no operation, or their cysts were removed after delivery. Table VIII shows that only two of the fourteen patients operated upon during pregnancy did actually abort. Both were operated upon during the first trimester, and the corpus luteum verum was present in both cyst walls. It would seem that the error in these cases was in the early operation rather than in the amount or type of medicine given. TABLE
VII.
POSTOPERATIVE
None Corpus luteum Sedation and corpus luteum No operation or operation post
partum
ANTIABORTION
THERAPY 10 3 1 11 25
It was noted earlier that in one patient cysts of the same ovary existed in two successive pregnancies two years apart. When removed during the second gestation the cyst was found to contain early carcinomatons change in a papilliferous cyst.adenoma. If the caysts in t.hese two pregnancies were actually but one persistent cyst, as seems likely, the question arises as to how TeLinde and Calvin,” long the carcinomatous change may have been present. Stevenson and Scipiades,’ and Pund? Kettles, Caldwell, and Vieburgs’ have all reported evidence to show that in cervical malignancy the neoplasm ma> remain in t.he early (intracpithelial) stage for several years. rt woL~ld not be unreasonable to assume that the same latency may occur in ~Jv~u-iaIl malignancy, thus emphasizing t,he possible risk of being 100 conservative when dealing with persistent ovarian cysts. There were nine cysts whose contents have long and generally been These include one cyst with considered as irritat.ing to the perjtoneurn. papilliferous cystadenocarcinolua, three dermoid tumors, one cornbined
during gestation, labor, or the puerperium with very few exceptions ‘call for surgical interference at once. ” A similar view was expressed by Capone. On the basis of our small experience reported here we are not impressed that the complications mentioned are of frequent occurrence, nor are we convinced that immediate surgical interference is frequently required. Instead, we prefer a policy of close observation, commonly deferring decision as to whether and when to operate in any individual case until time has permitted a fairer evaluation of the cyst and its probable nature and significance. This applies chiefly to the small cysts seen early in gestation. Of course, the larger ones are seldom physiologic, and their significance is more readily apparent. While it is neither advisable nor possible to lay down any hard and fast rules for the management of these cysts in pregnancy, we believe the following policies to be useful and logical. a. &null Cysts Discovered During the First Trimester.Unless such a cyst is causing symptoms requiring its immediate removal, we prefer to wait until the middle of the second trimester before making final decision regarding its removal. This policy allows time for the functional cyst to regress spontaneously, and also for corpus luteum function to be taken over by the placenta, thus minimizing the risk of removing a corpus luteum verum. Furthermore, as the uterus enlarges, the cyst may be drawn up out of the pelvis where it can no longer serve as an obstruction. It may then be possible to wait for final evaluation until after delivery, or if removal is still indicated, the operation will usually be easier and less traumatic because the cyst no longer lies deep in the pelvis. X-ray study of the pelvis may be of value in indicating certain dermoid tumors which contain calcium deposits, although, of course, the absence of calcification does not rule out a dermoid. The decision as to whether operation is necessary or not depends further upon due consideration of the data here reported which show that 36 per cent of these cysts were functional while about the same number (40 per cent) were neoplastic. Unfortunately, it was not possible to establish any dividing line between these two groups on the basis of size of cyst or age of patient. However, by the middle of the second trimester most of the func.tional cysts will have disappeared. Tkerefore, the majority of those persisting to or after this period of pregnancy are probably neoplastic, and removal is indicated. b. Cysts Discovered
During
the Second Trimester.-
What has just been said with regard to cysts discovered in early pregnancy and persisting through the middle of the second trimester applies equally well to those which are first recognized in mid-pregnancy. These are in all probability neoplastic, since most of the functional cysts would have disappeared and with few exceptions their removal is in order unless they are small. c. Cysts Discovered
During
the Last Trimester.-
Interference with wound healing due to overstretching of the abdominal wall, together with the proximity of labor may alter the situation somewhat when a cyst is first diagnosed late in pregnancy. Discretion must be used, and in general operation may wisely be deferred a few weeks until after delivery.
an abortion. 8. Operations carried out in the st~~otlcl risk of abortion. 9. A plan for the management 011 cysts presented.
1. 2. 3. 4. 5. 6. i. 8.
References
Litzenberg, ,J. C.: Am .1. Surg. 3: 5OB-51 I, 1927. Mathieu, A., and Holmn, All,ert: Sorthwehl Med. 30: r,?!). JJwr~nliw~. 19:I I. Priest, Fred: AM. .r. 013s~. & (+YNF:C. 31: XiR-888, May, 194fi. Falk, H., and Bunkin, 1.: AM. J. c)BST. K: GVSW. 54: S?-X7, .III~,I. I!UT. Capone, A. ;r.: Bm. .J. Hurg. 61: 387-393, .lHJ:% SM. J. 0~s~. KS GYNFX:. 48: 774~794, 194-L. TeLinde, R. W., and Galvin, G.: Rurg., Gp!C. & mst. 66: 822-X:35, 1938. 8tevenson, C. S., and Rcipiades, E.: Pund, E. R., N.ettles, .T. B., Caldwell, J. D., anti Xieburgs, H. I,:.: Ax. .I. O~wr, 55: 831-837, 1948.
# ~YNEI!.
Volume 58 Number 2
PREGNANCY
AND
ADNEXAL
289
CYSTS
Discussion DR.
EMMETT A. MECHLER, Denver, Cola.-The dangers of spontaneous abortion, sterility, and premature labor as a complication of adnexal or ovarian tumors have been In the light of this variously stated by Williams, Stander, Remy, McKarron, and others. series of. cases, however, it would seem that adnexal tumors have little or no effect upon the Stander has mentioned that any ovarian tumor of 4 cm. or less in size should pregnancy. be treated conservatively and that only if the tumor enlarges during pregnancy should surgical removal be considered. Recently Falk and Bunkin, and Miller and Wilson have stated that 95 per cent of all ovarian cysts which are 5 cm. or less in diameter are functional cysts and that “these cysts are no longer looked upon as part of t.he complex group of ovarian nenplasmn, but simply as enlargements t.lmt come about as a result of altered physiological beand they emphasize that the cyst be followed and that surgical treathavior of the ovary”; ment be instituted only if the cyst changes in size or becomes symptomatic. The high irmidence of adnexal cysts described by Dr. Haas is due ful and accurate examination of patient s during the first trimester of evidence of good prenatal care. There is no doubt that many patients of a pregnancy and delivery with undiagnosed adnexal tumors and wit,hout Many of the published reports deal only with cases in which plications. operation and do not take into account the question of functional cysts.
no doubt to the carepregnancy and is an this kind go through symptoms or comtumors are found at
In a series of 8,000 deliveries over a period of fifteen years at the Colorado Medical Center, we were able to find seven patients who had been operated upon for adnexal cysts Of these seven cases, three were simple complicating pregnancy; an incidence of 1 to 1,100. cysts, three were pseudomucinous c.ystadcnomas and one 1~s a dermoid cyst. Three of the patients were operated upon during the first trimester of pregnancy with no ill effect upon the course of the pregnancy. Only one patient in the series had mild symptoms referable to the tumor. I mention these statistics, not because they offer much in the way of clarifying this problem but because, like so many of the published reports, they refer only to cases seen at operation and do not reflect the true incidence of these tumors as reported here today. Further studies of the nature made by Dr. Haas in this paper are needed to help us in a It is probable that the true incibetter understanding of many features of this problem. dence of ovarian tumors complicating pregnancy is the same as in the nonpregnant patient of the same age group. Pregnancy has less effect upon the clinical course of ovarian tumors than in the case of uterine fibroids. In my private practice and clinical experience, I have been unable to confirm the of such a high incidence of functional cysts, and it seems that this matter should have discussion. It is pointedly stated by DeLee, Stander, Heil, Williams, Irving, and that an ovarian tumor when discovered during pregnancy should be removed as possible. We have taken the attitude that, any ovarian tumor complicating pregnancy be removed or explored, but that operation should be postponed until the fourth month of pregnancy to minimize the danger of miscarriage. Penduculated uterine fibroids manifestations, making a differential sorting to exploration.
often simulate ovarian tumors in location diagnosis difficult or sometimes impossible
finding further others soon as should or fifth
and clinical without re-
Although, as has been frequent,ly stated, the most common symptoms associated with adnexal tumors are those resulting from torsion, hemorrhage, or suppuration, the real danger to the patient lies in the possibility of the tumor’s being malignant or premalignant, or that the cyst contents might be irritating to the peritoneum in t.he event of a rupture or leak which would result in a serious peritonitis. It is impossible many times except in the cltse of some dermoid cysts which might contain rddiopaque material, to differentiate these from functional cysts other than by surgical exploration and biopsy. canal delivery
It is a rare clinical and during labor; is an unsatisfactory
experience to encounter an ovarian cyst which obstructs the birth it should be emphasized that reposition of the cyst to facilitate and possible dangerous procedure. Puncture with drainage of
290
Ii A AS
such a cyst through the cul-de-sac is, as !Villiams has said, ’ ‘2 tlnllgerous :rud reprehcrlsibtc procedure. ” Cesarran se&on mtl concoruitnut. remowl 0f t hf b i’yst. is the safer f,roae4rtrt~. The general note of conservatism a.11~1 individnalientioll of the patient. with nduess I cysts complicating pregnancy, together wit11 tli~ plan of management of rhese patients in the various stages of pregnancy, as stated in this paper, should 11t1 :L v:~I~~ablr aill in 031r twc-hing and should inspire further investigation of this Itinrl. DE. HAAS (Closing).-There is very little I wish to agltl except to say that thca pnrurrro peritoneum procedure was used at the University of Michigau many years ago and has been given up for various reasons. I do not see why pneumoperitoneography is a great advantage in this sort of case because these cysts arc usm~lly low in the pelvis where they are rradil! palpated without subjecting the patient to :I ~omrwhat corrlpliwi t~l ant1 rlni~llmfort able pncedure.
the Department
of Obstetrics
and Gynecology,
University
Hospital)
N THE course of an obstetric practice one not infrequently encounters the problem of pregnancy and a coexisting adnexal cyst. The exact frequency of this combination is difficult to determine, since reports in the literature reveal variable flndings (Table I). This report is based upon 25 pregnancies with associated parametrial cysts (24 were ovarian, and one was parovarian). They occurred in 23 patients over a thirteen-year-period including 7,598 pregnancies. Therefore, our incidence is one adnexal cyst in 304 pregnancies, or, if we omit the one parovarian cyst, we have an incidence of true ovarian cysts of one in 316 pregnancies. I
TABLE I.
INCIDENCE OF OVARIAN CYSTS IN PREGNANCY INCIDENCE
AUTHOR
Litzenberg Mathieu and Holman Priest Falk & Bunkin (Average of reports
1: 1: 1: 1:
in literature)
1,500 102 1,085 2,500
pregnancies pregnancies pregnancies pregnancies
HlGM
(All adnexal cysts) (Ovarian cysts)
1: 1:
304 pregnancies 316 pregnancies
It is notsurprising that there is considerable variation in the reported rate of occurrence of cysts during pregnancy, since this would depend not only upon the size of cysts included, but also upon the stage of pregnancy at the time of first examination. Realizing the difficulties of precise estimation of the size of pelvic structures, we have decided upon a lower limit of about 5 cm. We recognize that cystic enlargements of the ovary of less than 5 cm. occur not infrequently, but these are often difficult to distinguish from the normal ovarian variations, and therefore they are not included. The duration of gestation at the time of initial examination influences the number of cysts reported because in early pregnancy functional cysts are more common. On the other hand, many cysts disappear spontaneously in the latter half of pregnancy and so will not be detected by late examinations. As will be seen in Table II, nearly two-thirds (64 per cent) of these cysts were discovered during the first trimester and approximately one quarter (23 per cent) during the second. The fact that most patients are first examined before the end of the third month undoubtedly is a large factor in the high One cyst was discovered during incidence noteda during the first trimester. labor, and one at the time of discharge examination 12 days post partum. and
*Presented Gynecologists,
at
the Sixteenth Denver, Colorado,
Annual Sept.
Meeting of the 23 to 25, 1948.
283
Central
Association
of
Obstetricians
-
..__
--___----._
-
._I_-~..^-._30.
.__ ..-_~-_ ot
i'P:li(
~I'~N'l'A(~
I',
srri\rli 1 , First
tlinlt?st~r-------‘---~
Aecond Third
trimester
LabOr Post
shown
trimester
?,artuJ!l
After microscopic in Table III.
examination
these cysts were
fonnd to bc dist,ributed
as
-.__GKOU~
Functional Neoplaatic Endometrial Parovarian Simple cysts Unknown (Not operated Total
Both neoplastic
____-._
upon
)
NI‘MBER
OF CYSTS
5, IO 2 I 1 $4
---.--..-.-
--__-.
___--
of the functional cysts were cysts are listed in Table IV.
Monolocular serous cystadenomxs Multilocular pseudomucinous cystadenoma Combined dermoid and multilocular r’?etJtlonluc,inou. Complex teratoma Dermoid tumors Papilliferous C~Stad~nOnlit with early carcinomatow
-_22
--
of t,he corpus
lnteum
-_-----.-_
type.
The ten
3 1 cptatlcnorwl
I
I 3 change
--
1 _I--I II
The exact nature of the cyst was unknown in nine pregnancies since thase were not removed and studied. In one pregnancy the cyst was 5 cm. in diameter when discovered, and remained unchanged and asymptomatic through a normal breech delivery. The patient was not examined again until the fourth month of her second pregnancy, two years later, when she had an 8 cm. cyst of the same ovary. When removed this revealed early careinomatous change in a papilliferous cystadenoma. Another cyst occurred in conjunction with a hydatid mole, and regressed after curettage. Still another was discovered dul’ing labor and was displaced out. of the pelvis allowing delivery to occur. This cyst was still present six weeks post partum, and until the sixth month of the It could not be identified by second pregnancy which followed prompt,ly. The remaining five careful examination immediately aft.er t.he last delivery. cysts likewise disappeared spontaneously in the fifth and sixth months. $ince seven of t,hese nine cysts disappeared spontaneously, they must be assumed to have been of the functional type. Adding these to the two known functional cysts it is apparent, t,hat nine (36 per cent ) of the total series of 25 were functional. Fifteen of the cyst,s in this series involved the right ovary, while nine arose on the left side, In one case it was not possible to determine th(l origin.
PREGNANCY
AND
ADNEXAL
CYSTS
2x5
Symptoms referable to the cyst were few, and usually of vague nature ((Table V). Thirteen of the patients with adnexal cysts had no important complaints. Of the twelve patients who did present symptoms, ten had discomfort of some kind. This was not well localized, and in no case was it Two patients had sypmptoms severe enough to inconvenience the patient. suggesting torsion of the cyst, and one, with a cul-de-sac cyst complained c)f dyspareunia. It is apparent that adnesal cysts seldom product symptoms until they become large. TABLE
V.
SYMPTOMS
REFERABLE
TO CYST
SYMPTOM None Discomfort Symptoms Dyspareunia
suggesting
NO. OF PREGNAKCIES 13 10 2 7
torsion
-- -
Among the 25 pregnancies making up this series, there were no spontaneous abortions, and only three patients had bleeding or cramps suggesting a threatened abortion (Table VI). This makes the threatened abortion rate 12 per cent-not much different, than would be found among pregnancies in general. It appears, therefore, that the presence of a cyst during pregnancy does not materially increase the risk of abortion. TABLE
VI.
ABORTIOK
IK PATIENTS
NO.OF
TYPE
None Threatened Actual
WITH
ADNEXAL
PREGNANCIES 2" 5 0 25
CYSTS PERCENTAGEOFTOTAL 88 12 0 100
One of the chief problems in connection with the management of adnexal cysts encountered during pregnancy is that of abortions produced by ovariotomy. Consequently, various medications have been recommended with the hope of preventing loss of the pregnancy. In general, these agents have fallen into one of two classes, sedatives and hormones. The sedatives may be either narcotics or smoooth muscle relaxers, such as Pavatrine. The hormone is usually some corpus luteum preparation, although recently stilbestrol has also been advocated. We have not been impressed with the value of any of these preparations in preventing spontaneous abortions, although there might be some logic in their use when the corpus luteum serum is removed or when the uterus must be manipulated unduly. As shown in Table VII, ten patients in this series were given no antiabortion therapy postoperatively, three patients received a corpus luteum preparation, and one received both corpus luteum and sedation. Eleven other patient,s either had no operation, or their cysts were removed after delivery. Table VIII shows that only two of the fourteen patients operated upon during pregnancy did actually abort. Both were operated upon during the first trimester, and the corpus luteum verum was present in both cyst walls. It would seem that the error in these cases was in the early operation rather than in the amount or type of medicine given. TABLE
VII.
POSTOPERATIVE
None Corpus luteum Sedation and corpus luteum No operation or operation post
partum
ANTIABORTION
THERAPY 10 3 1 11 25
It was noted earlier that in one patient cysts of the same ovary existed in two successive pregnancies two years apart. When removed during the second gestation the cyst was found to contain early carcinomatons change in a papilliferous cyst.adenoma. If the caysts in t.hese two pregnancies were actually but one persistent cyst, as seems likely, the question arises as to how TeLinde and Calvin,” long the carcinomatous change may have been present. Stevenson and Scipiades,’ and Pund? Kettles, Caldwell, and Vieburgs’ have all reported evidence to show that in cervical malignancy the neoplasm ma> remain in t.he early (intracpithelial) stage for several years. rt woL~ld not be unreasonable to assume that the same latency may occur in ~Jv~u-iaIl malignancy, thus emphasizing t,he possible risk of being 100 conservative when dealing with persistent ovarian cysts. There were nine cysts whose contents have long and generally been These include one cyst with considered as irritat.ing to the perjtoneurn. papilliferous cystadenocarcinolua, three dermoid tumors, one cornbined
during gestation, labor, or the puerperium with very few exceptions ‘call for surgical interference at once. ” A similar view was expressed by Capone. On the basis of our small experience reported here we are not impressed that the complications mentioned are of frequent occurrence, nor are we convinced that immediate surgical interference is frequently required. Instead, we prefer a policy of close observation, commonly deferring decision as to whether and when to operate in any individual case until time has permitted a fairer evaluation of the cyst and its probable nature and significance. This applies chiefly to the small cysts seen early in gestation. Of course, the larger ones are seldom physiologic, and their significance is more readily apparent. While it is neither advisable nor possible to lay down any hard and fast rules for the management of these cysts in pregnancy, we believe the following policies to be useful and logical. a. &null Cysts Discovered During the First Trimester.Unless such a cyst is causing symptoms requiring its immediate removal, we prefer to wait until the middle of the second trimester before making final decision regarding its removal. This policy allows time for the functional cyst to regress spontaneously, and also for corpus luteum function to be taken over by the placenta, thus minimizing the risk of removing a corpus luteum verum. Furthermore, as the uterus enlarges, the cyst may be drawn up out of the pelvis where it can no longer serve as an obstruction. It may then be possible to wait for final evaluation until after delivery, or if removal is still indicated, the operation will usually be easier and less traumatic because the cyst no longer lies deep in the pelvis. X-ray study of the pelvis may be of value in indicating certain dermoid tumors which contain calcium deposits, although, of course, the absence of calcification does not rule out a dermoid. The decision as to whether operation is necessary or not depends further upon due consideration of the data here reported which show that 36 per cent of these cysts were functional while about the same number (40 per cent) were neoplastic. Unfortunately, it was not possible to establish any dividing line between these two groups on the basis of size of cyst or age of patient. However, by the middle of the second trimester most of the func.tional cysts will have disappeared. Tkerefore, the majority of those persisting to or after this period of pregnancy are probably neoplastic, and removal is indicated. b. Cysts Discovered
During
the Second Trimester.-
What has just been said with regard to cysts discovered in early pregnancy and persisting through the middle of the second trimester applies equally well to those which are first recognized in mid-pregnancy. These are in all probability neoplastic, since most of the functional cysts would have disappeared and with few exceptions their removal is in order unless they are small. c. Cysts Discovered
During
the Last Trimester.-
Interference with wound healing due to overstretching of the abdominal wall, together with the proximity of labor may alter the situation somewhat when a cyst is first diagnosed late in pregnancy. Discretion must be used, and in general operation may wisely be deferred a few weeks until after delivery.
an abortion. 8. Operations carried out in the st~~otlcl risk of abortion. 9. A plan for the management 011 cysts presented.
1. 2. 3. 4. 5. 6. i. 8.
References
Litzenberg, ,J. C.: Am .1. Surg. 3: 5OB-51 I, 1927. Mathieu, A., and Holmn, All,ert: Sorthwehl Med. 30: r,?!). JJwr~nliw~. 19:I I. Priest, Fred: AM. .r. 013s~. & (+YNF:C. 31: XiR-888, May, 194fi. Falk, H., and Bunkin, 1.: AM. J. c)BST. K: GVSW. 54: S?-X7, .III~,I. I!UT. Capone, A. ;r.: Bm. .J. Hurg. 61: 387-393, .lHJ:% SM. J. 0~s~. KS GYNFX:. 48: 774~794, 194-L. TeLinde, R. W., and Galvin, G.: Rurg., Gp!C. & mst. 66: 822-X:35, 1938. 8tevenson, C. S., and Rcipiades, E.: Pund, E. R., N.ettles, .T. B., Caldwell, J. D., anti Xieburgs, H. I,:.: Ax. .I. O~wr, 55: 831-837, 1948.
# ~YNEI!.
Volume 58 Number 2
PREGNANCY
AND
ADNEXAL
289
CYSTS
Discussion DR.
EMMETT A. MECHLER, Denver, Cola.-The dangers of spontaneous abortion, sterility, and premature labor as a complication of adnexal or ovarian tumors have been In the light of this variously stated by Williams, Stander, Remy, McKarron, and others. series of. cases, however, it would seem that adnexal tumors have little or no effect upon the Stander has mentioned that any ovarian tumor of 4 cm. or less in size should pregnancy. be treated conservatively and that only if the tumor enlarges during pregnancy should surgical removal be considered. Recently Falk and Bunkin, and Miller and Wilson have stated that 95 per cent of all ovarian cysts which are 5 cm. or less in diameter are functional cysts and that “these cysts are no longer looked upon as part of t.he complex group of ovarian nenplasmn, but simply as enlargements t.lmt come about as a result of altered physiological beand they emphasize that the cyst be followed and that surgical treathavior of the ovary”; ment be instituted only if the cyst changes in size or becomes symptomatic. The high irmidence of adnexal cysts described by Dr. Haas is due ful and accurate examination of patient s during the first trimester of evidence of good prenatal care. There is no doubt that many patients of a pregnancy and delivery with undiagnosed adnexal tumors and wit,hout Many of the published reports deal only with cases in which plications. operation and do not take into account the question of functional cysts.
no doubt to the carepregnancy and is an this kind go through symptoms or comtumors are found at
In a series of 8,000 deliveries over a period of fifteen years at the Colorado Medical Center, we were able to find seven patients who had been operated upon for adnexal cysts Of these seven cases, three were simple complicating pregnancy; an incidence of 1 to 1,100. cysts, three were pseudomucinous c.ystadcnomas and one 1~s a dermoid cyst. Three of the patients were operated upon during the first trimester of pregnancy with no ill effect upon the course of the pregnancy. Only one patient in the series had mild symptoms referable to the tumor. I mention these statistics, not because they offer much in the way of clarifying this problem but because, like so many of the published reports, they refer only to cases seen at operation and do not reflect the true incidence of these tumors as reported here today. Further studies of the nature made by Dr. Haas in this paper are needed to help us in a It is probable that the true incibetter understanding of many features of this problem. dence of ovarian tumors complicating pregnancy is the same as in the nonpregnant patient of the same age group. Pregnancy has less effect upon the clinical course of ovarian tumors than in the case of uterine fibroids. In my private practice and clinical experience, I have been unable to confirm the of such a high incidence of functional cysts, and it seems that this matter should have discussion. It is pointedly stated by DeLee, Stander, Heil, Williams, Irving, and that an ovarian tumor when discovered during pregnancy should be removed as possible. We have taken the attitude that, any ovarian tumor complicating pregnancy be removed or explored, but that operation should be postponed until the fourth month of pregnancy to minimize the danger of miscarriage. Penduculated uterine fibroids manifestations, making a differential sorting to exploration.
often simulate ovarian tumors in location diagnosis difficult or sometimes impossible
finding further others soon as should or fifth
and clinical without re-
Although, as has been frequent,ly stated, the most common symptoms associated with adnexal tumors are those resulting from torsion, hemorrhage, or suppuration, the real danger to the patient lies in the possibility of the tumor’s being malignant or premalignant, or that the cyst contents might be irritating to the peritoneum in t.he event of a rupture or leak which would result in a serious peritonitis. It is impossible many times except in the cltse of some dermoid cysts which might contain rddiopaque material, to differentiate these from functional cysts other than by surgical exploration and biopsy. canal delivery
It is a rare clinical and during labor; is an unsatisfactory
experience to encounter an ovarian cyst which obstructs the birth it should be emphasized that reposition of the cyst to facilitate and possible dangerous procedure. Puncture with drainage of
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such a cyst through the cul-de-sac is, as !Villiams has said, ’ ‘2 tlnllgerous :rud reprehcrlsibtc procedure. ” Cesarran se&on mtl concoruitnut. remowl 0f t hf b i’yst. is the safer f,roae4rtrt~. The general note of conservatism a.11~1 individnalientioll of the patient. with nduess I cysts complicating pregnancy, together wit11 tli~ plan of management of rhese patients in the various stages of pregnancy, as stated in this paper, should 11t1 :L v:~I~~ablr aill in 031r twc-hing and should inspire further investigation of this Itinrl. DE. HAAS (Closing).-There is very little I wish to agltl except to say that thca pnrurrro peritoneum procedure was used at the University of Michigau many years ago and has been given up for various reasons. I do not see why pneumoperitoneography is a great advantage in this sort of case because these cysts arc usm~lly low in the pelvis where they are rradil! palpated without subjecting the patient to :I ~omrwhat corrlpliwi t~l ant1 rlni~llmfort able pncedure.