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Rupture of an ovarian endometrioma during the first trimester of pregnancy
European Journal of Obstetrics & Gynecology and Reproductive Biology 76 (1998) 41–43
Rupture of an ovarian endometrioma during the first trimester of pregnancy a, *, Margarita Alvarez a , Angela Palumbo b , Antonio Gonzalez´ ´ Juan Antonio Garcıa-Velasco a a ´ ´ Gonzalez , Juan Ordas a
Department of Obstetrics and Gynecology, Hospital LA PAZ, Autonoma University of Madrid, Madrid, Spain b Department of Biochemistry and Molecular Biology, La Laguna University of Tenerife, Tenerife, Spain Received 27 January 1997; received in revised form 27 February 1997; accepted 18 July 1997
Abstract Rupture of an ovarian endometrioma presenting as a surgical emergency during pregnancy is a rare event. We report the first case to our knowledge of growth and rupture of an endometrioma in the first trimester of pregnancy. After laparotomy, the postoperative course was uneventful and the pregnancy is ongoing. 1998 Elsevier Science Ireland Ltd. Keywords: Pregnancy; Endometriosis; Ovarian cyst; Ruptured endometrioma
1. Introduction Although a few cases have been reported [1–7], rupture of an ovarian endometrioma complicating pregnancy is rare. To our knowledge, this is the first report of a ruptured endometrioma during the first trimester of pregnancy. Although endometriosis and infertility are closely related [8], pregnancy may occur in patients with quite severe endometriosis and endometriosis may present as an acute emergency during pregnancy.
2. Case report A 25-year-old white nulliparous woman was admitted to ‘Hospital Maternal La Paz’ of Madrid at 9 weeks’ gestation with the chief complaint of diffuse abdominal pain of several days duration. The patient had no history of infertility or endometriosis, but she had moderate dysmenorrhea. At the time of her last menstrual period she *Corresponding author, Reina Cristina 36, 28D, 28014 Madrid, Spain. Presently at Instituto Valenciano de Infertilidad c / Guardia Civil 23; 46020 Valencia. Fax: 134 6 3694735; e-mail: [email protected]
had been admitted to a local hospital with a diagnosis of left salpingitis (a sonogram was performed, showing a 49348 mm left adnexal mass) and received antibiotic treatment. She first presented at our hospital at 7 weeks’ gestation complaining of right lower quadrant pain. The abdomen was soft and an abdominal ultrasound revealed a 60320 mm left adnexal mass consistent with a corpus luteum. After 2 days observation, her symptoms subsided and the patient was discharged home. A follow-up abdominal ultrasound 10 days later revealed growth of the left adnexal mass, which now was 68355 mm in size. The patient remained asymptomatic. One day later she presented with acute abdominal pain. The patient’s general condition was of moderate distress, with normal blood pressure, pulse and temperature. Physical examination revealed diffuse abdominal tenderness with rebound, especially in the right lower quadrant, no mass was palpable, and bowel sounds were absent. There were no significant laboratory findings, the hematocrit was 36.8%, and there was no leucocytosis. No alterations on coagulation studies were found, including platelet count and fibrinogen determination. A real time abdominal ultrasound examination showed an intrauterine gestation with cardiac activity and an 83354 mm left adnexal mass with internal echoes
0301-2115 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0301-2115( 97 )00152-8
42
´ J. A. Garcıa-Velasco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 76 (1998) 41 – 43
Fig. 1. Sonogram showing intrauterine pregnancy and endometrioma at 6 weeks pregnancy (arrows).
Fig. 3. Corpus luteum of pregnancy: large luteinized cells, some of which contain hyaline bodies.
suggestive of a hemorraghic corpus luteum vs. endometrioma (Fig. 1). Laparotomy was indicated by clinical demonstration of acute abdomen, as diagnostic laparoscopy was not available at the time the patient entered the theatre. Upon exploration of the pelvis, abundant, thick chocolate saucelike fluid was covering the visceral peritoneum; the size of the uterus corresponded to gestational age, the left ovary was adherent to an ileal loop and to the posterior wall of the broad ligament, and was enlarged to 10 cm due to the presence of a ruptured endometrioma. No other endometriotic implants were found. Left salpingo-oophorectomy was performed as excessive bleeding impeded conservative surgery. The postoperative course was uneventful and the patient has now a normal ongoing pregnancy. Progesterone supplementation was not deemed necessary since the pregnancy had reached 9 weeks. Histopathologic examination revealed findings typical of endometriosis (Fig. 2) as well as a corpus luteum of pregnancy in the same ovary (Fig. 3).
3. Discussion
Fig. 2. The lining of the cyst consists of endometrial surface epithelium; the stroma shows a marked decidualization and in the lumen cellular debris are present.
This case illustrates the importance of considering endometriomas in the differential diagnosis of abdominal pain in pregnancy, especially in the face of an ultrasound examination revealing an ovarian cyst other than corpus luteum. Endometriosis is found almost exclusively in women of reproductive age, with an estimated prevalence of 3–10% in the general population, and of 25–35% in infertile women [9]. While it is clear that moderate to severe endometriosis with adhesions and disruption of the pelvic anatomy causes infertility, the role of minimal to mild endometriosis in the pathogenesis of infertility is unclear. Even less clear is the role of endometriomas. Endometriotic ovarian cysts are classified as moderate to severe disease in the AFS Classification. However, it seems unlikely that an ovarian endometrioma itself diminishes fertility [9]. Presently, diagnosis of endometriomas offers almost no clinical doubt with transvaginal ultrasound [10], with no additional information obtained from pulsed color Doppler ultrasound. In this case, as transvaginal ultrasound was not available, it was initially misdiagnosed. There were no typical sonographic homogenic echoes, so the differential diagnosis with a corpus luteum cyst could not be clarified. Thus, abdominal ultrasound does not have enough diagnostic power in early pregnancy and in gynecology in general, conferring transvaginal ultrasound a preponderant role [10]. Although pregnancy is generally thought to have beneficial effects on endometriosis, endometriosis may progress throughout pregnancy. This case illustrates progression of endometriosis with growth and rupture of an endometrioma in the first trimester. The ideal therapeutic procedure would have been a diagnostic laparoscopy to rule out any other cause of acute abdomen (adnexal torsion, ruptured ovarian cysts, heterotopic pregnancy, appendicitis, pelvic
´ J. A. Garcıa-Velasco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 76 (1998) 41 – 43
inflammatory disease . . . ) [2], and with the diagnosis of a ruptured endometrioma, a conservative approach — resection of the endometrioma with ovarian reconstruction — should have been used [1], but the excessive bleeding impeded it. Adhesions have been implicated as the cause of rupture of endometriomas during pregnancy due to the increased tension when the uterus is enlarged and its anatomical position altered [1,3,4]. In other cases, when adhesions are absent, the reduced abdominal space — as the pregnant uterus occupies the abdomen — may induce the cyst to rupture [5,8]. An alternative explanation is that increased ovarian blood flow during pregnancy can induce enlargement of the cyst and perhaps bleeding into the cyst itself and eventually rupture [9]. Furthermore, in our patient, the dense adhesions present between the ovary and the surrounding structures, may have contributed to the rupture. No coagulation disorders were found in this patient, and the only medication she was taking at the time of the rupture were folic acid and vitamins, so bleeding could not be the causal mechanism. Rupture of endometriomas during pregnancy may also occur secondary to softening of the lesion secondary to stromal decidualization. This has been noted in association with colonic perforation previously [11].
References [1] Rossman F, D’Ablaing G, Marrs RP. Pregnancy complicated by ruptured endometrioma. Obstet Gynecol 1983;62:519–21.
43
[2] Johnson TRB, Woodruff JD. Surgical emergencies of the uterine adnexae during pregnancy. Int J Obstet Gynecol 1986;24:331–5. [3] Vercellini P, Ferrari A, Vendola N, Carinelli SG. Growth and rupture of an ovarian endometrioma in pregnancy. Int J Gynecol Obstet 1992;37:203–5. ´ MJ, Neyro JL, Montoya F, Barrenetxea G, Rodrıguez´ [4] Barbazan Escudero FJ. Ruptured endometrioma during pregnancy. J Obstet Gynecol 1993;13:40. [5] Anderson M, Edmond RM. Rupture of an endometriosic cyst in late pregnancy. Br J Obstet Gynecol 1974;81:907–8. [6] Scott R. Endometriosis and pregnancy. Am J Obstet Gynecol 1944;47:608. [7] Steinberg P. Endometrial cyst ruptured during pregnancy. West J Surg Obstet Gynecol 1962;70:244. [8] Ishimaru T, Masuzaki H, Samejima T, Fujishita A, Nakamura K, Yamabe T. Influence of ovarian endometrioma on fertility. Am J Obstet Gynecol 1994;171:541–5. [9] Speroff L, Glass RH, Kase NG. Endometriosis. In: Mitchell C, editor. Clinical gynecologic endocrinology and infertility. Baltimore: Williams and Wilkins, 1994:853–72. ´ ´ ´ G. The role of [10] Alcazar JL, Laparte C, Jurado M, Lopez-Garcıa transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma. Fertil Steril 1997;67:487–91. [11] Clement PB. Perforation of the sigmoid colon during pregnancy: a rare complication of endometriosis. Br J Obstet Gynecol 1977;84:548–50.
Rupture of an ovarian endometrioma during the first trimester of pregnancy a, *, Margarita Alvarez a , Angela Palumbo b , Antonio Gonzalez´ ´ Juan Antonio Garcıa-Velasco a a ´ ´ Gonzalez , Juan Ordas a
Department of Obstetrics and Gynecology, Hospital LA PAZ, Autonoma University of Madrid, Madrid, Spain b Department of Biochemistry and Molecular Biology, La Laguna University of Tenerife, Tenerife, Spain Received 27 January 1997; received in revised form 27 February 1997; accepted 18 July 1997
Abstract Rupture of an ovarian endometrioma presenting as a surgical emergency during pregnancy is a rare event. We report the first case to our knowledge of growth and rupture of an endometrioma in the first trimester of pregnancy. After laparotomy, the postoperative course was uneventful and the pregnancy is ongoing. 1998 Elsevier Science Ireland Ltd. Keywords: Pregnancy; Endometriosis; Ovarian cyst; Ruptured endometrioma
1. Introduction Although a few cases have been reported [1–7], rupture of an ovarian endometrioma complicating pregnancy is rare. To our knowledge, this is the first report of a ruptured endometrioma during the first trimester of pregnancy. Although endometriosis and infertility are closely related [8], pregnancy may occur in patients with quite severe endometriosis and endometriosis may present as an acute emergency during pregnancy.
2. Case report A 25-year-old white nulliparous woman was admitted to ‘Hospital Maternal La Paz’ of Madrid at 9 weeks’ gestation with the chief complaint of diffuse abdominal pain of several days duration. The patient had no history of infertility or endometriosis, but she had moderate dysmenorrhea. At the time of her last menstrual period she *Corresponding author, Reina Cristina 36, 28D, 28014 Madrid, Spain. Presently at Instituto Valenciano de Infertilidad c / Guardia Civil 23; 46020 Valencia. Fax: 134 6 3694735; e-mail: [email protected]
had been admitted to a local hospital with a diagnosis of left salpingitis (a sonogram was performed, showing a 49348 mm left adnexal mass) and received antibiotic treatment. She first presented at our hospital at 7 weeks’ gestation complaining of right lower quadrant pain. The abdomen was soft and an abdominal ultrasound revealed a 60320 mm left adnexal mass consistent with a corpus luteum. After 2 days observation, her symptoms subsided and the patient was discharged home. A follow-up abdominal ultrasound 10 days later revealed growth of the left adnexal mass, which now was 68355 mm in size. The patient remained asymptomatic. One day later she presented with acute abdominal pain. The patient’s general condition was of moderate distress, with normal blood pressure, pulse and temperature. Physical examination revealed diffuse abdominal tenderness with rebound, especially in the right lower quadrant, no mass was palpable, and bowel sounds were absent. There were no significant laboratory findings, the hematocrit was 36.8%, and there was no leucocytosis. No alterations on coagulation studies were found, including platelet count and fibrinogen determination. A real time abdominal ultrasound examination showed an intrauterine gestation with cardiac activity and an 83354 mm left adnexal mass with internal echoes
0301-2115 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0301-2115( 97 )00152-8
42
´ J. A. Garcıa-Velasco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 76 (1998) 41 – 43
Fig. 1. Sonogram showing intrauterine pregnancy and endometrioma at 6 weeks pregnancy (arrows).
Fig. 3. Corpus luteum of pregnancy: large luteinized cells, some of which contain hyaline bodies.
suggestive of a hemorraghic corpus luteum vs. endometrioma (Fig. 1). Laparotomy was indicated by clinical demonstration of acute abdomen, as diagnostic laparoscopy was not available at the time the patient entered the theatre. Upon exploration of the pelvis, abundant, thick chocolate saucelike fluid was covering the visceral peritoneum; the size of the uterus corresponded to gestational age, the left ovary was adherent to an ileal loop and to the posterior wall of the broad ligament, and was enlarged to 10 cm due to the presence of a ruptured endometrioma. No other endometriotic implants were found. Left salpingo-oophorectomy was performed as excessive bleeding impeded conservative surgery. The postoperative course was uneventful and the patient has now a normal ongoing pregnancy. Progesterone supplementation was not deemed necessary since the pregnancy had reached 9 weeks. Histopathologic examination revealed findings typical of endometriosis (Fig. 2) as well as a corpus luteum of pregnancy in the same ovary (Fig. 3).
3. Discussion
Fig. 2. The lining of the cyst consists of endometrial surface epithelium; the stroma shows a marked decidualization and in the lumen cellular debris are present.
This case illustrates the importance of considering endometriomas in the differential diagnosis of abdominal pain in pregnancy, especially in the face of an ultrasound examination revealing an ovarian cyst other than corpus luteum. Endometriosis is found almost exclusively in women of reproductive age, with an estimated prevalence of 3–10% in the general population, and of 25–35% in infertile women [9]. While it is clear that moderate to severe endometriosis with adhesions and disruption of the pelvic anatomy causes infertility, the role of minimal to mild endometriosis in the pathogenesis of infertility is unclear. Even less clear is the role of endometriomas. Endometriotic ovarian cysts are classified as moderate to severe disease in the AFS Classification. However, it seems unlikely that an ovarian endometrioma itself diminishes fertility [9]. Presently, diagnosis of endometriomas offers almost no clinical doubt with transvaginal ultrasound [10], with no additional information obtained from pulsed color Doppler ultrasound. In this case, as transvaginal ultrasound was not available, it was initially misdiagnosed. There were no typical sonographic homogenic echoes, so the differential diagnosis with a corpus luteum cyst could not be clarified. Thus, abdominal ultrasound does not have enough diagnostic power in early pregnancy and in gynecology in general, conferring transvaginal ultrasound a preponderant role [10]. Although pregnancy is generally thought to have beneficial effects on endometriosis, endometriosis may progress throughout pregnancy. This case illustrates progression of endometriosis with growth and rupture of an endometrioma in the first trimester. The ideal therapeutic procedure would have been a diagnostic laparoscopy to rule out any other cause of acute abdomen (adnexal torsion, ruptured ovarian cysts, heterotopic pregnancy, appendicitis, pelvic
´ J. A. Garcıa-Velasco et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 76 (1998) 41 – 43
inflammatory disease . . . ) [2], and with the diagnosis of a ruptured endometrioma, a conservative approach — resection of the endometrioma with ovarian reconstruction — should have been used [1], but the excessive bleeding impeded it. Adhesions have been implicated as the cause of rupture of endometriomas during pregnancy due to the increased tension when the uterus is enlarged and its anatomical position altered [1,3,4]. In other cases, when adhesions are absent, the reduced abdominal space — as the pregnant uterus occupies the abdomen — may induce the cyst to rupture [5,8]. An alternative explanation is that increased ovarian blood flow during pregnancy can induce enlargement of the cyst and perhaps bleeding into the cyst itself and eventually rupture [9]. Furthermore, in our patient, the dense adhesions present between the ovary and the surrounding structures, may have contributed to the rupture. No coagulation disorders were found in this patient, and the only medication she was taking at the time of the rupture were folic acid and vitamins, so bleeding could not be the causal mechanism. Rupture of endometriomas during pregnancy may also occur secondary to softening of the lesion secondary to stromal decidualization. This has been noted in association with colonic perforation previously [11].
References [1] Rossman F, D’Ablaing G, Marrs RP. Pregnancy complicated by ruptured endometrioma. Obstet Gynecol 1983;62:519–21.
43
[2] Johnson TRB, Woodruff JD. Surgical emergencies of the uterine adnexae during pregnancy. Int J Obstet Gynecol 1986;24:331–5. [3] Vercellini P, Ferrari A, Vendola N, Carinelli SG. Growth and rupture of an ovarian endometrioma in pregnancy. Int J Gynecol Obstet 1992;37:203–5. ´ MJ, Neyro JL, Montoya F, Barrenetxea G, Rodrıguez´ [4] Barbazan Escudero FJ. Ruptured endometrioma during pregnancy. J Obstet Gynecol 1993;13:40. [5] Anderson M, Edmond RM. Rupture of an endometriosic cyst in late pregnancy. Br J Obstet Gynecol 1974;81:907–8. [6] Scott R. Endometriosis and pregnancy. Am J Obstet Gynecol 1944;47:608. [7] Steinberg P. Endometrial cyst ruptured during pregnancy. West J Surg Obstet Gynecol 1962;70:244. [8] Ishimaru T, Masuzaki H, Samejima T, Fujishita A, Nakamura K, Yamabe T. Influence of ovarian endometrioma on fertility. Am J Obstet Gynecol 1994;171:541–5. [9] Speroff L, Glass RH, Kase NG. Endometriosis. In: Mitchell C, editor. Clinical gynecologic endocrinology and infertility. Baltimore: Williams and Wilkins, 1994:853–72. ´ ´ ´ G. The role of [10] Alcazar JL, Laparte C, Jurado M, Lopez-Garcıa transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma. Fertil Steril 1997;67:487–91. [11] Clement PB. Perforation of the sigmoid colon during pregnancy: a rare complication of endometriosis. Br J Obstet Gynecol 1977;84:548–50.