J Cases Obstet Gynecol, 2016;3(4):121-124

Journal of Cas es in
Ob s te tri cs & G yn e co l o g y

Case Report

Papillary serous cystadenoma of ovary: A huge ovarian cyst complicating

the pregnancy

Batool Kamalimanesh1, Reza Jafarzadeh Esfehani2, Jila Agah3,*

1Department of nursing & midwifery, School of midwifery, Sabzevar University of Medical Sciences, Sabzevar, Iran.
2Student Research Committee, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.
3Department of Obstetrics & Gynecology, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.

Abstract
Managing ovarian masses during pregnancy is a critical issue while they can complicate pregnancy either by their size or nature. In this report, the manage-
ment of a large ovarian mass as an interesting incidental finding on ultrasonography will be discussed. In present report, a 33-year-old woman referred with
a dull abdominal pain in 32th weeks of gestation. Her sonographic evaluation revealed a large solid-cystic mass of right ovary about 20 centimeter length.
The patient underwent a laparotomy under regional anesthesia. There was a large mass originating from right ovary without any adhesion to surrounding
tissues and a normal pregnant uterine in third trimester. The right ovary complicated by a multilocular solid-cystic mass was removed and the pathology re-
port showed papillary serous cystadenoma of ovary. In outpatient management, the mother passed a normal pregnancy. In conclusion; physiological chang-
es during pregnancy may complicate manifestations of diseases in pregnancy. Under diagnosis of any abdominal compliant may lead to life-threatening
situations such as overgrowth or torsion of ovarian masses. Gentle action with minimal manipulation of pregnant uterus could prevent adverse outcomes.

Key Words:
Pregnancy, ovarian cysts, cystadenoma, serous, abdominal pain

Introduction Case Presentation

Ovarian masses during pregnancy can be functional, be- A 33-year-old woman referred to us with a dull abdomi-
nign or malignant neoplasm [1]. While most of ovarian nal pain. The patient was pregnant with gestational age of
cysts resolve till the second trimester and are not malignant, 32 weeks. She had a normal vaginal delivery 4 years ago.
sonographic evaluation as well as determining tumor mark- There was not any other event in her past medical history
ers in order to rule out malignancies is still an important is- except curettage for abortion. In physical examination, vital
sue [2]. Managing these masses during pregnancy depends signs were normal. The abdominal pain was mild and tol-
on many different factors. Tumor size, type, origin and pa- erable with minimal periumbilical tenderness. The uterine
tient gestational age and medical condition are the most im- height was the same as the gestational age. There wasn’t
portant factors in choosing an appropriate management [3]. any sign of vaginal bleeding or leakage. The membranes
In this report, the management of a large ovarian mass as were intact and the cervix wasn’t dilated. Fetus external
an incidental finding on ultrasonography will be discussed. monitoring showed normal heart rate and there wasn’t any
Article History: uterine contraction. Her sonographic evaluation revealed a
Received:24/10/2015 normal fetus in 32 weeks of gestation and a large sol-
Accepted:23/06/2016 id-cystic mass of right ovary about 20 centimeter length.
*Correspondence: Jila Agah So the patient was admitted and scheduled for surgical op-
Address: Department of Obstetrics & Gynecology, School of Medicine, eration. Laboratory tests including complete blood count,
Sabzevar University of Medical Sciences, Sabzevar, Iran.
E-mail: [email protected]
blood sugar and electrolytes and tumor markers (carcino
Tel: +98 910 510 1429
Fax: 44221002
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embryonic antigen (CEA) and CA125) were within nor- Discussion

mal limits (CA-125: 35 IU/ml - normal range according to
pregnancy trimester: 0 - 56.3 U/ml and CEA: 1.1 ng/ml –
normal range according to pregnancy trimester: ˂2.5 ug/L).
Ovarian masses are common findings in general gyne-
cology [4]. Ovarian cysts are found in 4.1% of second-tri-
According to her stable condition and gestational age, the mester and third-trimester obstetric sonographic exam-
operation was postponed for 48 hours. This delay was inations [5]. Of these, neoplasms constitute a significant
made in order to prescribe betamethasone for provoking number and most are benign [4]. Most of sonographic
fetal lung maturation. Thus the mother received two dos- detectable cysts are < 3.0 cm in diameter and usually de-
es of betamethasone (12 mg intramuscularly) separated by cline after 10th week of gestational age. Adnexal mass-
24 hours and parenteral ampicillin (2 grams) every 6 hours es persisting beyond 1st trimester are most likely to be
before surgery. At the surgery day, laparotomy was done neoplasms, especially if there are complex sonograph-
under regional anesthesia. There was a large mass originat- ic features [1]. Serous tumors are approximately one
ing from right ovary without any adhesion to surrounding half of all surface epithelial stromal ovarian tumors [6].
tissues and a normal pregnant third trimester uterus. The The most common symptom of adnexal masses is pain
right ovary was removed with minimal manipulation of which can be mild or sever and usually is the result of
the uterus. A multilocular solid-cystic mass with internal torsion or rupture [3, 7]. However, it should be consid-
hemorrhagic areas was removed (Figure1). The pathology ered that large masses may be manifested with only mild
report showed papillary serous cystadenoma of ovary (Fig- abdominal pain. As physiologic and anatomical chang-
ure2). During postoperative period, the patient was mon- es in pregnant women can cause abdominal pain, patho-
itored carefully for both maternal and fetal condition and logical conditions like ovarian mass may be ignored.
also uterine contractions. Also magnesium sulfate infusion As our case, a mild abdominal pain leads to finding of a
(2 grams per hour for 12 hours) was prescribed in order to large ovarian mass without torsion or rupture. Approxi-
control probable preterm labor. The patient was discharged mately 21% of benign tumors may develop torsion and
without any complications 3 days after surgery. During most of ovarian torsions are seen during first trimester
follow- up, the patient’s pregnancy course was unevent- [8,9]. Before developing common imaging modalities
ful. She gave birth to a healthy male infant (2700 grams) such as ultrasound, adnexal masses were found on phys-
under analgesic gas of entonox at 41 weeks of gestation. ical examination or whenever become symptomatic [3].
Ultrasound evaluation is 96.8% sensitive and 77% specif-
Figure 1. ic in diagnosing masses during pregnancy. Magnetic res-
onance imaging (MRI) can provide useful information in
order to rule out probable differential diagnosis when di-
agnostic workup is equivocal. However, relying on sono-
graphic finding is more helpful than MRI in presence of
amenable to ultrasound examinations [1]. CA-125 lev-
el over the first trimester is useful for malignancy follow
up and is elevated in 80% of epithelial ovarian malignan-
cies [1, 3]. However, CA-125 ranges are slightly different
during normal pregnancy trimesters. CA-125 during 1st
trimester is significantly higher than 2nd trimester. Also,
CEA level is higher during 3rd trimester. Ercan S et al. re-
ported that these elevations are within normal levels [10].
Measuring other serum markers such as alpha-fetoprotein
is useful in detecting germ-cell tumor [1]. However, mea-
suring these serum markers alone and without the aid of
imaging modalities can lead to unnecessary interventions
A multilocular solid-cystic mass weighting 3 kilo- [3]. Although it is not widely studied, laparoscopic surgery
grams with internal hemorrhagic areas was removed in pregnancy is as safe as open surgery. However, in order

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 Agah et al.

to avoid uterine perforation, open laparoscopy is preferred. Cysts smaller than 5 centimeter can be managed conser-
As this technique requires expert hands and equipment’s, vatively while only masses between 5 and 10 centimeters
this procedure is not widely used in our department and with ultrasonic appearance can be managed conservatively.
open surgery is preferred [11]. While the best time for sur- Septated cysts or cysts with solid or nodular parts should
gery is the beginning of 2nd trimester (to avoid spontaneous be removed as they are less likely to be resolved [12].
miscarriage in the first trimester and the risk of precipitat- Tumor size and gestational age are two independent fac-
ing preterm delivery in the third trimester), some masses tors, affecting the determination of operation type. Lapa-
can be carefully followed till term and removed during ce- roscopy is preferred for managing small tumors or tumors
sarean section (C/S) [2, 8]. Surgery of ovarian tumors in of early gestational age. Laparoscopic management is as-
pregnancy can be delayed until the onset of symptoms un- sociated with short hospital stay and lower estimated blood
less in the presence of a strong suspicion of malignancy. loss [13]. However, this approach is not possible patients
with large ovarian masses especially in the third trimester.
Figure 2. Considering watchful management and reserving surgery
in case of onset of symptoms can be considered for both
groups. Although aspirating simple masses can avoid ma-
jor surgery in some cases. It is not favorable in the case of
complex cysts and laparotomy seems to be the acceptable
approach [3]. It’s also important to keep in mind that sur-
gical intervention of adnexal masses in the third trimester
may be associated with rupture of membranes, preterm la-
bor and low birth weight [3, 14]. In our case, the opera-
tion was mandatory because of disturbing symptoms, en-
largement of the mass and sonographic features expressed
complex mass. As the operation was done with the least
manipulation of the large uterus in a short time, fortunate-
ly preterm labor was not happened. Also, for preventing
postoperative digestive complications one intramuscular
injection of metoclopramide was prescribed before sur-
gery [15]. Interestingly pregnancy was continued to 41
Pathologic specimen of the cyst, papillary serous cystad- weeks of gestation and she delivered under analgesic gas
enoma of ovary of entonox which is safe for both mother and baby [16, 17].
In conclusion, treatment of ovarian masses in pregnan-
cy should be structured individually. While physiological
In cases of acute torsion or rupture, emergency surgery is changes during pregnancy have special impact on clinical
needed and watchful waiting is not indicated [1]. Lee et al. manifestation of disease, paying special attention to even
found that there is no significant difference between women mild abdominal pain in pregnant women is important. Under
undergoing emergency surgery because of torsion and those diagnosis of such problems may lead to life-threatening situ-
undergoing elective surgery in term of adverse pregnancy ations such as overgrowth or torsion of ovarian masses. If the
outcomes [8]. Surgical management is indicated in three operation is scheduled, gentle action with minimal manip-
condition; 1- suspicion of malignancies, 2- development ulation of pregnant uterus could prevent adverse outcomes.
of complications, 3- masses above 5 centimeters near 18
weeks of gestation or rapid growing during pregnancy more
than 30-50% [1]. Thornton JG et al. claim that removing the Acknowledgement
The authors appreciate the manager and staff of Mobini hospital for
cysts which are suspected to rupture, torsion or those which
contribution in follow up the patient and collection the data.
are over 10 centimeter in diameter are reasonable [12].
Cysts occupying pelvis or obstructing labor canal will re- Declaration of Interest
quire C/S at term for preventing possible complications [2]. None

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