This document details the case of a 21-year-old pregnant woman with a large ovarian cyst identified during the second trimester, leading to surgical intervention for removal. The patient's cyst measured 18 cm and was diagnosed as a benign mucinous cystadenoma post-surgery, emphasizing the rarity and management considerations of large adnexal masses in pregnancy. It discusses various diagnostic markers, the approach to surgery during pregnancy, and the implications for suspected malignancies.

1. A Rare Case Of
Huge Ovarian
Cyst In Second
Trimester.
By
Dr. S. Sahitya 3rd
yr OG PG

2. Case Summary:
Mrs. Sharmila devi, a 21 years old primigravida from
Chennai
Came to IOG AN – OPD at 19weeks +4 days gestation
With ultrasound report showing a right Adnexal
multilocular hypoechoic cyst of size 19.6*14.5*18.4
cm.

3. COURSE DURING HER ADMISSION:
• Per abdominal examination revealed a distended abdomen.
On palpation, the abdomen was soft and non-tender. Deep
palpation revealed 20 weeks sized uterus.
• A huge mass of 18 cm × 15 × 10 cm was felt occupying
the right hypochondrium, epigastrium, and the right
lumbar region, with a smooth surface, cystic
consistency. The lower pole of the mass could be
reached, and the mass was non-tender.
• Tumor markers were done.
CA – 125 -13 (0-35units/ml)
CEA – 6.52 (0-2.5ng/ml)
AFP – 31.19. (0-40ng/ml)

4. MRI ABDOMEN AND PELVIS:
• Showed a large well
defined Abdomino-
pelvic cystic lesion
measuring 10.1*17*15cm
with multiple thin
internal septations
arising from right
adnexa and extending
to right sub – hepatic
space.
• No evidence of solid
components.
• Right ovary not
separately visualized.

5. DECISION TO
OPERATE:
• Exploratory
laparotomy with right
salpingo-ophorectomy
with omental biopsy
and peritoneal
cytology was planned.
• Inj. Proluton depot
(hydroxyprogesterone)
500 mg IM stat was
given a day before
surgery.

6. INTRA – OP:
• Midline
incision made.
• Peritoneum
entered.
• Peritoneal
aspirate sent
for cytology.
• Right adnexal
cyst of size
18*16*12cms was
identified and
exteriorized.

7. CONTD:

8. HISTOPATHOLGY:
• Benign mucinous cystadenoma
Fibrocollagenous cyst wall lined by single layer
of mucinous columnar epithelial cells. There is
no stratification or atypia.

9. CASE DISCUSSION:

10. GENERAL
POINTS:
• The prevalence of adnexal
masses in pregnant women is
0.19-6.0%.
• More than 90% of these are less
than 5 cm in size and are
spontaneously absorbed before
16th weeks of gestation.
• However, a rapidly enlarging
ovarian tumor during pregnancy
is rare and should raise the
suspicion for malignancy.
• In our Institution : 3 cases
(only those which are operated
in 1st and 2nd trimester).

11. DIFFERENTI
AL
DIAGNOSIS:

12. ARE TUMOR MARKERS
USEFUL?
• Ca–125 is a glycoprotein that
increases in ovarian
carcinoma, endometriosis,
uterine fibroids, pelvic
inflammation, menstruation
and pregnancy.
• Particularly during 1st and
3rd trimester, increased
amounts of Ca– 125 are
produced from amnion and
decidua.
• This marker is of importance
when it is greater than
100IU/ml, while its main use
is disease progression.
• CEA level is higher during

13. IOTA SIMPLE
RULES:
Rule 1: If one or more M
features are present in
absence of B feature,
mass is classified as
malignant.
Rule 2: If one or more B
features are present in
absence of M feature,
mass is classified as
benign.
Rule 3: If both M
features and B features
are present, or if no B
or M features are

14. MANAGEMENT:
• Management is dependent on the size and
nature of the cyst as well as any patient
symptoms.
• Generally surgery is avoided during
pregnancy.
• If ovarian torsion is suspected, then the
patient requires surgery.
• The torsion rate of adnexal masses during
pregnancy is about 10–15%.
• The majority of ovarian torsion during
pregnancy occurs at 8–16 weeks of gestation,

15. CONTD:
• Patients having asymptomatic cysts of size 5–10 cm
are reviewed after 16 weeks of pregnancy by
ultrasonography.
• For asymptomatic cysts of size >10 cm, because of
risk of torsion, malignancy, and labour obstruction,
surgical removal is advised.
• Surgery in first trimester, can increase the risk of
miscarriage and loss of luteal function.
• The recommendation to perform surgery is during the
second trimester rather than the third trimester is
primarily mechanical.
• The risk of preterm labour may be lower when surgery
is performed during the second trimester than
compared in the third trimester.

17. SURGICAL
APPROACH:
LAPAROTOMY
• Safer.
• Less anesthesia side
effects.
• Minimal uterine
manipulation.
LAPAROSCOPY
Optimally scheduled between 16 and 20
weeks of gestation.
Allows only mild inclination, to avoid
hypovolemia, hypotension and hypoxemia.
Primary trocar insertion should be by
open laparoscopy and supra-umbilical to
limit the chance of uterine perforation
by insertion of a Veress needle .

18. IF MALIGNANT?
• Very very rare.
• Most frequently reported are the non-epithelial tumours (germ-cell and sex-
cord) followed by epithelial ovarian cancers.
• For early stage ovarian cancer, stage I and II, pregnancy preserving treatment
may be considered.
• Removal of the adnexa and surgical staging by cytology, peritoneal biopsies,
omentectomy and appendectomy in mucinous tumours.
• For high-grade stage I and any stage II disease, standard adjuvant
chemotherapy (carboplatin-paclitaxel) can be considered after 14weeks of
gestation.

19. CONTD:
• For advanced stage III and IV, adnexectomy/biopsy
during pregnancy is aimed for, followed by completion of surgery
after delivery.
• When the patient wants to proceed the pregnancy, neoadjuvant
chemotherapy (carboplatin and paclitaxel) until fetal maturity
and complete cytoreductive surgery after delivery is
recommended.

20. REFERENCES:
• de Haan J, Verheecke M, Amant F. Management of ovarian cysts and cancer in pregnancy. Facts
Views Vis Obgyn. 2015;7(1):25-31. PMID: 25897369; PMCID: PMC4402440.
• Kamalimanesh, Batool, Reza Jafarzadeh Esfehani, and Jila Agah. "Papillary serous
cystadenoma of ovary: A huge ovarian cyst complicating the pregnancy." J Cases Obstet
Gynecol 3.4 (2016): 121-4.
• Kalmantis K, Petsa A, Alexopoulos E, Daskalakis G, Rodolakis A. Ovarian cysts in pregnancy.
surgical treatment required and when monitoring preferred?
• Rodriguez, S., Aviles, T. and Faro, R. (2021) ‘A Rapidly Enlarging Ovarian Cyst in a
Pregnant Patient: The Surprise’, <i>Journal of Scientific Innovation in Medicine</i>, 4(2),
p. 39. Available at: https://doi.org/10.29024/jsim.140.