Early Human Development, Elsevier Scientific Publishers

EHD

29 (1992) 363-361 Ireland Ltd.

363

01304

Antenatally detected ovarian cysts dilemma

a therapeutic

S. Suita”, N. Handaa and H. Nakanob ‘Department

of Pediatric

Surgery,

bDepartment of Obstetrics and Gynecology, Kyushu University, Fukuoka (Japan)

Faculty

of Medicine,

Twenty-four instances of ovarian cysts detected antenatally are reported. Most cysts were functional in origin, histologically benign simple cysts. Pregnancy was clinically uncomplicated in all, followed by a spontaneous vaginal delivery in 20 cases between the 33rd and 41st week, four neonates were delivered by a cesarean section for obstetrical reasons. Nine cysts more than 5 cm in diameter at birth were treated surgically. The operative indications were as follows; 5 neonates had clinical symptoms caused by abdominal distention or vomiting. The remaining four showed a sign of hemorrhage following torsion. Thirteen cysts less than 5 cm in diameter, and two cysts more than 5 cm in diameter began to regress spontaneously within 6 months after birth and finally 10 of them disappeared between 2 weeks and 2 years. Key words: ovarian cyst; antenatal diagnosis

Introduction Neonatal ovarian cysts of clinical significance have previously been considered uncommon. With the increased use of sonography, antenatal and postnatal detection of both small and large cysts has increased [l-3]. This increased incidence in perinatal diagnosis of ovarian cysts poses new therapeutic dilemmas. Previous reports stressed a high percentage of complications and recommended early surgery in all newborns with ovarian cysts. Because of the decrease in hormonal stimulation that occurs after birth, ovarian cysts especially of small diameter, should spontaneously regress and more conservative management may be equally effective. Correspondence to: S. Suita, Department of Pediatric Surgery, Fukuoka Maidashi, Higasi-Ku, Fukuoka-shi 812, Japan. 0378-3782/92/%05.00 Printed and Published

0

1992 Elsevier in Ireland

Scientific

Publishers

Faculty

Ireland

of Medicine,

Ltd.

Kyushu

University,

364

The purpose of this paper is to analyse 24 instances of antenatally detected ovarian cysts and propose a suitable regimen of management for ovarian cysts detected antenatally. Patients, Methods and Results Between January 1976 and October 1991, 24 instances of antenatally diagnosed ovarian cysts came to our attention. The cysts were detected between the 28th to the 40th gestational weeks during routine ultrasonographic examination in 22 instances. The remaining two cysts were detected because of investigations for delay of delivery in one instance and because of intrauterine growth retardation in the other. The size of the cysts at the diagnosis were < 3 cm in diameter in three cases, 3-5 cm in 11 cases and > 5 cm in 10 cases. Pregnancy was clinically uncomplicated in all, followed by a spontaneous vaginal delivery in 20 cases between the 33rd and the 41st week. Four neonates were delivered by an Cesarean section, because of obstetrical reasons. The weight of the placenta was between 450 and 700 g, this was a normal range approximately one-sixth to one-fifth the birth weight of each of the neonates. All newborns were in good condition with normal Apgar score and birth weight over 2500 g except one with 2218 g. There were three patterns of size change in the cysts, such as increase tendency, decrease tendency and no changes (Fig. 1). In nine of the newborns, the cysts were treated surgically. All cysts were more than 5 cm in diameter at birth. The indications of operation were as follows; 5 neonates had clinical symptoms caused by abdominal distention or vomiting. The remaining four neonates had no clinical symptoms, but no changes in cyst size. Solid area demarcated with a septum was noted on the ultrasonogram in the cysts, suggesting a hemorrhage following torsion. The age at the operation was between 3 days and 6 months. The affected side was different from the preoperative diagnosis in four. Three cysts operated upon showed counterclockwise torsion; 180, 360 and 180 degree. Furthermore, one showed autoamputation and floating cyst was found in the abdominal cavity. Oophorectomy was performed in 6 of them and excision of cyst in 3 cases leaving a small part - OPERATED

GROUP

(cm)

-

- NON-OPERATED

GROUP

-

(cm) 100 -

50-

-T

at diagnosis

at birth

~~~

at operation

Fig. 1. Patterns of size changes in cysts.

3vlc

365

of ovarian tissue. Five of the contralateral ovary showed a minor cystic lesion, which was not detected antenatally and remained untouched. Histological examination revealed follicular cysts in four instances, a follicular-lutein cyst in one and necrotic ovarian tumour with no specific epithelial findings in two, hemorrhagic cyst in one and unknown in one. Fifteen of the neonates were managed conservatively and followed at one week to three months intervals by ultrasound examination. Except two, the size of these cysts were less than 5 cm in diameter at birth and the size decreased gradually. Finally 10 of them disappeared spontaneously between 2 weeks and 2 years. The concentration of luteinizing hormone (LH), follicular stimulating hormone (FSH) in the plasma of the infants showed normal range except for two cases. The infants with high concentration of plasma LH and FSH had no clinical abnormalities and their levels of LH and FSH returned to normal range within 3 weeks after birth. The concentration of LH and FSH in the cystic fluid was higher in infants who were operated on early as opposed to those operated on late. Discussion Ultrasound examination for fetal ovarian cyst diagnosis can be made by three basic criteria; (1) confirmation of female gender. (2) identification of normal urinary tract anatomy (kidneys, ureters and bladder) in both full and empty states, and (3) identification of normal gastrointestinal tract structures (stomach, small and large bowel) [2]. As to the antenatal complications of fetal ovarian cysts, there are few reports about visceral compression such as renal compression, displacing the fetal diaphragm upward compressing the thorax. Rupture of the cyst is a relatively rare complication while torsion is the most important complication. The true incidence of torsion is not known. But nearly 20-30% had been reported and in our series, 4 of the 24 cases (16.7%) showed torsion. Most torsions occur antenatally. Antenatal suspicion of torsion is based on a change in cyst appearance on serial sonograms: an echolucent, simple cyst became echodense and complex with septa formation, development of a fluid-debris level or finding of a retracing clot. Interestingly, there is no evidence of fetal distress or decompensation in utero [4,5]. Cyst

< 5 cm in diameter

without

sludge

with

Cyst

2 5 cm in diameter

sludge

L serial J Spontaneous resolution

US L

\ No resolution or P increase in size

” Operation

Fig. 2. Proposed therapeutic regimen for the treatment of ovarian cysts.

366

Significant questions arise regarding the optimal delivery route for the fetus with ovarian cyst. At the early stage, many authors have recommended cesarean section with a large ovarian cyst to avoid catastolophic rupture [6]. However, based on the analysis of the many reported cases, routine cesarean delivery predicted alone on cyst size is not necessary. Cesarean section should be performed for obstetrical indication only. What is the optimal management of the newborn with an ovarian cyst? Because ovarian cyst formation’ in the perinatal period is a self-limiting process, treatment options depend on the risk of complications and the ability to differentiate these benign cysts from other ovarian tumour [7]. Based on our experience, we propose the therapeutic regimen for the treatment of neonatal ovarian cyst as shown in Fig.2. When the cyst size is less than 5 cm in diameter and without sludge in the cyst, it should be left in tact with serial ultrasound examination. They will resolute within 6 months. No resolution and/or sludge formation in the cyst, or larger than 5 cm in diameter at birth, timely surgical intervention will avoid potential complications. As to the surgical procedure, oophorectomy, cystectomy, unroof of the cyst and aspiration of the cyst have been reported. If the ovarian tissue is viable, it should be preserved and 90% of the membrane of the cyst trimmed off. Infarction of the ovary may necessitate an oophorectomy. Brandet has reported that even if no ovary is macroscopically visible, ovarian tissue may still be present and the surgery should be limited to removal or unroofing of the cyst [3]. Recently ultrasound-guided aspiration of neonatal ovarian cyst has been reported, revealing that aspiration may be a viable option thus potentially avoiding an operation with removal of normal ovarian tissue [8]. However, aspiration of the cyst in utero is less likely to be effective, because of the continued hormonal stimulation, which would encourage regrowth of the cyst. Conclusions Neonatal ovarian cysts are being diagnosed more often now because routine ultrasonographic examinations are done antenatally and postnatally. This fact poses a therapeutic dilemmas because the natural history of these lesions is not well known. However, based on our experience, we can relate the following results: (1) most cysts are functional in origin and histologically benign, simple cyst, (2) vaginal delivery is the optimal route for delivery and the cesarean section should be performed for obstetrical indications only, and (3) the choice of postnatal therapy is dictated by the size and appearance of cyst. References 1 Suita, S., Sakaguci, T., Ikeda, K. and Nakano, H. (1990): Therapeutic dilemmas associated with antenatally detected ovarian cysts. Surg. Gynecol. Obstet., 171, 502-508. 2 Sakala, E.P., Leon, A.Z. and Rouse, G.A. (1991): Management of antenatally diagnosed fetal ovarian cysts. Obstet. Gynecol. Surg., 46, 407-414. 3 Brandt, M.L., Luks, F.I., Filatrault, D., Garel, L., Desjardins, J.D. and Youssef, (1991): Surgical .1~--~~--- ‘_ .__ .--.-,1.. >>^_____ 2 ___^Le.. ^_.^.^ 1 n...A:-... P..-- ,L ,-IL 101

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Kirkinen, P. and Jouppila, P. (1985): Perinatal aspects of pregnancy complicated by fetal ovarian cyst. J. Perinat. Med., 13, 245-251. Holzgreve, W., Winde, B.S., Willital, G.H. (1985): Prenatal diagnosis and perinatal management of a fetal ovarian cyst. Prenat. Diagn., 5, 155-158. Rizzo, N., Gabrielli, S. and Perolo, A. (1991): Prenatal diagnosis and management of fetal ovarian cysts. Prenat. Diagn., 9, 97-101. diZerega, G.S. and Ross, G.T. (1980): Clinical relevance of fetal gonadal structure and function. Clin. Obstet. Gynecol., 23, 849-853. Gaudin, J., LeTreguilly, C., Parent, P., Guern, H.L., Chabaud, J.J. and Jehannin, B. (1988): Neonatal ovarian cysts: Twelve cysts with antenatal diagnosis. Pediatr. Surg. Int., 3, 158-164.

Antenatally detected ovarian cysts--a therapeutic dilemma.

Twenty-four instances of ovarian cysts detected antenatally are reported. Most cysts were functional in origin, histologically benign simple cysts. Pr...
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