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OBSTETRICS

The Prevalence of Incidental Simple Ovarian Cysts 3 cm Detected by Transvaginal Sonography in Early Pregnancy
Phyllis Glanc, MD,1 Nicole Brofman, MD,2 Shia Salem, MD,3 Anat Kornecki, MD,4 Jason Abrams, BSc,5 Dan Farine, MD6
1 2 3 4

Department of Medical Imaging, Sunnybrook Health Sciences Centre, Womens College Hospital, Toronto ON Clinica Imagem Centro Diagnostico, Florianopolis, Brazil Department of Medical Imaging, Mount Sinai Hospital, Toronto ON

Department of Diagnostic Radiology and Nuclear Medicine, Faculty of Medicine & Dentistry, London Health Sciences Centre (University Campus), London ON Schulich School of Medicine and Dentistry, University of Western Ontario, London ON Department of Obstetrics and Gynecology, Mount Sinai Hospital Toronto ON

5 6

Abstract
Objective: To determine the prevalence of simple ovarian cysts of 3 cm diameter detected by transvaginal sonography (TVS) in a population of asymptomatic women in early pregnancy. Methods: We conducted a retrospective review of 10 830 consecutive women presenting prior to 14 weeks gestational age (GA) for early dating TVS. The records of all women with simple cysts 3 cm in diameter were included. The study population was divided into five groups by GA: 6 weeks; 6.18 weeks; 8.110 weeks; 10.112 weeks; and 12.114 weeks. Results: A simple cyst 3 cm in diameter was present in 4.9% of women at 6 weeks gestation, in 5.1% between 6.1 and 8 weeks, in 5.3% between 8.1 and 10 weeks, in 3.2% between 10.1. and 12 weeks, and in 1.5% between 12 and 14 weeks. Overall, a simple cyst 3 cm was present in 516 women (4.8%). Prior to 10 weeks, 5.1% had simple cysts 3 cm, dropping to 2.7% after 10 weeks, a statistically significant decrease ( P < 0.0001). Between 10.1 weeks and 12 weeks, the prevalence dropped to 3.2%, and then to 1.5% in the 12.114 week group. Conclusion: This investigation provides reference data on the prevalence of detecting simple ovarian cysts 3 cm by TVS in an asymptomatic early pregnancy population. A progressive decline in the frequency of detecting simple ovarian cysts 3 cm begins after 10 weeks gestational age.

Rsum
Objectif : Dterminer la prvalence des kystes ovariens simples dont le diamtre 3 cm qui sont dcels par chographie transvaginale (TV) au sein dune population de femmes asymptomatiques aux dbuts de la grossesse. Mthodes : Nous avons men une analyse rtrospective portant sur e 10 830 femmes conscutives se prsentant avant la 14 semaine de gestation (SG) pour une TV de datation prcoce. Les dossiers de toutes les femmes prsentant des kystes simples dont le diamtre 3 cm ont t retenus. La population ltude a t divise en cinq groupes, en fonction du nombre de SG : 6 semaines; 6,18 semaines; 8,110 semaines; 10,112 semaines; et 12,114 semaines . Rsultats : Un kyste simple dont le diamtre 3 cm tait prsent chez 4,9 % des femmes 6e semaine de gestation; chez 5,1 %, e e entre la 6,1 et la 8 semaine de gestation; chez 5,3 %, entre la e e e 8,1 et la 10 semaine de gestation; chez 3,2 %, entre la 10,1 et e e la 12 semaine de gestation; et chez 1,5 %, entre la 12 et la 14e semaine de gestation. Globalement, un kyste simple 3 cm e tait prsent chez 516 femmes (4,8 %). Avant la 10 semaine de gestation, 5,1 % des femmes prsentaient des kystes simples 3 cm, pourcentage qui passait 2,7 % aprs la 10 e semaine de gestation, soit une baisse significative sur le plan statistique e e (P < 0,0001). Entre la 10,1 et la 12 semaine de gestation, la prvalence est passe 3,2 %, puis 1,5 % dans le groupe e e 12,1 14 semaine de gestation. Conclusion : Cette recherche offre des donnes de rfrence quant la prvalence de la dtection de kystes ovariens simples 3 cm par TV au sein dune population asymptomatique aux dbuts de la grossesse. Un dclin progressif de la frquence de la dtection de kystes ovariens simples 3 cm se manifeste la suite de la e 10 semaine de gestation. J Obstet Gynaecol Can 2007;29(5):502506

Key Words: Ovary, cyst, early pregnancy, transvaginal sonography Competing Interests: None declared. Received on October 16, 2006 Accepted on January 9, 2007

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The Prevalence of Incidental Simple Ovarian Cysts 3 cm Detected by Transvaginal Sonography in Early Pregnancy

Figure 1. Percentage with simple ovarian cysts 3 cm by gestational age

Percentage

6.0% 4.9% 5.0% 4.0% 3.2% 3.0% 2.0% 1.0% 0.0% <6 6.1 - 8 8.1 - 10 10.1 - 12 Gestational Age (weeks) 12.1 - 14 5.1% 5.3%

1.5%

INTRODUCTION

he widespread use of early pregnancy ultrasound examinations has created controversy about how the additional information should be incorporated into existing management protocols.1 The assessment of the ovaries and adnexa is considered to be an integral component of the early pregnancy ultrasound examination.24 The majority of first trimester ultrasound examinations will identify a simple cyst prior to eight weeks gestational age (GA).57 Typically these represent hormonally responsive cysts in the 1 to 3 cm range, such as the corpus luteal cyst of pregnancy, which present no risk to the pregnancy. The corpus luteum is required initially to maintain the pregnancy, with regression occurring at approximately eight weeks gestation as the placenta takes over progesterone production.5,711

biometric data (crownrump length or gestational sac mean diameter) corresponding to 14 weeks GA. If a woman had more than one ultrasound evaluation within the same pregnancy, only the first was included. Acutely symptomatic women, women with a suspected or confirmed ectopic pregnancy, and women with higher order pregnancies were excluded from the study. All ultrasound examinations were performed with a 4 to 8 MHz transvaginal transducer (Phillips ATL 1500) by experienced certified sonographers, as was routine in this dating population. All cases were supervised by a radiologist. The study was approved by the Research Ethics Board of Sunnybrook and Womens College Health Sciences Centre. Standard transvaginal technique was used, with an empty maternal urinary bladder. Once the transducer was placed into the vagina and advanced to the posterior fornix, an attempt to visualize the ovaries was initially made along both sides of the uterus, especially at the level of the cornua. If this method failed, the area along the internal iliac vessels would be insonated. If insonation was unsuccessful, gentle manual pressure was applied to the anterior lower abdominal wall to bring the ovary to the field of view of the transducer or to displace overlying bowel loops. The presence of an ovary was confirmed in two orthogonal views, as was the presence of a simple cyst, and the views were recorded on videotape. The maximum diameter of a simple cyst was recorded. A simple cyst was defined as a thin-walled anechoic structure with no internal echogenicity or septations. Only simple cysts of 3 cm diameter were included in the study. All other ovarian lesions were excluded.
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This study was undertaken to determine the prevalence of a subset of ovarian lesions, the simple cyst measuring 3 cm in diameter discovered incidentally by transvaginal sonography (TVS) during early pregnancy. This information on the prevalence during early pregnancy of the larger simple cyst may be helpful to guide early management of asymptomatic patients.
MATERIALS AND METHODS

The records of a population of women in early pregnancy presenting consecutively for a dating ultrasound between January 2000 and December 2003 at the Womens Health Centre in Toronto, Ontario, were reviewed. The study population included all women with a confirmed intrauterine pregnancy (yolk sac, embryo, and/or fetus present) and

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Size of simple cysts

Gestational age 6 weeks 6.18 weeks 8.110 weeks 10.112 weeks 12.114 weeks Mean diameter (cm) 4.3 4.1 4.2 3.7 4.6 Maximum diameter (cm) 10.7 12.7 8.6 5.8 5.9

The study population was divided into five chronological groups according to gestational ages: 6 weeks (group 1); 6.1 to 8 weeks (group 2); 8.1 to 10 weeks (group 3); 10.1 to 12 weeks (group 4); and 12.1 to 14 weeks (group 5). The gestational age groups were compared for the presence of ovarian cysts using a chi-square test.
RESULTS

difference in prevalence between the first three chronological GA groups. Between 10.1 and 12 weeks GA the prevalence reduced to 3.2%, subsequently reducing to 1.5% in the 12.1 to 14 weeks GA group. During the four years of the study, the annual overall frequency of detecting a simple ovarian cyst 3 cm did not vary significantly (ranging from an annual minimum of 4.2% to an annual maximum of 5.5%), suggesting that neither equipment nor sonographer bias affected the results. The size range for ovarian cysts across the chronological GA groups also did not vary significantly.
DISCUSSION

The study population included 10 830 pregnant women in whom both ovaries were visualized. There were 1942 women (17.9%) in group 1; 4581 (42.3%) in group 2; 2727 (25.2%) in group 3; 1165 (10.8%) in group 4; and 415 (3.8%) in group 5. The scan and reporting protocols included routine imaging of the adnexa and comments on all simple cysts 3 cm in diameter or any complex lesion, thus achieving uniformity in the reporting standard. Lesions were characterized as either simple or complex. There was an equal distribution of simple cysts in the right ovary and in the left ovary. Overall 272 women (2.5%) had a simple cyst 3 cm in the right ovary, 249 (2.3%) had a simple cyst 3 cm on the left, and 6 (0.1%) had bilateral simple cysts 3 cm. A complex ovarian lesion was present in 258 women (2.4%), and 22 women (0.2%) had both a simple cyst 3 cm and a complex ovarian lesion. No further analyses of the complex ovarian lesions were performed for the purposes of this study. A simple cyst 3 cm was present in 96 women (4.9%) in group 1; in 233 (5.1%) in group 2; in 144 (5.3%) in group 3; in 37 (3.2%) in group 4; and in 6 (1.5%) in group 5 (Figure 1). The mean diameter of a simple cyst 3 cm was 4.3 cm (maximum 10.7 cm) in group 1; 4.1 cm (maximum 12.7 cm) in group 2; 4.2 cm (maximum 8.6 cm) in group 3; 3.7 cm (maximum 5.8 cm) in group 4; and 4.6 cm (maximum 5.9 cm) in group 5 (Table). Overall, a simple cyst 3 cm was present in 516 (4.8%) pregnant women. Prior to 10 weeks GA, 5.1% of women had simple cysts 3 cm. After 10 weeks GA, 2.7% of women had simple cysts 3 cm, a statistically significant decrease (P < 0.0001) (Figure 2). There was no significant
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The widespread use of diagnostic ultrasound during pregnancy has contributed to an increase in the incidental detection of ovarian lesions. The purpose of our study was to determine the prevalence of detecting larger simple ovarian cysts of 3 cm diameter by TVS in early pregnancy, thus providing reference data that may be used in counselling patients or managing early pregnancies. The study population comprised consecutive asymptomatic patients who presented for a dating ultrasound in an outpatient clinic setting at 14 weeks GA and who subsequently underwent routine TVS. Acutely symptomatic patients, patients with a suspected or confirmed ectopic pregnancy, and patients with higher order pregnancies were excluded from the study. The threshold diameter of 3 cm was chosen because the routine scan and reporting protocols required specific comments on any simple cyst 3 cm in diameter or any complex lesion (including hemorrhagic corpus luteal cysts). This diameter (3 cm) of cyst is commonly used as a threshold to prompt a recommendation for a follow-up ultrasound.5 Although the reporting structure included quantification and description of the complex lesions, no follow-up was obtained in these cases, limiting the utility of this information. This study has a number of significant limitations, particularly the retrospective nature of the data and the lack of longitudinal data. The strength of the data lies in the large

The Prevalence of Incidental Simple Ovarian Cysts 3 cm Detected by Transvaginal Sonography in Early Pregnancy

Figure 2. Percentage of simple cysts = 3 cm < or > 10 weeks Gestational Age

6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0%

Percentage

< 10

> 10
P < 0.0001

Gestational Age (weeks)

number of data points (> 10 000), permitting crosssectional population data analysis on the prevalence of the subset of simple cysts 3 cm during early pregnancy. In 99.5% of women with sonographically confirmed pregnancies 14 weeks GA, one or both ovaries can be visualized by TVS.1215 In the present study, a simple cyst 3 cm was present in 4.8% of women. Previous reports have suggested a peak incidence of pregnancy-associated ovarian cystic lesions at approximately eight weeks gestation, with subsequent regression,6,9 but our findings suggest that regression in the subset of simple cysts 3 cm may be delayed until after 10 weeks gestation. It is widely acknowledged that the majority of ovarian masses identified in early pregnancy are physiological, hormonally responsive cysts that represent no risk to the pregnancy and that may be followed expectantly.6,1619 The fact that most simple cysts regress, sometimes after 10 weeks gestation, will be reassuring when counselling a pregnant patient with an incidentally discovered simple ovarian cyst 3 cm.2024 This information supports the practice of delaying a repeat ultrasound examination in women found to have a simple cyst until at least 12 to 14 weeks gestation. In pragmatic terms, one may consider combining a repeat examination with the timing of the nuchal translucency ultrasound examination at 11 to 14 weeks. If the lesion has decreased in size, no further follow-up is necessary. If the lesion has remained stable, has increased in size, or has developed internal complexity, then further evaluation is required to determine appropriate management.2529

CONCLUSION

This study provides reference data on the prevalence of detecting simple ovarian cysts 3 cm in diameter by TVS in a population of asymptomatic women with an early pregnancy. The results demonstrate a progressive decline in the frequency of detecting simple ovarian cysts 3 cm after 10 weeks gestational age.
ACKNOWLEDGEMENTS

The authors wish to thank Terri Myhr MSc, Research Manager at the Research Facilitation Office of the Centre for Research in Womens Health, for undertaking the statistical analysis on the project.
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