Case Report

DOI: 10.17354/cr/2015/03

Dilemma in the Management of Ovarian Cyst in

Pregnancy: ASeries of Three Different Cases
Ramya Ramadoss1, P Abhinaya1, Jamila Hameed2, N Narmadha3, S Radhika2

1
Post-graduate, Department of Obstetrics and Gynaecology, Vinayaka Missions Medical College and Hospitals, Karaikal, Puducherry, India, 2Professor,
Department of Obstetrics and Gynaecology, Vinayaka Missions Medical College and Hospitals, Karaikal, Puducherry, India, 3Senior Resident,
Department of Obstetrics and Gynaecology, Vinayaka Missions Medical College and Hospitals, Karaikal, Puducherry, India

The incidence of ovarian cyst in pregnancy is increased due to ovulation induction and dating ultrasound. Mostly they are benign and managed
by observation. Surgery is indicated if there are complications or any suspicion of malignancy. Here, we have presented three different cases of
ovarian cyst in pregnancy, which was managed by surgery. The first case is a 27-year-old second gravida with para1 live1 with complaints of
pain in right iliac fossa at 15weeks of gestation that was diagnosed as a dermoid cyst of right ovary. She underwent laparoscopic cystectomy.
Rest of the antenatal period was uneventful, and she delivered vaginally at term. The second case is 31year old third gravida with para2 live2
came with complaints of lower abdominal pain around 14weeks of gestation which was diagnosed as fibroma of ovary for which laparotomy
and right salphingo-oophorectomy was done. Rest of the antenatal period was normal, she delivered by caesarean section at term. The third
case was 30-year-old second gravid with para1 live1 with left ovarian mass presented at term for which cesarean section along with left
salphingo-oophorectomy done.

Keywords: Cesarean section, Ovarian cyst, Pregnancy

INTRODUCTION
The incidence of adnexal masses in pregnancy ranges from
1 in 81 to 1 in 8000 pregnancies.1 The incidence of ovarian
cyst in pregnancy is increased with the use of dating
ultrasound in the first trimester and also due to an increase
in ovulation induction. It enhances anxiety to the pregnant
women as it involves increased investigations, admission
and antenatal visits.2 The most common types are dermoid
25%, corpus luteal cyst, functional cyst, paraovarian 17%,
serous cystadenoma 14%, mucinous cystadenoma 11%,
enodmetrioma 8%, carcinoma 2.8%, low malignant potential
tumor 3% and leiyomyoma 2%.3 Complications of the cysts
associated with pregnancy are torsion, rupture, infection,
malignancy, impaction of cyst in the pelvis causing retention
of urine, obstructed labor and malpresentations of the
fetus. Ovarian cysts should be differentiated from uterine
leiomyoma, non-pregnant horn of bicornuate uterus,
appendiceal abscess, diverticular abscess, pelvic kidney,
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retroperitoneal tumor, endometrioma, hydrosalphinx,

mesenteric cyst, abdominal pregnancy, metastatic
lymphoma and sarcoma. 4 Asymptomatic and benign
cysts can be managed conservatively and typically resolve
through the pregnancy or in the postnatal period. Persistent
symptomatic ovarian cysts are at increased risk of torsion,
rupture and rarely obstructing labor and few cases with
atypical features may represent malignancy. In these
instances, surgical intervention may be done.2 If the surgery
is needed it is ideal to perform a laparoscopic ovarian
cystectomy at 16-23weeks of gestation.5 However at any
time, if there is evidence of malignancy, torsion or rupture
immediate surgery is required.6

CASE REPORTS
The consent from Ethical Committee of our college and
patients consent were obtained.
Case 1
A 27-year-old gravida 2 para1 live1 presented in our
antenatal clinic with dating scan for routine antenatal
checkup at 10weeks of gestation. The ultrasound showed
a single live intrauterine gestation corresponding to
10weeks 3days with complex cyst measuring 6.6cm
3cm 2.8cm originating from the right adnexal echogenic
mass with shadowing suggestive of dermoid cyst seen. The

Corresponding Author:
Dr.Jamila Hameed, Department of Obstetrics and Gynaecology, Vinayaka Missions Medical College & Hospitals, Karaikal, Puducherry, India.
Phone:+91-9444611107. E-mail: jamilahameed@gmail.com

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Ramadoss, et al.: Ovarian Cyst in Pregnancy

patient had no specific complaints. She was asked to come

for regular antenatal checkup and repeat ultrasound was
performed at 12thand 14thweek of gestation that revealed
no increase in the size of the cyst. Around 15weeks of
gestation, patient came with acute lower abdominal
pain. On general examination, her vitals were stable. Per
abdomen revealed tenderness and guarding in the right
iliac fossa. Basic laboratory investigations were normal.
Ultrasound confirmed single live fetus with biparietal
diameter and abdominal circumference corresponded
to gestational age and an echogenic mass of size 6.8cm
2.5cm 3cm with shadowing in the right adnexa. On
laparoscopy, gravid uterus with normal left ovary and
tubes, smooth peritoneal surface and a cyst of size 6cm
3cm 3cm (Figure 1) was found in the right adnexae.
Laparoscopic cystectomy was performed by dissecting
away the cyst from the right ovarian tissue. Peritoneal wash
was given. The intra-abdominal pressure was maintained
below 12mmHg throughout the procedure. Fetal heart
rate monitored before and after the procedure which was
normal. Post-operative period was uneventful, and the
patient was discharged after a week. Histopathological
examination of the cyst suggested dermoid. Patient was
asked to review once in every 2weeks in the antenatal clinic,
and the subsequent antenatal period was uneventful. At
38weeks, she presented with labor pain and spontaneously
delivered an alive, healthy female baby weighing 2.7kg
with Apgar score 8 at 1min and 9 at 10min.

in the left iliac fossa. Basic laboratory investigations were

normal. We advised ultrasound abdomen that showed a
single live intrauterine gestation corresponding to 13weeks
2days along with a solid hyperechoic mass in the right
pelvic adnexa measuring 86mm 60mm 58mm size.
Laparotomy was done. Afirm mass of size 90mm 50mm
50mm (Figure2) found in the right adnexa next to the
gravid uterus. The adnexal mass was removed. Fetal heart
rate monitored before and after the procedure that was
normal. Post-operative period was uncomplicated and
patient discharged after a week. Histopathology of the
cyst was suggestive of fibroma of ovary. Patient was asked
to review once in every 2weeks in the antenatal clinic and
the subsequent antenatal period was uneventful. She was
admitted at 39weeks with spontaneous labor and due to
non-progression of labor, she had lower segment cesarean
section done. Per operatively both her ovaries and tubes
were normal. An alive female baby weighing 3.4kg with
Apgar score of 7 at 1 and 10 at 10min was born.

Case 2
A 31-year-old gravida 3 para2 live2 presented in our
antenatal clinic for routine antenatal check-up at 14weeks
of gestation with complaints of lower abdominal pain.
Pregnancy was confirmed outside by urine pregnancy test
at 8weeks of gestation. In the first trimester, patient had
no specific complaints. On examination, her vitals were
stable. Per abdomen revealed tenderness and guarding

Figure 2: Fibroma of ovary

Figure 1: Laproscopic cystectomy in pregnancy (16 weeks): A case of dermoid

Figure 3: Serous cystadenoma of ovary

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Ramadoss, et al.: Ovarian Cyst in Pregnancy

Case 3
A 30-year-old second gravid live1 presented in our
antenatal clinic for the first time at 38weeks of gestation
with complaints of abdominal pain. Patient had an
ultrasound report which showed left ovarian cyst of
size 10 cm 9 cm. Per abdomen revealed excessively
distended abdomen with mild uterine contractions.
Ultrasound suggested single viable fetus corresponding
to 37weeks 2days with good cardiac activity and a single
anechoic cystic lesion of size 9cm 8cm (Figure3) with
thin septations and no solid components lying above the
uterus. Caesarean section done and she delivered an alive
and healthy male baby of weight 2.5kg delivered with
Apgar score of 8 at 1min and 10 at 10min following which
left salphingo oophorectomy was done. The other side
tube and ovary were normal. Post-operative period was
uneventful and patient discharged on 7thpost-operative
day after suture removal. Histopathology of the cyst
suggested serous cystadenoma of the ovary.

DISCUSSION
The frequency of ovarian cyst in pregnancy ranges from 1 in
81 to 1 in 8000 pregnancies1 and those which are malignant
represent about 1 in 15,000 to 32,000 pregnancies.2 Most
often the cyst present in the first trimester are functional
cysts and are asymptomatic, usually disappear after first
trimester. Some become persistent and cause complications
or become malignant.7
Ultrasound is the primary investigation used for
differentiating benign from malignant lesions based on
morphology.8 The level of tumor markers like CA125,
hCG are insignificant in diagnosis as they are usually raised
in pregnancy. However, they can be used as indicators for
the followup in tumour control.9

Each case has to be individualized, and the management

should be done accordingly.
Giant ovarian cyst in pregnancy when it causes symptoms,
malignancy should be ruled out following which puncture
can be done during pregnancy, later in the postpartum
period cystectomy can be done.13
In a study it is stated that surgical intervention done
even in the second trimester may result in preterm labor,
miscarriage and intrauterine growth restriction.15 When
surgery is done in case of malignancy, staging has to be
done. Sometimes chemotherapy can be used in pregnancy
for a malignant tumor with minimal fetotoxic drugs when
maternal mortality outweighs the fetal outcome.16

CONCLUSION
The management of ovarian cyst in pregnancy is usually
conservative with serial ultrasound monitoring. The
nature of an ovarian cyst should be studied in detail and
malignancy has to be ruled out. If the surgery is indicated
laparoscopic cystectomy can be done without much
complication between 16 and 23weeks. Anxious patient
should be counseled about the pros and cons of conservative
and surgical management.

ACKNOWLEDGMENT
Dr. Suriyaprakash, CRRI in Department of Obstetrics and
Gyneaccology, Vinayaka Missions Medical College and
Hospitals, Karaikal.

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There is a study where a right serous cyst, which was

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How to cite this article: Ramadoss R, Abhinaya P, Hameed J, Narmadha N,
Radhika S.Dilemma in the management of ovarian cyst in pregnancy: Aseries
of three different cases. IJSS Case Reports & Reviews 2015;1(8):10-13.
Source of Support: Nil, Conflict of Interest: None declared.

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