Ovarian cysts are one of the more common types of female disease, and the vast majority of them may be discovered during a physical examination or during a gynecological examination for other reasons. However, people are often anxious about the nature of ovarian cysts, especially women who are preparing to become pregnant or who are post-pregnant and are concerned about whether ovarian cysts will have a negative impact on their pregnancy.
Case Replay
Last week, Zhang, who was supposed to have a follow-up appointment in 2 weeks, came back to my clinic with a nervous look on her face and could not wait to take out an ultrasound report slip of her NT test at 12 weeks of pregnancy. The results indicated that the length of her baby’s head and buttocks were consistent with the month of menopause and the NT (thickness of the posterior nuchal translucency) was within the normal range; however, a 35 mm diameter well-defined anechoic area was found in the right posterior part of the uterus, with no blood flow signal around it and no liquid dark area in the posterior sunken recess. After routine blood pressure and weight measurements, I used the Doppler fetal heart monitor to let her hear her baby’s heartbeat for the first time, and then explained to her about this cyst that was unexpected for her. I told her that the cyst was most likely a corpus luteum cyst, and that from the current ultrasound results, it should be benign, and that it might disappear at the next examination, so there was no need to worry too much, and that she should come to the clinic at any time if she had acute abdominal pain or other discomfort. The first thing you need to do is to go home with a relaxed smile on your face.
Ovaries – the master of female endocrine
We know that the ovaries are the gonadal organs of women, a place where the endocrine function of women is in charge. After puberty, the ovaries mature and ovulate regularly. Usually, the ovaries gradually decline when women reach menopause in their 40s or 50s.
The ovary is part of the reproductive organs and has a large internal cellular component. Under the cyclic action of hormones, there is a process of development of the initiating follicle between each menstrual cycle, ovulation, and formation of the corpus luteum; if not conceived, it becomes a white body.
This shows that ovarian cells are quite active in differentiation and function, and therefore, they are also a site prone to tumor development.
What are ovarian tumors?
● Ovarian tumors can develop at all ages. Epithelial tumors occur most frequently, with the majority being between the ages of 50 and 55, followed by germ cell tumors, with the majority being in the younger age group.
The factors of ovarian tumor development are not very clear. They are related to race, environmental factors (industrial pollution, high cholesterol food, etc.), genetic factors, endocrine factors, and oncogene activation under certain circumstances.
Ovarian masses are mostly cystic masses, also commonly known as “ovarian cysts”, and are classified as pure cysts, cystic solid cysts, etc. Most of them are benign or even physiological (e.g. luteal cysts).
Benign ovarian cysts may appear on ultrasound as an echogenic area, which may be separated, with a smooth inner wall, no peripheral blood flow, and no fluid dark areas in the pelvic or abdominal cavity.
These include simple ovarian cysts, plasmacytotic ovarian cysts, mucinous ovarian cysts, benign ovarian teratomas, and endometriotic cysts (commonly known as “ovarian chocolate cysts”).
Complications can occur during the development of ovarian masses, such as tumor rupture, torsion, infection, and Menges syndrome (benign ovarian tumor with ascites).
Malignant ovarian masses are usually solid ovarian masses, or cystic masses are common. They are mostly accompanied by ascites and wasting, and the masses grow rapidly, and abnormal manifestations such as abundant local blood flow in the masses can be found during ultrasonography. At the same time, malignant ovarian masses (also called “ovarian cancer”) also have many abnormal tumor markers, such as CA125 and CA199. If there is metastasis, there will be corresponding manifestations.
What are the effects of combined ovarian cysts during pregnancy?
Usually smaller ovarian cysts do not cause significant effects.
If the cyst is large, early pregnancy may result in miscarriage due to the tumor being embedded in the pelvis and “squeezing” the uterus.
In mid-term pregnancy, as the uterus grows, the cyst (especially a medium-sized cystic ovarian cyst) can become an acute abdomen due to the change in position of the cyst and may cause abdominal pain after a change in position or morning urination, accompanied by nausea and vomiting.
The cyst may cause abnormal fetal position, rupture of the tumor or obstructed labor during delivery.
What should I do if I find ovarian cysts while preparing for pregnancy?
Physiological cysts.
For example, corpus luteum cysts are usually within 5 cm in diameter, have good mobility and no pressure pain, and most of them can disappear naturally after follow-up. Therefore, your doctor will usually recommend a review within the next 2 to 3 menstrual cycles. If the cyst persists or grows further (more than 5 cm), it will not be considered physiological, but “neoplastic” and needs to be considered for further treatment.
Simple cysts.
Mostly ovarian plasmacytic cysts. If there are multiple internal compartments, the doctor will consider mucinous cysts of the ovary to be more likely. These are from the epithelial tissue of the ovary. Sometimes papillary findings are also seen on ultrasound in the lining of the cyst, but in benign cases, there is not an abundance of blood flow in the tissue.
Cystic solid cysts.
Sometimes ovarian cysts present as cystic-solid, which means that they are partly cystic and partly solid, and are most often seen in teratomas. This tumor tissue is of diverse origin and consists of multiple germ layers. 5% to 24% are bilateral, 9% to 17% can be torsional, and skin, bone, fat, and hair are visible inside the cyst.
Chocolate cysts.
If your doctor suspects that you have an ovarian endometriosis cyst (chocolate cyst), then your doctor will want to evaluate whether your lesion will affect your pregnancy.
● Since ovarian chocolate cysts often change in size with the menstrual cycle and repeated bleeding may cause local adhesions, in addition to causing menstrual pain, they may also affect ovulation and tubal peristalsis causing difficulty in getting pregnant.
● If the cysts are not large and you have not had contraception for a long time, you can be patient and wait for a pregnancy. If pregnancy is not easy, your doctor may recommend ovarian chocolate cyst debulking, during which pelvic and abdominal adhesions can also be loosened. The success rate of pregnancy is significantly higher after most procedures. In individual cases, a short period of postoperative endocrine medication will be recommended.
If a non-physiological ovarian cyst is suspected, appropriate ancillary tests may be performed to check serum for tumor markers to identify the nature of the tumor. However, in such cases, if pregnancy is not urgently needed, surgery for ovarian cysts can be performed first.
Nowadays, surgical and anesthesia techniques are improving, and in many cases, open surgery is no longer needed, but non-invasive laparoscopic surgery, so that not only the postoperative recovery is fast, but also there is no surgical scar on the abdomen.
In addition, the cysts are sent to the pathology department for pathological diagnosis after the surgery, which can clarify the nature of the ovarian cysts and eliminate the doubts and worries if they develop after pregnancy.
Types of ovarian cysts in pregnancy
In many cases, it is after pregnancy that ovarian cysts are discovered, overshadowing the excitement that would otherwise be associated with pregnancy with a layer of anxiety. With this comes the question of whether the ovarian cyst is malignant? Will it cause a miscarriage or premature birth? Will it affect delivery? Does it require surgery? The questions come and go, sometimes even running to multiple hospitals for checkups and consultations.
Pregnancy in combination with ovarian cysts is more common
Ovarian cysts combined with pregnancy is still relatively common, but it should be taken seriously because of the increased risk of ovarian cysts combined with pregnancy compared to non-pregnancy. The clinical manifestations of combined ovarian cysts in pregnancy are mostly inconspicuous and are often detected during early pregnancy triage or complications, or accidentally during prenatal ultrasound.
In pregnancy, more than 90% of benign ovarian cysts are mature cystic teratomas and plasmacytic or mucinous cystadenomas.
Malignant tumors combined with pregnancy are extremely rare accounting for about 5% of ovarian tumors combined with pregnancy, but some of these cases are more dangerous and can endanger maternal life. Asexual cell tumors are more common in young mothers, followed by embryonal carcinoma, immature teratoma and endodermal sinus tumor, and epithelial ovarian cancer is more common in mothers around 40 years old. Due to pelvic congestion and rapid tumor growth during pregnancy, malignant cases are very likely to spread.
In addition to the above-mentioned ovarian neoplastic cysts, there are also ovarian cysts that are caused by the unique hormonal “stimulation” during pregnancy.
Luteal cysts in pregnancy are usually common within the third trimester and occur unilaterally. On pelvic examination, a cystic mass can be found on one side of the uterus, usually less than 5 cm in diameter, with good mobility and no pressure pain. Ultrasonography reveals a well-defined echogenic zone in the adnexal region with smooth inner wall and no obvious blood flow signal in the periphery. Luteal cysts in pregnancy usually become smaller and disappear after the third month of pregnancy, and are not prone to rupture or torsion.
Luteinizing cysts after ovulation promotion therapy
Another condition, which tends to occur after ovulation treatment, is ovarian hyperstimulation due to the stimulation of topical ovulation-promoting drugs, which tends to develop larger lutein membrane cysts, which occur bilaterally, with internal separation, sometimes accompanied by ascites, and even triggering electrolyte disturbances. This condition requires hospitalization for observation and treatment to correct the water-electrolyte balance.
What should I do if ovarian cysts are found during pregnancy?
The doctor will decide the treatment based on the clinical presentation, ultrasound pattern, tumor size and the gestational week.
Early Pregnancy
If the ovarian tumor is less than 5 cm in diameter, luteal cysts in pregnancy cannot be completely excluded, and surgery at this time is also likely to lead to miscarriage, so its growth can usually be closely monitored.
Optimal surgical period
Experts generally consider 14 to 16 weeks of gestation to be the most appropriate period for surgery for ovarian cysts (and other ovarian masses as well).
At this time, the fetus is basically developed, and anesthesia and medication will not increase the risk of fetal malformation.
In addition, the uterus is not overly enlarged at this time, leaving some space in the abdominal cavity, which facilitates laparotomy. The surgeon will perform unilateral adnexal resection or tumor removal according to the situation, and postoperative care should be taken to actively preserve the fetus to prevent miscarriage.
● Due to the current advances in anesthesia and laparoscopic surgery, laparoscopic ovarian cyst debridement or resection under general anesthesia is increasingly performed during pregnancy, and the postoperative recovery is fast, and there is no scar of conventional open surgery in the abdomen, which relieves the discomfort caused by the scar of abdominal surgery as pregnancy progresses, etc.
After 28 weeks of gestation, the uterus has occupied most of the abdominal cavity, which makes the operation difficult and makes the operation more difficult and prone to preterm labor, so it is best to wait until after delivery under close observation.
As we all know, the specimens removed during surgery should be sent to the pathology department for pathological diagnosis to find out the origin of the tumor and the nature of the tumor, except for malignant lesions. When the mass is suspected to be malignant, fresh tissue specimens will be sent for frozen pathology during routine surgery to determine the extent of further surgery. However, frozen pathology results during pregnancy may be influenced by pregnancy hormones and may easily affect the tissue grading of the tumor. Therefore, despite the intraoperative sending of frozen pathology, it is still recommended to wait for the final paraffin pathology section results, so a second surgical treatment may be required.
What is the mode of delivery if I have ovarian cysts?
Is it necessary to have a cesarean section and surgery for ovarian cysts at the same time? “If the ovarian cyst does not obstruct the birth canal or if there is a risk of rupture during labor, it is generally not indicated for termination of pregnancy by cesarean section. If the cyst obstructs the birth canal or there is a risk of rupture, a cesarean section can be performed to terminate the pregnancy and the tumor can be removed at the same time, depending on the situation.
● In late pregnancy, if the ovarian cyst has been retreated outside the pelvis, there is no possibility of obstructing the birth canal, and there is no suspicion of cyst malignancy, vaginal delivery can be performed after postpartum surgery.
After vaginal delivery, the pelvic and abdominal cavities become larger again due to uterine contraction, and the position of the ovarian cysts may change, and the possibility of cyst torsion may occur during the puerperium.
In addition, regular pelvic review or ultrasound examination should be done after delivery, and surgery for ovarian cysts should be performed if necessary.
Regular physical examination is very important to treat any disease early. Especially before preparing for pregnancy, it is better to go to the obstetrician for prenatal consultation and physical examination. If ovarian cysts are found, you will be advised through physical examination and ancillary tests whether you can get pregnant or have surgery before pregnancy.
There is no need to be overly stressed and anxious when ovarian cysts are found after pregnancy. Cooperate with your doctor’s examination in order to decide whether you need surgery during pregnancy and what is a safer way to operate. Ovarian cysts in pregnancy are prone to complications such as cyst tip torsion and rupture. When sudden acute abdominal pain occurs, you should seek medical attention promptly. If complications occur in ovarian cysts during pregnancy, or if malignancy is suspected, immediate surgery should be performed. Cesarean section is recommended for termination of pregnancy only if the ovarian cyst is at risk of obstructing the birth canal or may rupture during labor; otherwise, the pregnancy can be delivered vaginally. Regular follow-up of ovarian cysts should be performed after delivery and complications should be noted.