Ovarian Tumors. Diagnosis

Ovarian tumors are much rarer than fibroids during pregnancy. Since cysts of the ovary are common the conclusion seems justified that they predispose to sterility.

The influence of pregnancy on the non-malignant tumor is usually not bad. Most women go to term without the knowledge of its existence and the growth of the neoplasm is not accelerated as it is in the case of fibroids. While dyspnea and palpitation, due to excessive size of the tumor, are rare, torsion of the pedicle, hemorrhage into the cyst, suppuration and necrosis occur occasionally. Labor exerts no influence unless the tumor lies in the pelvis, exposed to the trauma of delivery. In this case it may burst or be crushed or its pedicle torn.

The puerperium has no special influence but complications are likely to arise as the result of bruising of the tumor. Torsion has been observed much more frequently than in non-pregnant women.

Pregnancy is but little affected by ovarian cysts. Abortion is common only when the tumors are extremely large or incarcerated in the pelvis, when they interfere with the growth of the uterus or when they become twisted or infected. In labor ovarian cysts exert a harmful action only when they are incarcerated in the pelvis and block the path of the child. To a certain extent, but not as much as with fibroids, the tumor is drawn out of the way. A small or soft tumor may allow the passage of the child. Malpresentations are common. The puerperium is often stormy because of the bruising of the tumor, necrosis, hemorrhage, infection and suppuration, sometimes with the escape of pus into adjacent organs. Tumors which become adherent to the rectum are likely to be infected with colon bacilli. Dermoid cysts are the most dangerous because if they burst during labor fatal peritonitis may result. Usually dermoids can be detected in roentgenograms.

Diagnosis. In the early months it is usually easy to differentiate the pregnant uterus from the rounded, movable, pedunculated tumor lying at its side, but sometimes great difficulties are encountered. When the tumor is intraligamentous or prolapsed in the pelvis behind the uterus, a differentiation from ectopic gestation and retroflexed gravid uterus must be made. A large tumor may conceal the uterus and give the impression of a pregnancy and since the signs and symptoms of the latter are present this mistake is likely to be made. Fibroids and splenic and renal tumors must be considered in the differential diagnosis. One should remember that torsion of an ovarian cyst simulates ruptured ectopic pregnancy and appendicitis.

In the later months and during labor various difficulties are encountered in locating the tumor. If high in the abdomen it may slip under the liver or spleen. If adherent to the uterus the suspicion of twins, fibroid or double uterus arises. If attached low in the pelvis a shoulder presentation might be considered. Tumors incarcerated in the pelvis during labor are discovered easily but their nature and origin are not determined so easily. A cyst under the compression of labor becomes as hard as a fibroid and if it is adherent it may simulate a tumor of the pelvic periosteum. Rectal examination will exclude this class of neoplasms. An ovarian cyst has been mistaken for the head of a second twin and forceps have been applied; or when enucleation of a supposed fibroid was attempted a prolapsed kidney, a full rectum or a hematoma were encountered.

An important part of the diagnosis is the decision as to whether the tumor will block the delivery; in estimating this one must never forget to measure the bony pelvis also.

Prognosis. At present few women die from this complication because the troublesome tumors are usually removed as soon as found and because operation substitutes for the brutal obstetric deliveries of former times.

Treatment during Pregnancy. Most authors are strongly in favor of immediate removal of the tumor when discovered but we believe one must individualize. However, an operation should be performed in most cases when the cyst is large and in all cases when sudden symptoms of torsion of the tumor develop. There is not much danger of abortion. Even if the tumor contains the corpus luteum of pregnancy, there is rarely any risk in removing the tumor if the pregnancy is twelve or more weeks old.

Therefore, if an ovarian cyst is detected at the beginning of pregnancy and it is to be removed, it is advisable to wait until the end of the third month or beginning of the fourth month of pregnancy. If the tumor can be shelled out of its bed, leaving part of the ovary, this should be done. There are forty-six reported cases in which both ovaries were removed during pregnancy because of bilateral dermoid cysts. In twelve cases the pregnancy continued to full term in spite of the fact that the operations had been done within the third month. If a cyst is not removed and the pelvis is not obstructed labor may be allowed to take place as usual, and the tumor extirpated afterward. Rapid growth of the tumor in pregnancy suggests malignancy.

Indications for immediate operation in pregnancy are: suspicion of malignancy, torsion of the pedicle, signs of infection of the tumor and overdistention of the abdomen. The pregnant uterus must be handled as little and as gently as possible and progesterone is to be given for several days afterward in an attempt to restrain excessive uterine action.

Treatment during Labor. The location of the neoplasm, the state of the parturient canal as regards infection, the tumor as regards prolonged pressure, bruising from attempts at reposition, delivery and the like are also to be considered. Abdominal ovariotomy is followed by delivery from below and laparotrachelotomy is followed by extirpation of the ovarian tumor.

After delivery of the child an immediate laparotomy is performed and the tumor is extirpated. It is best not to delay the removal of the cyst because the latter may have been ruptured or injured by the manipulations or delivery, and delay might mean fatal peritonitis.

In the puerperium ovariotomy is to be performed in all cases in which a large ovarian cyst is still present, and preferably within twenty-four hours. If operation is postponed a careful watch is kept for the first symptoms of infection of the tumor or torsion of its pedicle.