Gynecology
5 min read

Management of a Large Cystic Teratoma in the Second Trimester of Pregnancy

Management of a Large Cystic Teratoma in the Second Trimester of Pregnancy

Table of Contents

Video Description

This video discusses the successful management of a large cystic teratoma during the second trimester of pregnancy. It highlights the diagnosis, surgical steps including laparoscopic salpingo-oophorectomy, and the patient’s positive post-operative outcome. The case emphasizes safe surgical techniques and ongoing maternal-fetal health.

Presented By

Dr. Belma Kamencic
 
Dr. Arohumam Kan
Dr. Darrien Rattray

Affiliations

University of Saskatchewan

Watch on YouTube

Click here to watch this video on YouTube.

What is Large Cystic Teratoma in the Second Trimester of Pregnancy?

A large cystic teratoma during the second trimester of pregnancy is a type of benign ovarian tumor that consists of tissues such as fat, hair, teeth, or cartilage. These tumors, also known as dermoid cysts, are rare during pregnancy but can pose challenges due to their size and location, potentially causing abdominal discomfort, pain, or complications such as torsion or rupture. Key points about large cystic teratomas in pregnancy:

  • They are usually detected through ultrasound or MRI as complex masses in or near the ovaries.
  • Symptoms may include abdominal pain, distension, or other signs of mass effect.
  • Elevated CA-125 levels may sometimes occur but do not necessarily indicate malignancy.
  • Management typically involves surgical removal, often through minimally invasive techniques like laparoscopic salpingo-oophorectomy, to protect maternal and fetal health.
  • Successful treatment allows for the continuation of a healthy pregnancy in most cases.

Prompt diagnosis and multidisciplinary care are critical for ensuring positive outcomes for both mother and baby.

What are the Risks of Large Cystic Teratoma in the Second Trimester of Pregnancy?

A large cystic teratoma during the second trimester is a rare condition that can present unique challenges to both maternal and fetal health. While generally manageable, several risks are associated with this condition:

  • Ovarian Torsion: The weight and size of the mass can cause the ovary to twist on its ligament, leading to compromised blood flow and acute pain.
  • Cyst Rupture: Large cysts may rupture, spilling contents into the abdominal cavity, causing peritonitis and severe abdominal pain.
  • Compression of Nearby Structures: The mass can press against the bladder, intestines, or other organs, leading to symptoms like urinary retention or bowel dysfunction.
  • Preterm Labor or Miscarriage: Irritation of the uterus or physical space constraints can trigger uterine contractions, increasing the risk of pregnancy complications.
  • Infection: Ruptured or inflamed cysts can lead to infections, including pelvic abscesses, which pose risks to both the mother and fetus.
  • Obstruction During Delivery: Untreated large teratomas may obstruct the birth canal, complicating vaginal delivery and necessitating a cesarean section.
  • Misdiagnosis or Delayed Diagnosis: Differentiating a benign teratoma from malignant or other complex masses can delay treatment, increasing risks.

Careful monitoring, timely imaging, and appropriate surgical intervention are crucial to minimize these risks and support a healthy pregnancy outcome.

Video Transcript: Large Cystic Teratoma in the Second Trimester of Pregnancy

Management of a large cystic teratoma in the second trimester of pregnancy. Consent has been obtained to present and share this following case. This is a 37-year-old G2P0 at 17 weeks and zero days who presented with periumbilical pain and abdominal distension with a known large complex adnexal mass. Her Ca-125 was slightly elevated at 49, but all other tumour markers were negative.

She had an ultrasound at eight weeks and two days that revealed a large, complex heterogeneous mass originating from the left ovary and extending towards the midline that measured 18 by 13 by 9.7 cm. A follow-up MRI further characterised this large heterogeneous pelvic slash abdominal mass. Here, we see the MRI images in the sagittal and the transverse plane, highlighting the mass and gravid uterus.

She was consented for a laparoscopic salpingo-oophorectomy and laparotomy to remove the cyst. The steps of the procedure are to enter the abdomen and assess the anatomy, drain the cyst, perform a salpingo-oophorectomy and remove the cyst via a mini laparotomy. The foetal heart rate was auscultated prior to starting the case. The stomach was decompressed with an oral gastric tube and the abdomen was entered at Palmer’s point using a Veress needle.

Ports were inserted under direct visualisation. A diagnostic laparoscopy was performed and revealed a normal upper abdomen and large left ovarian multi-cystic mass, most in keeping with a dermoid. As you can see, the cyst itself has spontaneously started to drain prior to starting the case. A large sheet of omentum is draped over the cyst. And therefore, we are moving it in order to facilitate drainage.

Step two, drain the cyst. The Endoloop suture was inserted. A trocar and sleeve were then used to puncture the cyst and the trocar was replaced with laparoscopic suction. This was done within the Endoloop so that it could be tied off prior to removal. Once the cyst was punctured, a copious amount of sebaceous fluid was suctioned. Unfortunately, due to the thickness of this fluid, only 150 mils was actually removed before it became occluded.

Another trocar was inserted in order to help us tie off the cyst. Step three, perform the salpingo-oophorectomy. Here, we identified the infundibulopelvic ligament and the utero-ovarian vessels that feed the ovary. We visualise the left ureter running along the side wall, well away from the vessels and utero-ovarian ligament. Luckily, the pedicle was stretched long to accommodate the growth of this large mass.

There was no evidence of torsion. We were able to use bipolar to safely seal and transect the ovary away from the utero-ovarian and the infundibulopelvic ligament. After transecting the pedicle, we then ensured that there was good haemostasis. Step four, remove the cyst via a mini laparotomy. The specimen was grasped and moved down towards the pelvis. A few more omental adhesions were removed in order to free the mass.

Then 2 cm above the pelvic brim, an 8 cm Pfannenstiel incision was made. The specimen was grasped and slowly brought to the incision. A smaller Alexis O ring was placed as a skin retractor and used to help facilitate visualisation. However, there were large, calcified and very hard components of the mass. And thus, we had to morcellate the specimen in order to facilitate removal. As you can see, the specimen had a substantial number of teeth and large areas of calcification.

The abdomen was irrigated with sterile water, haemostasis confirmed and the mini Pfannenstiel closed in the usual fashion. In conclusion, a safe removal of a large cystic teratoma is possible in pregnancy. The patient was discharged home the following day with minimal pain control requirements. She has had a continuing, healthy pregnancy to date.