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Introduction

Nearly 1 of all pregnant women have an

adnexal tumor diagnosed on ultrasonography1, and

the percentage of malignant tumors or tumors with

low malignant potential among the adnexal tumors

removed during pregnancy has been reported to be

62024..

Ovarian malignancy is often called thesilent

killerbecause symptoms do not develop until

advanced stages when the prognosis is poor. In 2000,

Goff et al.5 reported that only 11 of women with

Stages III and 3 with Stages IIIIV did not com-

plain of symptoms before their diagnosis of ovarian

carcinoma. During pregnancy, on the other hand,

ultrasonographic examination is now used for routine

check ups of patients with no symptoms. Thus, the

incidental diagnosis of ovarian tumors including

ovarian malignancies with no symptoms may be

higher in pregnant women than in non-pregnant

women.

The aim of this study was to investigate the pre-

operative symptoms in pregnant and non-pregnant

patients undergoing operations for primary ovarian

tumors.

Patients and methods

We retrospectively analyzed the medical records

Original

Primary Ovarian Tumor Undergoing Surgical

Management During Pregnancy

Tsutomu Takeuchi, Shunji Suzuki, Zuisei Hayashi,

Toshiya Shinagawa and Tsutomu Araki

Department of Obstetrics and Gynecology, Nippon Medical School

Abstract

The aim of this study was to evaluate the preoperative symptoms of patients with

primary ovarian tumors undergoing surgery during pregnancy and non-pregnancy. We

retrospectively analyzed the medical records of 71 pregnant patients who underwent surgeryfor primary ovarian tumorspregnantand 580 non-pregnant patientsnon-pregnantaged

1544 years old. In the non-pregnant group, 79.7 of the patients complained of abdominal

pain at the first examination. However, in the pregnant group, 62.0 of the patients reported

no symptoms and 31.0 of them reported abdominal painp

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Table 1 Patient data at the first medical examina-

tion

PregnancyNon-pregnancy

71580N

Ageyr

32.35.131.14.5MeanSD

15451545Range

811.3%17126.5%Multipara

p0.05 compared with the non-pregnant group.

Table 2 Chief type of symptom at the first medical

examination


71580N

Chief type of symptom

4462.0%41 7.1%No symptoms

2231.0%46279.7%Pain

38 6.6%Dysmenorrhea

1 1.4%22 3.8%Bleeding

4 5.6%17 2.8%Others


at Nippon Medical School Hospital between January

1991 and March 2001, during which time there were

more than 5,400 deliveries in the hospital. Seventy-

one patients aged 1544 years old underwent

surgery for primary ovarian tumors at 13.54range:

537weeks of pregnancypregnant group, while

580 non-pregnant patients of the same age range

underwent surgerynon-pregnant group. During the

time of this study, a total of 928 patients underwent

surgery for primary ovarian tumors197 malignancies

in our hospital.

In our hospital, ultrasonographic examination is

routinly used in obstetrics. The indications for sur-

gery of ovarian tumors during pregnancy in our

department are as follows:1the ovarian tumor

is 7 cm or larger and persists beyond 12 weeks of

gestation;2the tumor contains a solid portion sug-

gesting malignancy; or3the patient has symptoms

associated with the tumor. On the other hand, the

indications for surgery of ovarian tumors during

non-pregnancy are as follows:1the ovarian tumor

is 7 cm or larger;2the tumor contains a solid

portion suggesting malignancy; or3the patient has

symptoms associated with the tumor. Data collected

included age, parity, symptoms, surgical pathologicfindings and maximum tumor diameter in cases of

mature teratoma and Stage Ia ovarian malignancies.

All data were analyzed with either 2 test or by

Student t test when appropiate. A value of p

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Table 3 Histologic diagnoses on operative findings of ovarian tumors.


71580N

6591.5%54293.4%Benign tumors

9220Endometrial cyst

26204Mature teratoma2751Serous cyst adenoma

618Mucinous cyst adenoma

339Others

6 8.5%38 6.6%Malignancies

012Serous cyst adenocarcinoma

24Mucinous cyst adenocarcinoma

Low malignant potential

35Mucinous cyst adenoma

18Others

09Others

Stage of malignancies

6100%

2257.9%a 0 0%0 0%b0 0%1642.1%c


Table 4 Symptoms and maximum tumor diameter

in patients with ovarian mature teratoma

at the first examination


26204NAgeyr

27.64.830.23.4MeanSD

619%4924%Multipara

Symptom

726.9%15274.5%Pain

1973.1% 5225.4%No-pain

Maximum diametercm

6.61.87.22.4MeanSD


Table 5 Symptom in patients with ovarian malig-

nancies at the first examination


638N

Ageyr

33.45.234.24.5MeanSD

00%1436.8%Multipara

Symptom

116.7%3489.5%Pain

583.3% 410.5%No-pain


Table 6 Symptoms and maximum tumor diameter

in patients with Stagea ovarian malig-

nancies at the first examination


622NAgeyr

33.45.232.25.6MeanSD

00%522.7%Multipara

Symptom

116.7%1986.4%Pain

583.3% 313.6%No-pain

Maximum diametercm

6.22.07.22.6MeanSD


higher than in the non-pregnant group. The inci-

dence of abdominal pain in the non-pregnant group

at first examination was significantly higher than

those in the pregnant group.

Discussion

In this study, the sonographic detection rate of

ovarian tumor during pregnancy that met the

indications for surgery in our department was

approximately 1.3, of which ovarian malignancies

accounted for 8.5. These results were consistent

J Nippon Med Sch 2002; 691 41

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with previous studies14.

In 2000, a large national survey confirmed that the

majority of women with ovarian malignancies are

symptomatic and frequently have delays in diagnosis5.

In this study, 89.5 of non-pregnant patients with

ovarian malignancies complained of abdominal pain,

and 42.2 of them were diagnosed as stage Ic,

although the age of the subjects was restricted to

1544 years old. However, 83.3 of the pregnant

women with ovarian malignancies reported no

symptoms. We consider that this result supports our

hypothesis and confirms the clinical utility of routine

sonographic examination for ovarian tumors during

pregnancy, because early detection is the key to

saving life: 90 are cured by salpingo-ovariectomy

alone if diagnosis is at Stage I5.

Another possible reason why the incidence

of stage Ic in ovarian malignancies in the

non-pregnant group was higher than that in the

pregnant group is that an increased risk of

advanced-stage ovarian carcinoma has been associated

with incessant ovulation and infertility7. The most

important susceptibility factors for ovarian surface

epithelium and carcinogenesis have been reported

to be nulliparity and an affected first-degree relative6

.In this study, the pregnant women with ovarian

malignancies were all primipara and their mean

age was 33.4 years old, which supports findings in

previous reports6.7.

In conclusion, ovarian tumors including ovarian

malignancies are diagnosed with no symptoms

during pregnancy significantly more often than

during non-pregnancy. Thus, innovative approaches

to screening for ovarian tumors in women with

no symptoms are needed.

References

1Nelson MJ, Cavalieri R, Graham D, Sanders RC:

Cysts in pregnancy discovered by sonography. J Clin

Ultrasound 1986; 14: 509512

2Hess WL, Peaceman A, OBrien WF, Winkel CA,

Cruikshank DP, Morrison JC: Adnexal mass occuring

with intrauterine pregnancy: report of fifty-four pa-

tients requiring laparotomy for definitive manage-

ment. Am J Obstet Gynecol 1988; 158: 10291034

3Whitecar P, Turner S, Higby K: Adnexal masses in

pregnancy: a review of 130 cases undergoing surgi-

cal management. Am J Obstet Gynecol 1999; 181:

1924

4Sherad G, Hadi H, Williams J, Tait D, Semer D,

Hodson C: Adnexal masses in pregnancy: maternal

and fetal implications. Am J Obstet Gynecol 2001;

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5Goff BA, Mandel L, Muntz HG, Melancon CH: Ovar-

ian carcinoma diagnosis. Cancer 2000; 89: 20682075

6Murdoch WJ: Ovarian surface epithelium, ovulation

and carcinogenesis. Biol Rev Camb Philos Soc 1996;

71: 529543

7Karlan BY, Marrs R, Lagasse LD: Advanced-stage

ovarian carcinoma presenting during infertility

evaluation. Am J Obstet Gynecol 1994; 171: 13771378

Received, July 30, 2001

Accepted, August 22, 2001

42 J Nippon Med Sch 2002; 691

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