spontaneous rupture of endometriotic cyst in 3rd trimester of pregnancy

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Apollo Medicine 2012 SeptemberVolume 9, Number 3; pp. 246e248 Case Report

Spontaneous rupture of endometriotic cyst in 3rd trimesterof pregnancy

Sarat Battinaa,*, Bhushan Ramesh Murkeyb, Shiva Singh Shekhawatc

aHOD,*CorreReceivCopyrihttp://d

ABSTRACT

Endometriosis is a well established cause of female infertility and may be associated with early pregnancy losses.Association of endometriosis with pregnancy is rare. Ruptured endometriotic cyst presenting as acute abdomen inpregnancy is even a rarer presentation.We present hereby a rare and interesting case, presented in our hospital, of Spontaneous rupture of endometioticCyst in 3rd trimester of pregnancy and its subsequent management.

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Rupture of endometriotic cyst, 3rd trimester of pregnancy, Endometrioma

INTRODUCTION

Endometriosis is an enigmatic disease mostly seen inwomen in their reproductive period. It is a fascinating entitybecause of diverse clinical presentation and discordancebetween severity of lesions and symptoms. It is a wellestablished cause of female infertility (15e25% incidence)1

and may be associated with early pregnancy losses. Notmuch data is available regarding its coexistence or associa-tion with more advanced pregnancy.

CASE REPORT

d Mrs JS, 28 year old lady, first visit in July 2010. She wasmarried for 3 years and was anxious to conceive. Cycleswere regular, average flow, associated with severedysmenorrhea. H/O Bronchial Asthma since childhood,no H/O of any other major medical illness. In surgicalpast history, she had H/O acute pain abdomen and vom-iting in Jan 2008 for which she visited her doctor and anEmergency Laparoscopy was done in view of sus-pected torsion of ovary/suspected ruptured chocolate

bRegistrar, cSenior Resident, Apollo Hospitals, Chennai 600006, Indsponding author. email: [email protected]: 5.6.2012; Accepted: 2.7.2012; Available online: 7.7.2012ght � 2012, Indraprastha Medical Corporation Ltd. All rights reservedx.doi.org/10.1016/j.apme.2012.07.006

cyst/suspected Rare possibility ovarian abscess. Opera-tive findings were: Omentum fixed to the pelvic cavity.Uterus, tubes and ovaries could not be made out clearly.Pus aspirated and peritoneal lavage done.Husband eMr. S, 29 yrs old. No H/O any major medical

or surgical illness. No H/O smoking/alcohol. No H/O anydrug intake. No H/O retrograde ejaculation. Normal sexuallife. Husband Semen Analysis: Normozoospermia.

TVS (July2010): Uterus Normal size, anteverted, Endo-metrial thickness e 7 mm. Right Ovary containeda cyst �6.8 � 4.6 cm with low level internal echoes. LeftOvary contained a cyst e 5.0 � 4.7 cm with low levelinternal echoes. Both ovaries adherent to each other sugges-tive of Bilateral Endometriotic cysts.d In view of previous laparoscopy findings and anticipated

pelvic adhesions decided to go ahead with ART (IVF/ICSI) instead of laparoscopy.

d In view of large endometriomas,Ultrasound guided aspi-ration of endometriotic cysts was done first in August2010. Decided to put her on ultra long protocol for ICSI.

d Inj Zoladex 3.6 mg sc monthly were given for 3 dosesand decided to review in November 2010 with TVSreport for ultra long protocol for ICSI.

ia.

.

Spontaneous rupture of endometriotic cyst Case Report 247

d But patient returned in Jan 2011.d TVS (Jan2011): Right ovaryea cyst measuring

6.4 � 4.5 cm with low level internal echoes and onesmall follicle. Left ovary e cysts measuring3.8 � 3.7 cm and 1.7 � 1.4 cm filled with internalechoes and a clear cyst measuring 3.0 � 1.9 cm andone follicle. Imp: Bilateral Endometriotic cysts.

d Ultrasound guided aspiration of the endometriotic cystswas done again.

d As patient reported late and started mensturating again,patient was put on long protocol for ICSI

d Repeat ultrasound guided aspiration of the endo-metriotic cysts was done on the day 3 of the cycle.16 oocytes retrieved, 13 oocytes were of good quality.All were inseminated. 13 good quality embryos were ob-tained. 3 embryos transferred. 10 embryos frozen

d She conceived in first cycle of ICSI.d The early pregnancy (at 7 wk gestation) e Transvaginal

ultrasound showed a Heterotopic pregnancyThe left tubal pregnancy aborted spontaneously at 8 wk

gestation.First Trimester Screening was normal. First trimester

scan e Menstrual age e 12 wk 2 days, Gestational age e11 wk 2 days. Cystic structure suspected endometriotic cystin right adnexa �9.3 � 6.3 cm. Placenta e posterior and iscovering the internal os. Nuchal translucency e 1.2 mm.

At 15 wk þ 4 days e Cyst measuring 7.8 � 5.6 cm per-sisted in right adnexa. Placenta e posterior and coveringthe internal os (she remained asymptomatic for both).GTT Fasting 80 mg/dl 1 hr 192 mg/dl, 2 hr 205 mg/dl. Dia-betologist opinion sought and she was started on Insulin.d Second trimester scan e No anomaly detected in fetus

but continued to have complete Placenta Previa andEndometriotic cyst e 7.7 � 5.1 cm. All other parame-ters were within normal limits.

d Her pregnancy faired well till 29 wk gestation.Suddenly, she presented in the labor room at 3AMwith c/o

acute pain abdomen since 1 h. NoH/O bleeding or leaking pervaginum,NoH/O dysuria or fever, NoH/O discharge per vag-inum,NoH/O fall or trauma, Perceiving fetalmovementswell.General condition was fair, Hydration adequate, Temp e98.4 F, PR e 82/min, regular, good volume, BP e 130/90 mm of Hg. No pallor/icterus/cyanosis. Mild pedal edemawas present. RS e B/L NVBS heard, CVS e S1,S2 þ CNS e No focal neurological deficit. Per Abdomen eFundal height : 28e30 week gestation, suspected longitudinallie, Mild contractions present, FHSþ/regular/good. No leak-ing or bleeding per vaginum. Inj. Betamethasone 12 mg imgiven. Continuous CTG monitoring was done. Vitals weremonitored. She was kept NBM, was Catheterized. Pretermlabor was suspected provisionally. Ultrasound showed eSingle live intrauterine gestation 29e30 wk, Breech,

Complete placenta previa, AFI 10.5. A 11 � 7 cm heteroge-nous echogenic lesion extending to either adnexawith no coloruptake. Impressione ?haemorrhagic/suspected endometrioticcyst/suspected torsion of cyst.d Patient continued to have pain with increased intensity

and FHR showed decelerations at 11:45 AM.d Decided to take up for Emergency LSCS in view of

suspected abruptio placenta. Per Operative Findingswere Massive intraperitoneal bleeding was present.Central placenta previa. Liquor e Clear. Baby deliveredas breech, didn’t cry at birth, handed over to pediatrician,could not be resuscitated. Ruptured left ovarian endo-metrioma adherent to the posterior wall of the uterus.Raw bleeding areas were present at the posteriorsurface of the uterus, same cauterized. Hemostasis wasensured. 3 units of PRCs transfused preoperatively.She was shifted to ICU where patient was put on venti-

lator. 1 unit of PRC and 4 units of FFP transfused. CBC,renal functions and coagulation profile done. HB e9.9 gm% .Other investigations and coagulation profilewas WNL. Hematologist opinion taken.

Post operative day 1 e Patient extubated, NBM, Urineoutput adequate, HB 7.8 gm%, TLC 28,000, DIC profilenormal.

Post operative day 2 e Shifted to the ward. Orallyallowed, Foleys removed, Dressing was changed. Pallorwas present. Mobilized out of the bed.

Post operative day 3 e Repeat Hb e 6.3 gm%. Twounits of PRCs transfused. Patient improved symptomati-cally. Her Hb became 9.6 gm%. She was discharged onpost operative day 5.

DISCUSSION

Association of endometriosis with pregnancy is rare.Ruptured endometriotic cyst presenting as acute abdomenin pregnancy is even a rarer presentation.1

Pregnancy is known to favor retrogression of endometri-osis. In fact endometriosis has been linked with femaleinfertility (15e25% incidence)2 and recurrent pregnancylooses (38e52 L Pittway, Groll).3

Possible causes of rupture:- Increasing pressure by the fluid inside the cyst- Adhesions causing increased tension as the uterusenlarges and its anatomical position is altered

- Decreased abdominal space as pregnant uterusoccupies the abdomen and cyst ruptures

- Increased blood flow during pregnancy can induceenlargement of cyst and perhaps bleeding into thecyst itself and eventually rupture

- Secondary to softening of lesion due to stromaldecidualisation.

248 Apollo Medicine 2012 September; Vol. 9, No. 3 Battina et al.

Hence it poses a diagnostic problem when it coexistswith advanced pregnancy. As signs of ruptured endometri-otic cyst are not localized to lower abdomen with advancedpregnancy, the acute abdomen is often attributed to surgicalcauses like appendicitis etc. Hence, in our patient also, wecould only diagnose this entity intraoperatively followed byhistopathological confirmation.

CONFLICTS OF INTEREST

All authors have none to declare.

REFERENCES

1. Puri M, Jain S, Thomas S, Trivedi SS. Acute abdomen in preg-nancy e ruptured endometrioma e a rare cause. Indian J MedSci. 2000;54:246e248.

2. Bie Nkiewicz A, Kazimierak W. Spontaneous rupture of anendometriotic cyst in pregnancy near term. Ginekol Pol.1996;67:160e162.

3. Bulot F, Eroukhnanoff P. Rupture of an edometrioticcyst during pregnancy (letter). Presse Med. 1991;20:1786.

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