Ovarian cystectomy by laparotomy in second trimester pregnant
patient with diagnosed DVT during pregnancy
Introduction
The frequency of ovarian cysts in pregnancy is reported to be 1 in 1000 pregnancies. The surgical
management of ovarian tumors in pregnancy is similar to that of non-pregnant women. Most of these
tumors are not malignant, and if they are small then treatment can be left until after the birth.
However, if the tumour is larger that 6 cm in diameter, it is suggested that it is better to operate and
remove them during pregnancy, as they may interfere with the birth of the baby. Surgical procedures
for these non-malignant tumors of the ovary during pregnancy can be performed by open surgery
(laparotomy) or by keyhole surgery (laparoscopy) techniques.
Case presentation
After being treated in a general hospital, a 34-year-old primigravida in the ninth week of gestation was
sent as the in utero transfer into our clinic for further examination and treatment. An ultrasound scan
confirmed normal fetal anatomy and a large cyst arising from the pelvis, which filled the entire right
hemiabdomen and measured approximately 29 cm.
The mass appeared to be cystic with no solid component. That same day she underwent the color
Doppler ultrasound of the veins of the leg that showed deep venous thrombosis (DVT) of the right
external iliac vein, right femoral vein, left external iliac vein, left femoral vein and left popliteal vein.
From the ninth to the fifteenth week of gestation, the patient was treated for acute deep vein
thrombosis with therapeutic values of low molecular weight heparin. In the fifteenth week of
gestation, control color Doppler ultrasound of the veins of the leg showed deep vein patency of the
deep veins of the right leg with no signs of acute venous thrombosis. The patient was prepared for the
surgical procedure.
The ovarian cyst was not complex and was reported to be a simple cyst. Left ovary was not visualized
because of the relationship of the cyst with the uterus, but because of the cyst being so big it was
suggested to be of ovarian origin. The overall morphological features of the mass did not indicate
malignancy. In the view of the large size of the cyst, the surgical option to remove the cyst by the
laparotomy technique was discussed with the patient, which she agreed to. Surgery was performed in
the sixteenth week of gestation.
The patient was premedicated with intravenous metoclopramide and ranitidine. After rapid sequence
induction with thiopental and succinylcholine, the general endotracheal anaesthesia was maintained
with the combination of sevoflurane and intravenous fentanyl and rocuronium. The patient was
mechanically ventilated with the intermitent positive pressure ventilation (IPPV) mode and with the
use of the positive end expiratory pressure (PEEP) of 10 cm H2O. The patient woke up about twenty
minutes after the surgery without reversion of the muscle block. Nasogastric tube was passed to
remove any gaseous distension of the stomach. Anesthesia passed without complications and adverse
events.
During laparotomy, a large cystic formation which filled the entire right hemiabdomen and
compressed the surrounding structures was visualised. The surgeon punctured the cyst and the
resulting content was sent for the emergency cytological analysis. Cytological findings suggested it
was a benign serous cyst. The surgeon aspirated cystic content and the 10 liters of serous fluid was
drained initially. The ovarian cystectomy was performed by dissecting away the cyst wall from the
ovarian tissue. The right ovary was completely neat, as well as the left ovary. The size of the uterus
corresponded to the sixteenth week of gestation. Both Fallopian tubes were normal. The whole
surgical procedure was uneventful.
1
No tocolytics were used as there was no clinical evidence for administration of tocolytics during the
geastational age of our patient. Prophylactic antibiotics were administered. The fetal heart was
auscultated before and after the procedure.
Postoperative recovery was uncomplicated. Eight days after the surgical procedure, the patient was
transfered to the department of obstetrics and gynecology at the general hospital, from which she
initially came to our clinic.
Discussion
The frequency of ovarian tumours is about 1 in 1000 pregnancies and those which are malignant
represent about 1 in 15,000 to 32,000 pregnancies [1,2]. Management of the adnexal mass, whether it
is conservative or surgical, still remains controversial. Surgical removal is considered to reduce the
risk of undiagnosed malignancy, torsion, infection, rupture, haemorrhage and obstruction of labour.
Furthermore, the risk of the obstruction of the labour by the adnexal mass is calculated to be 17% to
21% [3].
Most adnexal masses during pregnancy are ideally surgically managed in the second trimester, after
the organogenesis is completed and thus: the risk of fetal loss is decreased, 15% to 20% of the
spontaneous miscarriage risk is eliminated and spontaneous regression of the mass is more likely to
occur [4]. There are some evidence which suggest that laparoscopy and laparotomy do not differ in
regard to the fetal outcome which includes fetal weight, gestational age, growth restriction, infant
survival and fetal malformations. Historically, open surgery was more often used as the operating
method, but the modern keyhole surgery seems more attractive today because it appears to reduce the
number of the hospitalisation days and there is also a quicker return to normal activitities [5] .
However, the insufflation of the gas into the abdomen during the key-hole procedure may have
adverse effects on the baby so the additional gasless technique is also under study. Due to dimensions
of the tumor, it was safer, both for the patient and the baby, to perform open surgery (laparotomy).
Given the proven DVT we started a treatmet of DVT before cystectomy. We decided to act according
to the 2012 guidelines of the American College of Chest Physicians (ACCP) on the venous
thromboembolism (VTE) and pregnancy, although more different guidelines exist nowadays and
several solutions are possible.
According to the 2012 guidelines of the ACCP on the VTE and pregnancy, once it is determined that
anticoagulation is indicated, therapy should be initiated by using subcutaneous low molecular weight
heparin (SC LMWH), intravenous unfractionated heparin (IV UFH), or subcutaneous unfractionated
heparin (SC UFH) [6].
Subcutaneous LMWH is preferred over IV UFH or SC UFH in most patients because it is easier to use
and appears to be more efficacious and to have a better safety profile [7].
Inferior vena cava (IVC) filters have been used during pregnancy [8,9]. There are circumstances in the
management of thromboembolic events during pregnancy when anticoagulant therapy is either
contraindicated or not advisable, such as when pulmonary embolism (PE) or DVT is diagnosed close
to the term, given the risk of bleeding during delivery. In these cases, the thromboembolic risk can be
controlled by using temporary inferior vena cava filters (T-IVCFs) [10].
Another solution is thrombolysis/thrombectomy. Teratogenicity of the thrombolytic agents has not
been reported, but the risk of maternal hemorrhage is high. As a result, thrombolytic therapy should be
reserved for pregnant patients with life-threatening acute PE (ie, persistent and severe hypotension due
to the PE) [11]. Case reports of thrombectomy suggest that it can be used successfully as a life saving
measure when other measures have failed [12,13].
Our main question was when can we perform cystectomy with respect to the time of thrombosis and
with the minimum risk of fatal PE. In our case, given the good response to the therapeutic doses of
LMWH, there was no need for additional treatment of DVT, even though we know that the most
2
serious complication of DVT or nonfatal PE is fatal PE. However, reliable sources for the risk of fatal
PE in patients with treated DVT or nonfatal PE are lacking [14].
Therefore, it was only reasonable to think and to seek non-invasive possibility of reducing the risk of
the fatal PE. Although it was done on animal models, there is a study which examines the influence of
the unilateral positive end expiratory pressure (PEEP) on the hemodynamic changes and physiologic
shunting across the right and left lung after fat embolism, using the contralateral lung as well as the
lungs of the animals with no PEEP as controls. The role of the PEEP was evaluated in preventing the
deleterious mechanical respiratory effects of fatty acid pulmonary embolism, and it confirmed the
value of the PEEP in the therapy of the pulmonary manifestations of the fat embolism. PEEP can not
only significantly decrease the amount of shunting but can also can maintaine normal respiratory
mechanics and normal systemic oxygen saturation [15].
Also Zasslow et al. showed that PEEP up to 10 cmH2O does not alter the pulmonary arterial wedge
pressure (PAWP) – right atrial pressure (RAP) difference, and it can be safely applied without the
concern of paradoxical arterial embolism [16]. Further trials are needed due to the lack of reports
about the possibility of using PEEP for the prevention of pulmonary embolism in patients with proven
DVT.
The process of recanalization was shown to be successful mainly during the first 6 weeks after the
thrombosis and shows little progression afterward. The report by Bert van Ramshorst et al. showed
that the recanalization of the thrombus in the lower limb is not a slow process, as was suggested in the
past [17].
The natural course of venous thrombosis is threefold [18]. Initial loose thrombus becomes adherent to
the vein wall by the end of the first week. The local inflammatory response of the vessel wall initiates
the organization of thrombus with subsequent contraction, and spontaneous lysis of areas within the
thrombus finally leads to recanalization. Thrombus regression reflects the overall outcome of these
processes.
In our case, after exactly six weeks after the diagnosis and treatment of the DVT, ultrasound
confirmed deep vein patency of the deep veins of the right leg, with no signs of acute venous
thrombosis.
A series of ultrasounds may be done over several days to determine if a blood clot is growing or to be
sure a new one has not developed [19].
Every move considering our case, in the terms of the treatment of the DVT, prevention of the
pulmonary embolism during surgery, successful laparotomy and monitoring of the pregnancy, led us
to the various questions and dilemmas.
The primary question was when is it safe enough to perform cystectomy with respect to the time of
thrombosis?
Is there some kind of solution for preventing fatal pulmonary embolism other than placing filter in the
inferior vena cava? The solution may be in the application of the concept of the PEEP during
anesthesia as the prevention method for the potential fatal effects of the thromboemboli originating
from the lower extremities [15].
What is the time required for the thrombus resolution and the vein wall remodeling?
How many ultrasound controls do we need to perform during the treatment of the DVT and after the
thrombus resolution?
Given the size of the cyst, there was no doubt about the need for the surgical treatment. Due to the risk
of the DVT during pregnancy, ovarian cystectomy was only a question of time.
3
Conclusions
This case demonstrates that, at sixteenth week of gestation, an ovarian cystectomy is possible for a 29
cm cyst using the laparotomy approach after drug therapy for the DVT.
In our case, the pregnancy of our patient was doubly burdened, first by the DVT and then by the
presence of a large ovarian cyst. Both diagnoses were endangering the patient and the fetus. We
decided to act according to the guidelines of the ACCP on VTE and pregnancy, after which the
cystectomy was done by the surgical laparotomy.
We know that reliable sources for the risk of the fatal PE in patients with treated DVT or PE are
lacking, and according to the guidelines, we did not have an indication for setting IVC filters, with an
additional problem in our case which was the presence of the cyst which occupied the entire right
hemiabdomen and made pressure on the surrounding structures.
Due to the lack of reports about the possibility of using PEEP as the prevention method for the
pulmonary embolism in patients with proven DVT, further trials are needed.
Our experience and knowledge gained from this case suggests a good response to the treatment of the
DVT with LMWH during pregnancy, as well as the ultrasound confirmation that the process of
recanalization is faster than was previously thought. We also confirmed that adnexal masses during
pregnancy are managed ideally in the second trimester after organogenesis is complete and thus
decreasing the risk of fetal loss.
After both types of treatment, the patient and the fetus are well. At the time of writing this case report
a patient is in the last trimester of pregnancy, currently without complications and adverse events.
References
1. Hermans RHM, Fischer DC, van der Putten HWHM, van de Putte G, Einzmann T, Vos MC,
Kieback DG: Adnexal masses in pregnancy. Onkologie 2003, 26:167-172.
2. Goffinet F: Ovarian cyst and pregnancy. J Gynecol Obstet Biol Reprod 2001, 30:100-108.
3. Yuen PM, Chang AM: Laparoscopic management of adnexal mass during pregnancy. Acta Obstet
Gynecol Scand 1997, 76(2): 173-176.
4. Fawzia Sanaullah* and Ashwini K Trehan: Ovarian cyst impacted in the pouch of Douglas at 20
weeks' gestation managed by laparoscopic ovarian cystectomy: a case report Journal of Medical Case
Reports 2009, 3:7257 doi:10.1186/1752-1947-3-7257
5. Mendilcioglu I, Zorlu CG, Trak B, Ciftei C, Akinci Z: Laparoscopic management of adnexal
masses. Safety and effectiveness. J Reprod Med 2002, 47(1):36-40.
6. Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and
pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e691S.
7. Van Dongen CJ, van den Belt AG, Prins MH, Lensing AW. Fixed dose subcutaneous low molecular
weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane
Database Syst Rev 2004; :CD001100.
8. Thomas LA, Summers RR, Cardwell MS. Use of Greenfield filters in pregnant women at risk for
pulmonary embolism. South Med J 1997; 90:215.
9. Milford W, Chadha Y, Lust K. Use of a retrievable inferior vena cava filter in term pregnancy: case
report and review of literature. Aust N Z J Obstet Gynaecol 2009; 49:331.
10. E. González-Mesa, P. Azumendi, A. Marsac, A. Armenteros, N. Molina, I. Narbona, J. Herrera, I.
Artero, and J.M. Rodríguez-Mesa. Use of a temporary inferior vena cava filter during pregnancy in
4
patients with thromboembolic events.Posted online on February 18, 2015.
(doi:10.3109/01443615.2015.1007928)
11. Ahearn GS, Hadjiliadis D, Govert JA, Tapson VF. Massive pulmonary embolism during
pregnancy successfully treated with recombinant tissue plasminogen activator: a case report and
review of treatment options. Arch Intern Med 2002; 162:1221.
12. Herrera S, Comerota AJ, Thakur S, et al. Managing iliofemoral deep venous thrombosis of
pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity. J Vasc
Surg 2014; 59:456.
13. Funakoshi Y, Kato M, Kuratani T, et al. Successful treatment of massive pulmonary embolism in
the 38th week of pregnancy. Ann Thorac Surg 2004; 77:694.
14. Douketis JD1, Kearon C, Bates S, Duku EK, Ginsberg JS. Risk of fatal pulmonary embolism in
patients with treated venous thromboembolism. JAMA. 1998 Feb 11;279(6):458-62.
15. Katsuyuki Kusajima, M.D., Watts R. Webb, M.D., Frederick B. Parker Jr., M.D., Carl E.
Bredenberg, M.D., Bedros Markarian, M.D. Pulmonary Responses of
Unilateral Positive End Expiratory Pressure (PEEP) on Experimental Fat Embolism
16. Zasslow MA, Pearl RG, Larson CP, Silverberg G, Shuer LF. PEEP does not affect left atrial-right
atrial pressure difference in neurosurgical patients. Anesthesiology. 1988;68:760–763. [PubMed]
17. Bert van Ramshorst, MD; Paul S. van Bemmelen, MD, PhD; Hans Hoeneveld, RVT; Joop A.J.
Faber, PhD; and Bert C. Eikelboom, MD, PhD : Thrombus Regression in Deep Venous Thrombosis
Quantification of Spontaneous Thrombolysis With Duplex Scanning
18. Browse NL, Burnand KG, Lea-Thomas M, in Diseases of the Veins. London, Hoddor and
Stoughton Ltd, 1988, pp 307-308
19. http://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/basics/tests-diagnosis/con20031922
NO CONFLICT OF INTEREST
5
Abstract
Ovarian cystectomy by laparotomy in second trimester pregnant patient with diagnosed DVT during
pregnancy
The surgical management of ovarian tumors in pregnancy is similar to that of the non-pregnant
women. Most of these tumors are non-malignant and their treatment is often left until after the birth.
However, if the tumour is larger that 6 cm in diameter, it is suggested that it is better to operate and
remove them during pregnancy, as they may interfere with the birth of the baby.
This is a case report on a 34-year-old primigravida who was diagnosed with ovarian cyst and deep
venous thrombosis in the ninth week of gestation. The patient was initially treated with therapeutic
values of the low molecular weight heparin. After the control ultrasonographic scan in the fifteenth
week of gestation showed deep vein patency of the right leg with no signs of acute venous thrombosis,
the patient was prepared for the surgery. Even though laparoscopic surgery during pregnancy has
numerous advantages compared to open laparotomy, due to the dimensions of the tumor, it was safer
to perform laparatomy. The patient had an uneventful operation and recovery, as well as the
subsequent antenatal period.
6
Ovarian cystectomy by laparotomy in second trimester pregnant patient with diagnosed DVT
during pregnancy
Clinical Hospital Center Zagreb, Obstetrics and Gynecology Clinic
Petrova 13, 10 000 Zagreb
Croatia, European Union
Cover Letter
Dear Editors of the Journal of Anesthesia and Surgery,
hereby I would like to express my intent in submitting a manuscript solely to the Journal of Anesthesia
and Surgery. As the corresponding author, I confirm that this manuscript is an honest, accurate, and
transparent account of the case being reported and that no important aspects of the case report have
been omitted. The case report being submitted counts 2638 words on 5 pages of the manuscript,
including the title, subtitles and the references. The submitted manuscript includes no tables and
graphs. All of the financial issues are covered by the Obstetrics and gynecology clinic at the Clinical
hospital center Zagreb. The patient, which case is being reported, has given her approval for the
publication. Also, the case report wass additionally approved by the Ethical Committe of the
Obstetrics and gynecology clinic at the Clinical hospital center Zagreb. All of the authors of the
submitted manuscript are very interesed in publishing our case report concerning ovarian cystectomy
in pregnant DVT patient in the Journal of Anesthesia and Surgery because we want to share our
clinical experience with our collegues from all around the world, as well as we would like to improve
the knowledge about ovarian cystectomy and the treatment of the deep venous thrmobosis during
pregnancy. Thank you in advance for considering my application. I look forward to receiving your
positive response.
Best regards,
The corresponding author,
Krešimir Reiner, MD.
7
Ovarian cystectomy by laparotomy in second trimester pregnant
patient with diagnosed DVT during pregnancy
Clinical Hospital Center Zagreb, Obstetrics and Gynecology Clinic
Petrova 13, 10 000 Zagreb
Croatia, European Union
List of the authors
1. Author (The Main Author)
Name and title: Ana Vuzdar Trajkovski, MD, Resident in Anaesthesiology
Affiliation: Anaesthesiology
Email: ireland514@gmail.com
2. Author
Name and title: Marko Čačić, MD, Resident in Cardiology
Affiliation: Cardiology
Email: markthelad@gmail.com
3. Author
Name and title: Ljiljana Mihaljević, MD, Phd, Specialist in Anaesthesiology
Affiliation: Anaesthesiology
Email: lmlmihaljevic@gmail.com
4. Author (The Corresponding Author)
Name and title: Krešimir Reiner, MD, Resident in Anaesthesiology
Affiliation: Anaesthesiology
Email: kresimirovichmd@gmail.com
Phone number: 091 761 53 64
5. Author
Name and title: Slobodan Mihaljević, MD, Phd, Assistant Professor, Specialist in
Anaesthesiology
Affiliation: Anaesthesiology
Email: smsmihaljevic@gmail.com
8