Laparoscopic management of ovarian cysts during pregnancy under urgent situations

As the use of ultrasound imaging develops into a routine in obstetric examinations, the incidental diagnosis of the lesions of the ovary is more prevalent and the vast majority of these adnexal masses are ovarian cysts. Based on previous studies, the incidence rate of adnexal masses complicating pregnancy varies from 0.05% to 2.4%, and only 1% to 6% of them are malignant.[ 1 2 ] Since most of these cysts are physiological in nature, the majority of them are resolved spontaneously as pregnancy progresses;[ 3 ] but, in a few cases, urgent interventions are required because of their acute complications. The superiority of laparoscopy over conventional laparotomy in the surgical management of benign ovarian masses has been thus far established.[ 4 5 ] However, huge ovarian masses, advanced gestational age and emergency surgery are among complex conditions, challenging surgeons due to some technical problems such as trocar insertion, location of trocars, uterine injury, as well as cyst ruptures. Neonatal malformations, preterm birth[ 6 ] and foetal acidosis attributed to the effects of pneumoperitoneum are the other concerns about laparoscopy during pregnancy.[ 7 ] Therefore, this retrospective study was conducted on the laparoscopic management of ovarian cysts at advanced gestational ages under urgent situations. Furthermore, the study aimed to demonstrate the feasibility and the efficacy of laparoscopic surgery, as a minimally invasive procedure, for adnexal masses during pregnancy, even in emergencies.

This retrospective cross-sectional study was performed on a sample of pregnant women in need of emergency ovarian surgeries, undergoing laparoscopy at Al-Zahra Teaching Hospital affiliated with Tabriz University of Medical Sciences, Tabriz, Iran. For this purpose, a total number of 48 pregnant women in their first and second trimesters, between March 2018 and March 2021 were included in this study. The patients with contraindications due to medical problems or unwillingness to have laparoscopic surgery were also excluded from the study. Before preparing this study and collecting the patients’ profiles, permission was obtained from the Ethics Committee of Al-Zahra Teaching Hospital to access the related data. As well, a written informed consent was obtained from all patients before publish this article. As outlined in the informed consent, all the patients were assured about the confidentiality of their identity. Gravida, parity, medical history, main complaints, gestational age, as well as cyst size and characteristics; for example, being unilateral or bilateral and its pathological type, operation time, changes in haemoglobin (Hb) levels before and after the operation, all were recorded as patients’ data. Whether the patient had a history of ovarian cysts before pregnancy or she had accidentally noticed a cyst in her ovary during pregnancy and whether the patient had planned for elective surgery of her ovarian cyst in pregnancy before emergencies arise, or she wanted to be monitored during pregnancy and had sought for treatment after the pregnancy had ended were all the clinical data obtained from the patients and recorded in their files. Quality and manner of prenatal care of all patients were also noticed as clinical data in this study. However, after admission and initial evaluations, the patients underwent laparoscopic surgery. Pre-operative ultrasonographic study was further performed on all patients before the operations. Excruciating pain, ovarian cyst torsion, cyst rupture and acute abdominal symptoms were thus amongst the factors that had necessitated emergency surgery. The patients preferably underwent ovarian cyst resection and some of them received oophorectomy. The Trendelenburg position by 15°–25° and gas pressure <18 mmHg were also used during the surgery. In cases wherein the height of the uterus was below the umbilicus, the primary trocar was inserted into the abdomen at a distance of 2 cm above the umbilicus. In cases in which the uterine fundal height was above the umbilicus, the primary trocar was inserted 4–6 cm above the umbilicus. The only existing difference in laparoscopic techniques was the adjustment in the location of the primary and secondary trocar placement depending on the gestational age and the side where the pathology was located. The port entrance was designed so that there was at least 6 cm of distance between the uterus or the adnexal lesion and the top of the instrument or telescope. There was also a difference in the intra-abdominal gas pressure and Trendelenberg angle of the surgical bed based on the gestational age. The maximum intra-abdominal gas pressure was 18 mmHg and the maximum Trendelenberg angle of the surgical bed was 15–25 mmHg, which was adjusted depending on the gestational age. Direct peritoneal access was additionally employed in most of the patients except for the cases of advanced gestational age, in which intraperitoneal gas insufflation was performed through left subcostal Veress needle placement before primary port insertion. Other accessory trocars were also placed based on the patients’ condition and the cyst characteristics. All the surgeries were performed by one surgeon. Bipolar instrument was then used for homeostasis and the surgical endo bag, applied from the lateral trocar, was utilised to remove the cyst or the ovary. Ovarian sutures were used in some cases. Besides, minimally uterine manipulation was performed to preserve the pregnancy. Most of the cysts especially functional haemorrhagic ones and endometriomas were drained before resection to facilitate the surgery and to minimise uterine manipulation. All the patients underwent 50 mg of injectable progesterone twice daily for 10 days after surgery, and all of them were hydrated well. Tocolytic therapy was required in three patients. Intravenous paracetamol was also used to relieve post-operative pain. Moreover, post-operative ultrasonographic study was then performed on all patients to evaluate foetal status. Changes in Hb levels and operation time were then assessed in all patients. Descriptive statistics, including mean, standard deviation, frequency and percentage, were also employed to explore the data. All the qualitative and quantitative variables were analysed using the Chi-square test and the t -test, respectively. The significant level was considered by P < 0.05.

The main study findings were summarised in tables [Tables 1 and 2 ]. The mean age of the patients was 32 and the mean body mass index was in the range of 25–30. Other demographic characteristics are detailed in Table 1 . Most of the patients accidentally noticed a cyst in their ovary during pregnancy and planned to have elective surgery in their pregnancy. There was no conversion to laparotomy. There were no cases of pregnancy loss or preterm labour too. All the women had given birth after 37 weeks of gestation and there were no significant intra-abdominal adhesions in the cases with caesarean section (C-section). The mean operation time was 45 min and there was no significant decrease in serum haemoglobin level. The mean intra-abdominal pressure was equal to 15 mmHg (ranging from 12 to 17 mmHg) and the mean end-expiratory carbon dioxide (CO 2 ) pressure was 34 mmHg (ranging from 30 to 39 mmHg). The operating table was at an average 20° angle to the Trendelenburg position. The mean gestational age was 17.3 weeks on the patient’s admission and the mean cyst size was 8.2 cm based on the intraoperative findings [ Table 2 ]. The most common pathology diagnosed was mature teratoma, followed by haemorrhagic cysts, endometriomas and luteal cysts [ Figure 1 ], as well as serous and mucinous cyst adenomas. In eight patients, due to the large size of the ovarian cyst (>9 cm), part of the thin ovarian wall had been resected along with the cyst. Total oophorectomy had been further performed in four patients following multilocular ovarian cysts, small projections of cyst walls and probability of malignancy. The tumour markers had not been requested before surgery due to the urgent need for surgery in addition to the high possibility of false-positive or false-negative results of these tests during pregnancy. The pathologic study of the specimens also revealed no malignancy. In another two patients, oophorectomy had been correspondingly performed because of severe adnexal adhesion. As well, mild-to-moderate intraperitoneal adhesions had been found in four other patients, managed through laparoscopic surgery. Ovarian torsion and cyst rupture were further diagnosed in 22 and 16 patients, respectively [ Figure 2 ]. Massive intra-abdominal haemorrhage had been similarly reported in four patients, both requiring blood transfusions. The other two blood transfusions were due to the primary low Hb levels of a woman with irregular perinatal care and chronic anaemia. Moreover, tocolytic therapy was needed in six women with advanced gestational age and relatively more uterine manipulation. In addition, 34 (70.83%) patients had given birth by C-section and the mean gestational age of delivery was 38.2 weeks. All the infants also obtained normal Apgar scores. Demographic features of women who underwent laparoscopic surgery SD: Standard deviation, BMI: Body mass index Cystectomy characteristics based on laparoscopic and pathologic findings SD: Standard deviation (a) Huge ovarian cyst that complicated pregnancy in early gestational age, (b) Huge ruptured endometrioma with acute abdomen, (c) A large multiloculated mucinous cystadenoma at 14 th week of gestation (a) Abdominal pain due to large right ovarian cyst at 16 th week of pregnancy, (b) Acute abdominal pain due to ovarian torsion at 16 weeks of gestation, (c) Acute abdominal symptoms due to ovarian torsion at 17 th week of pregnancy

Minimally invasive surgeries may be the procedure of choice in pregnancy. The study findings confirmed that laparoscopic surgery could be safe and performed easily during pregnancy, with no maternal or neonatal complications, even in emergencies like ovarian torsions or ruptured ovarian cysts. In previous studies, laparoscopic cystectomy was limited to non-emergency elective pregnant patients in early gestational ages of pregnancy; however, we used this procedure in emergency situations of advanced gestational age and obtained good results. Nil. There are no conflicts of interest.

Ovarian cyst management during pregnancy can be a challenge for either an obstetrician or a patient. Although most of the adnexal masses in pregnancy are accidentally diagnosed at the time of the first-trimester ultrasound imaging, approximately 1%–2% of such masses may complicate pregnancy and demand surgical interventions.[ 8 ] Despite the obvious advantages of laparoscopic surgeries in the management of adnexal masses, there are still concerns about this procedure in pregnant women due to the possibility of uterine and consequent foetal injuries, which are related to the insertion of trocars as well as negative effects attributed to the outcomes of pneumoperitoneum.[ 7 9 ] Conventionally, the surgical management of ovarian masses in pregnancy has been performed via laparotomy to provide the best exposure to the pelvis and the upper abdomen. The disadvantages of open laparotomy include long hospital stays while recovering, more post-operative pains caused by large incisions, long-term immobilisation, giving rise to thromboembolism in susceptible women, additional uterine manipulation, as well as financial inefficiency in terms of length of hospital stays.[ 10 ] These conditions have thus led to many studies on the feasibility and safety of laparoscopic surgeries during pregnancy.[ 4 11 ] Lower morbidity, earlier discharge from hospital, decreased post-operative pains, less adhesion formation, more acceptable cosmetic results, less wound infections, lower blood loss, faster recovery and earlier return to typical activities are accordingly among the potential benefits of laparoscopic surgeries. The study findings also revealed that lower uterine manipulation and, consequently, lower risk of preterm labour were other advantages of such minimally invasive procedures. This might be due to better intraperitoneal vision during laparoscopic surgery and the presence of enough space in the upper abdomen to perform this operation without uterine manipulation. All of these advantages make this minimally invasive surgery more cost-effective than laparotomy. In most of the previous studies, surgeries had been performed at early gestational age in non-emergency conditions, and few studies had been conducted during an emergency at an advanced stage of pregnancy. The present study was performed in an urgent situation like ovarian torsion or cyst rupture, either in the first or in the second trimesters, wherein the maximum gestational age was 24 weeks. All of the patients also had critical conditions and were in need of emergency interventions. Despite the emergency, the maximum length of surgery was 85–90 min in the patients with ruptured teratomas and intraperitoneal haemorrhage, respectively. Although the umbilicus is the typical area for primary port insertion,[ 12 ] alternative insertion sites such as the left upper quadrant or Palmer’s point and also the middle upper abdomen (Lee-Huang point) should be considered in patients with periumbilical adhesions, huge uterine or adnexal masses and also in pregnancy.[ 13 14 ] Port positioning at least 6 cm above the uterine fundus while the abdominal wall is elevated, is approximately a safe method of port placement in pregnant women. This placement provides an adequate distance between the laparoscope and the uterine fundus to allow adequate visualisation and instrumentation. Subxiphoid, left upper quadrant or right upper quadrant insertion point helps to avoid the enlarged uterus and also decreases the risk of uterine and foetal injury by Veress needle or primary port in advanced gestational ages.[ 15 ] Majority of port placements in advanced gestational ages in this study were in the middle upper abdomen between the xiphoid process and the umbilicus, approximately 5–6 cm above the uterine fundus. However, the umbilicus was the most preferred site for primary abdominal entry in the first trimester of pregnancy. No cases of insertion-related uterine or foetal injury were reported in this study. Adequate functional intraperitoneal space will accordingly increase surgeons’ ability to do the surgery and will consequently prevent excessive uterine manipulation and consequent obstetrics complications such as preterm delivery and foetal loss. To facilitate this procedure, most of the cysts were drained before resection except in the cases of suspected malignancy.[ 16 ] Indeed, cyst suction was considered in selective patients only after the exact evaluation of malignancy risk, not as a routine. In order to fulfil the cyst drainage, the trocar was inserted inside the cyst and its contents were emptied so that the contents of the cyst would not leak.[ 17 ] Exact peritoneal washing was further done after cyst depletion in order to prevent the peritoneal spread and uterine stimulation. In previous studies, the maximum gestational age was below 19 weeks during surgery.[ 11 18 ] This was due to the concern about the insertion of trocars into the uterus or uterine damage from surgical instruments.[ 7 19 ] It should be noted that CO 2 insufflation is also another concern about laparoscopy during pregnancy. Although cardiorespiratory circulation can be affected due to CO 2 pneumoperitoneum and the Trendelenburg position, as well as foetal acidosis following maternal conversion of CO 2 to carbonic acid (H 2 CO 3 ), laparoscopy can be safely performed in each trimester of pregnancy,[ 20 21 ] according the Society of American Gastrointestinal and Endoscopic Surgeons. Surgeons’ expertise in laparoscopic surgery is once again highlighted; obviously, the more skilful the surgeons, the faster the performance, the shorter the length of surgery and the less the unwanted complications of intra-abdominal gas. Intra-abdominal pressure of <15 mmHg during laparoscopy will prevent unwanted side effects of pneumoperitoneum.[ 22 ] Measurement of end-tidal CO 2 pressure (capnography) is adequate for intraoperative CO 2 monitoring in pregnant women. By keeping the end-tidal CO 2 at 32–34 mmHg, respiratory acidosis can be avoided. If maternal acidosis is confirmed, it should be reversed by maternal hyperventilation and decreasing intraabdominal pressure. These can resuscitate the foetus by improving placental blood flow and foetal oxygenation.[ 20 ] The mean end-tidal CO 2 pressure was 34 mmHg in this study. No cases of maternal acidosis were reported in this study. There were also no cases of intraoperative foetal monitoring. Foetal loss may further happen in 4%–5% of all pregnancies after laparoscopic operations or laparotomy.[ 22 ] The tocolytic therapy should be considered in the presence of pre-term labour signs either before or after the surgery.[ 23 ] No cases of miscarriage or preterm labour also occurred in the present study. As well, the tocolytic therapy had been postoperatively used in three patients who presented with severe abdominal pain from a ruptured cyst. Other cases had been prescribed with 50 mg of injectable progesterone twice daily for 10 days after surgery and all of them had been hydrated well. The study findings showed that the routine use of tocolytic therapy after surgery was not required during pregnancy, and they were only needed in the cases of threatened preterm labour. Complete perinatal care was further performed after discharge. No side effects had been observed during pregnancy as well as no low APGAR score at delivery. As expected, there were no new significant intra-abdominal adhesions in the cases of C-section. This was one of the most important advantages of minimally invasive surgeries with reference to the previous studies.[ 24 ] Recently, there are significant improvements in ultrasound imaging techniques, resulting in the ability to better characterise ovarian cysts and to distinguish benign from malignant masses during pregnancy.[ 25 26 27 28 ] Therefore, close observations are reasonable alternatives to antepartum surgery in selected patients, with an ovarian cyst in pregnancy.[ 29 30 ] However, emergencies may arise that necessitate surgery. Twenty patients in this study were aware of ovarian cysts before pregnancy. They had been refused surgery to prevent ovarian reserve depletion. Although in specific pathologies, such as endometriomas, adnexal surgery can reduce ovarian reserve,[ 31 ] it probably has no effect on ovarian reserve in other types of adnexal surgery.[ 32 33 ] Therefore, surgical resection for larger ovarian cysts before pregnancy seems reasonable to minimise complications during pregnancy. Twenty-two patients in the present study had planned for elective surgery after pregnancy. Antepartum surgery had been thus performed in all of them due to urgent situations. Ovarian torsion is a common potential complication concerning the expectant management of ovarian masses during pregnancy that occurs in 6%–7% of cases.[ 29 34 35 ] In this sense, ovarian torsion was the most common reason for the need for emergency surgery in this study. The high prevalence of ovarian torsion here compared with previous studies is related to case selection. All the patients in this study were in need of emergency surgery, and thus, ovarian torsion was the most diagnosed pathology. However, there were some limitations facing this study. First, the present study was limited in the case number. Of note, it is difficult to conduct a larger study since complicated cases of adnexal masses in need of emergency surgery are not common in pregnancy. This may be the reason of the absence of post-operative abortion and preterm delivery in this study compared with those reported in the related literature (4%–5%).[ 22 ] The second limitation was the lack of long-term follow-up of infants regarding their global and neuronal development. Indeed, the study failed to explain the effect of different surgical and anaesthetic techniques on newborns precisely. No adverse long-term side effects, including cognitive and developmental disorders, have been reported according to available researches, but data are sparse. Since developmental and cognitive disorders are influenced by many genetic, congenital, environmental and social factors, therefore, commenting on the effect of laparoscopic surgery on developmental disorders is not easy and requires advanced and numerous multicentre studies. The absence of pregnancy in the late second trimester is another limitation of our study. Certainly, further studies with larger sample sizes and in various gestational ages are needed to evaluate the effect of laparoscopy in a pregnancy outcome and the possibility of safe laparoscopic surgeries in advanced gestational ages. Conversely, the presence of emergency surgery was one of the strengths of this study compared with previous researches even though it has limited the number of patients studied.[ 4 8 11 16 24 ]