Saturday, February 5, 2011

A Pregnant Lady who had a big Ovarian Cyst

If only life had readymade answers to all the questions.If only there was no shade called grey.....and there were just blacks and whites.If only..........But unfortunately life quite often gives us situations where we have to exercise our brain and heart to come to a gray decision.
About 2 weeks back a 28 year old female trying to conceive since last year came for her routine early pregnancy check up.On her Ultrasound it was found that she had 6 weeks pregnancy with a 15 cms x 15cms (Which is quite big) ovarian cyst ( A dermoid).She had heaviness on that side of her abdomen but yes there was no evidence of any torsion yet.Now what do I do?She looked quite expectantly at me to say 'all is well'.
My mind was ticking fast.....I have to break this bad news to her and I am not yet ready as to how to make the impact of the report less traumatic.Then I gathered all my skills learnt at various breaking bad news sessions in UK and also my clinical practice and told her so.She was in tears.Actually howling.
Now how do I manage her?Do I leave her for a torsion to develop or do I operate her now if she agrees.Situation had started taking a grey turn.I recalled the sages guidelines on laparoscopy in pregnancy.

It clearly said Laparoscopy is safe in all trimesters of pregnancy.But then old school of thought says defer surgery till second trimester or defer it till she delivers.But then when her uterus will grow bigger,the cyst which is already so big is bound to complicate the pregnancy and then may be with a big vascular uterus and a torsion I might end up opening her than perform a minimally invasive laparoscopy.
Then I also remembered a lady who had been operated upon by some doctor for torsion of dermoid with early pregnancy.She had come to meet me as she was suffering from post traumatic stress following a termination of pregnancy along with cyst removal.She wasn't happy at all with the doctors involved.

What Do I do Know.As usual,I told them the evidences,ref of Pubmed and Sages guidelines and left the decision on her.She and her husband wanted to get it removed laparoscopically at around 7 weeks.I was questioned by our anaesthesia chief about a possible side effect of anaesthetic drugs on fetus but in the times of evidence based medicine can't tell the patient my gut feeling.Every gut feeling needs evidence in support.And I had none to suggest a Termination of pregnancy to her or even to tell her laparoscopy increases the chances of miscarriage.Even one of my gynaecologist colleague didn't seem to like the collective decision which we ( My patient and myself had taken).

Anyways.....She was operated last week.Both mother and fetus stood the surgery well and were discharged the very next day.An ultrasound done post surgery confirmed an ongoing viable pregnancy.
Will keep on updating as we move further in her journry of becoming a mom. 

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