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Rawal Medical JournalAn official publication of Pakistan Medical Association Rawalpindi Islamabad

branch

Established 1975

Volume 36 Number 2 March- June 2011

Original Article

The outcome of antenatally diagnosed ovarian cysts

Hashem E. Aqrabawi

Department of Pediatrics, King Hussein Medical Center, Amman, Jordan

ABSTRACT

ObjectiveTo determine clinical outcome of ovarian cysts diagnosed antenatally.

MethodsThe study was conducted over two years period from January 2008 to December

2009. Eight newborns were diagnosed to have ovarian cysts by antenatal ultrasound.

All were followed regularly in the neonatal clinic. Postnatal ultrasound was done at

one, three, six months and one year of age.

ResultsAll cysts disappeared by the age of one year. None of them had any symptom during

the follow up period.ConclusionConservative approach with serial ultrasound is recommended for follow up of infants

with antenatally diagnosed asymptomatic ovarian cysts.Surgery should be reserved

for symptomatic and large cysts not regressing by the age of one year. (Rawal Med J

2011;36:147-149).

Key wordsOvarian cysts, neonates.

INTRODUCTION

Ovarian cysts are one of the most common causes of lower abdominal cystic masses

in a female neonate or fetus. Before the introduction of ultrasonography, ovarian cysts

were thought to be rare. With the extended use of real time ultrasonography, prenatal

detection has increased.1 The etiology of fetal ovarian cysts has not been entirely

clarified. These cysts arise from mature follicles. The distinction between a mature

follicle and an ovarian cyst is based on size alone: cysts larger than 2 cm are

considered pathological.2 The gestational age at diagnosis is usually 28 weeks.2

On the basis of their sonographic features, cysts are divided into two types: simple

which are completely anechoic and have imperceptible walls, and complex, also

known as complicated, twisted, or hemorrhagic, which show specific characteristic

such as debris-fluid level, clot, septa, and echogenic wall.

3

Management ofasymptomatic neonatal ovarian cysts is controversial. In this observational study, we

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share our experience with the usefulness of conservative approach in the management

of these lesions.

PATIENTS AND METHODSThis prospective observational study was conducted over a two years period starting

from January 2008 to December 2009. Collaboration between the involved feto-maternal specialist, neonatologist, and the radiologist was high. A register for all

pregnant mothers with abnormal antenatal fetal ultrasound (U/S) was established. All

female newborns with antenatal diagnosis of intra-abdominal cystic lesion were

included in the study. Male infants and infants with multiple congenital anomalies

were excluded from the study. All newborns were observed in the neonatal unit for a

minimum of 48 hrs after delivery for any symptom. All underwent postnatal

abdominal U/S on the second day of life.

Newborns that were diagnosed to have ovarian cysts were followed in the neonate

clinic at two weeks, one, three, six months and one year of age. Detailed physical

examination and abdominal U/S were performed regularly in each visit. The presence

of "daughter cyst" sign, which is a specific sonographic finding for an ovarian cyst,was used to differentiate ovarian cysts from other cystic masses in the postnatal

abdominal U/S.

RESULTSBetween January 2008 and December 2009, twelve female newborns were diagnosed

in the feto-maternal unit to have intrabdominal cystic lesions by antenatal U/S (Fig 1).

Postnatal U/S on the second day of life showed that in three infants (25%) the cysts

were mesenteric in origin and in one infant (8%) the cyst was a distended urinary

bladder (Table 1). Eight of the twelve infants (67%) had ovarian cysts as confirmed

by the presence of "daughter cyst" sign (Fig 2).

Fig 1. Antenatal fetal scan at 35 wks gestation showing cystic mass in the

abdomen.

All of the ovarian cysts were unilateral in origin. The size of the cysts varied between

three and ten cm in diameter. All infants with these ovarian cysts were observed in the

nursery for at least 48 hrs before discharge. None of them had any symptom

(vomiting, not passing meconium, excessive crying).

Fig 2. Postnatal abdominal U/S confirming the presence of the cyst (note the

presence of the daughter cysts in the wall of the cyst).

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Follow up in the neonate clinic up to age of one year did not reveal any manifestation

that could be related to these cysts.

Table 1. Intra-abdominal cystic lesions in 12 newborns.

Ovarian cysts 8 ( 67% )

Mesenteric cysts 3 ( 25% )

Urinary bladder 1 ( 12% )

Postnatal U/S showed regression of the cysts size by the age of one to three months

and complete resolution of cysts by the age of 6 months in six infants (75%); and by

the age of one year in the remaining two (25%).

DISCUSSION

Before introduction of U/S, ovarian cysts in neonates were thought to be rare and

could only be diagnosed postnatally. Cysts were only discovered if they were palpable

or became symptomatic. Neonatal ovarian cysts are being diagnosed more frequentlynow that routine ultrasonography is carried out antenatally and postnatally. The

pathogenesis of neonatal ovarian cysts is unknown. It is postulated that the stimulus

for the formation of neonatal ovarian cysts is human chorionic gonadotrophin (HCG)

that stimulates the fetal ovary during pregnancy.4 It occurs more often in newborns

whose mothers had high level of HCG (diabetes, Rh isoimmunization, toxemia). An

immature hypothalamus-pituitary-ovarian feedback is thought to be responsible for

the higher incidence in premature infants.5

According to Nussbaum, ovarian cysts are divided into two types: simple (completely

anechoic) and complex or complicated (characterized by fluid-debris level, septa, clot,

and echogenic wall).6 Most neonatal ovarian cysts are asymptomatic and discovered

incidentally. Complication associated with ovarian cysts include torsion with loss ofovary, rupture, hemorrhage and compression of other viscera. Torsion is the most

common complication and occurs more likely with cysts of >5 cm size. There is a risk

of pulmonary hypoplasia and polyhydramnios developing in fetuses with large cysts.

Malignant change is extremely rare in simple ovarian cysts and is seen in complex

lesions.7

The treatment of neonatal ovarian cysts is controversial. Until recently the

recommended treatment was surgical. The rationale for this was the risk of possible

torsion, or the replacement of the entire ovary by cyst making cystectomy impossible.

Most authors recommend surgical removal for symptomatic cysts >5 cm in diameter

and complex cysts regardless of their size. Postnatal aspiration and laparoscopic

removal have been advocated.

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These operations carry a high risk of removing all normal ovarian tissue, thereby

rendering the patient at risk of sterility. Recently, a good outcome has been achieved

with conservative management because of spontaneous remission within a few

months.8 This approach has the advantage of sparing the patient an operation;

secondly prevents the possible removal of normal ovarian tissue. In our study, we

found complete resolution of the ovarian cysts, regardless of their size in eight femalenewborns without any complication and without surgical intervention. Our study

supports the conservative "wait and see" approach with serial U/S in management of

these cases.

CONCLUSIONConservative management with clinical and sonographic monitoring should be

considered for asymptomatic neonatal ovarian cysts. Most neonatal ovarian cysts

involute spontaneously by the age of one year. Surgery may be considered for

symptomatic cysts and large lesions not regressing by the age of one year.

Correspondence: Dr Hashem E. Aqrabawi MBBS, MRCPCHConsultant neonatologist, King Hussein Medical Center

Amman, Jordan. PO Box: 850892. Post Code: 11185

E mail: h_aqrabawi@hotmail.com

Tel: 00962799018504

Received: January 9, 2011 Accepted: April 17, 2011

REFERENCES

1. Enriquez G, Duran C, Toran N, Piqueras J, Gratocos E, Aso C, et alConservative Versus Surgical Treatment for complex Neonatal Ovarian Cysts:

Outcomes Study AJR 2005; 185: 501- 508

2. Widdowson D J, Pilling D W, Cook RCM Neonatal obaraian cysts:therapeutic dilemma Arch Dis Child 1988; 63: 737- 742

3. Oak SN, Parelkar SV, Akhtar T, Pathak R, Vishwanath N, Satish KV, et alLaparoscopic management of neonatal ovarian cysts J Indian Assoc Pediatr

Surg 2005; 10: 100 - 102

4. Hengester P, Mendari G Ovarian cysts in the newborn Pediatric surgeryinternational 1992; 7: 372- 375

5. Lee H J, Woo S K, Kim JS, Suh S J Daughter Cyst Sign: A SonographicFinding of Ovarain Cyst in Neonates, Infants, and Young Children AJR 2000;

174: 10131015

6. Schmahman S, Haller J O Neonatal ovarian cysts: pathogenesis, diagnosisand management Pediatric Radiology 1997; 27: 101105.

7. Tehrani F H E, Kavehmanesh Z, Kaveh M, Tanha F D Neonatal OvarianCyst: A case Report Iran J of Pediatr 2007; 17: 379382

8. Krasuski P, Poniecka A, Gal E, Neonatal Ovarian Cysts Prenatal andNeonatal Medicine 2001; 6: 190 - 191

mailto:h_aqrabawi@hotmail.commailto:h_aqrabawi@hotmail.com

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