lnt J Gynecol Obstet.
International
203
1992. 31: 203-205
Federation
of Gynecology
and Obstetrics
Growth and rupture of an ovarian endometrioma P. Vercellini”, “Department Istituti
A. Ferraria,
of Obstetrics and Gynecology
Clinici di PerfeSonamento,
Milan
N. Vendolab, “L. Mangiagalli”.
in pregnancy
S.G. Carinellib University of Milano
School
of Medicineand
hDepartment of Pathology,
(Italy)
(Received April 24th. 1991) ,(Revised and accepted June 16th. 1991)
Abstract Pregnancy has long been considered to have beneficial effects on endometriosis. We describe a patient who underwent emergency exploratory laparotomy at gestation week 3.5 for rupture of an ovarian endometrioma.
Keywords: Endometriosis; pregnancy; abdominal pain.
ovarian
cyst;
Introduction
That pregnancy has beneficial effects on endometriosis is a long-standing clinical tenet, and anecdotal observations form the basis for the use of continuous high-dose progestins. We report the case of a woman in whom endometriosis developed rapidly, with an acute manifestation at week 35 of gestation. Case report
A 29-year-old primigravida came to our department at 35 weeks of gestation, reporting diffuse intermittent moderate abdominal pain. Apart from appendectomy performed at age 13 years, the history was unremarkable. The menstrual flows preceding conception were regular and not painful. Pelvic examinations and ultrasound scans performed before and during pregnancy were normal. The woman’s general condition was good, the size 0020-7292/92/$05.00 0 1992 International Federation Printed and Published in Ireland
of the uterus corresponded to gestational age. The cervix was uneffaced, posterior and 1 cm dilated. The membranes were intact. Presentation was cephalic and unengaged. The fetal heart beat was regular. Threatened preterm labor ,was diagnosed. The woman was admitted, and intravenous infusion of ritodrine was started. During the following 24 h the abdominal pain became progressively more severe and was accompanied by vomiting, no passage of feces or gas, and slight fever (37.5”C). At physical examination the abdomen was distended and very tender. The cervical status was unchanged. A diagnosis of bowel obstruction was made, and a laparotomy decided upon. On exploration the abdominal cavity was found to be tilled with chocolate-colored fluid. A cesarean section was performed and a healthy male infant weighting 2730 g delivered. At exploration of the pelvis, the cecum and two ileal loops adhered to the right ovary, which was enlarged due to the presence of a ruptured and collapsed 8 cm endometrioma. Endometriotic implants were disseminated on the sigmoid, parietal peritoneum, vesicouterine fold and pouch of Douglas. The intestinal adhesions were lysed and the cyst enucleated; the peritoneal implants were electrocoagulated. Histological examination confirmed the clinical diagnosis (Fig. 1). The postoperative course was uneventful. Seven weeks after delivery the paCase Report
of Gynecology
and Obstetrics
204
Fig. I.
Endomefriosis
Histologic
und pregnancy
preparation
of the right ovarian
stroma with intense decidual reaction (hematoxylin
endometrioma
showing a mucosal lining of endometrial
and eosin; original magnification
x IO).
type epithelium
C. cyst cavity; E. epithelium;
and
S. stroma;
0, ovarian parenchyma.
tient was menstruated normal.
asymptomatic. and the pelvic
She has not examination is
Discussion The scanty data available on behavior of endometriosis in pregnancy are contradictory and/or derived from studies of implants induced surgically in experimental animals. McArthur and Ulfelder [l] analyzed the clinical effects of pregnancy on 23 women with endometriosis and observed that the course of the disease during gestation is variable. Some patients presented marked progression of endometriosis throughout pregnancy. Furthermore, persistence of the disease after delivery was more frequent than regression. The role of steroids in the initia1n1 J Gynecol
Ohstrt
37
tion and maintenance of endometriotic implants in castrated monkeys with surgically induced endometriosis was studied by Di Zerega et al. [2] who observed that progesterone alone was capable of maintaining implant viability. Although it is impossible to know whether our patient had endometriosis before conception, pelvic examination and ultrasonography excluded the presence of ovarian cysts. The time-honored clinical precept that pregnancy has beneficial effects on endometriosis has long influenced the criteria of medical treatment and led numerous authors to advocate early marriage and childbearing as prophylactic measures to prevent development or progression of the disease. Epidemiologic studies to investigate these beliefs might yield interesting results.
Vercellini
References 1 2
205
Address for reprints:
MC Arthur JW, Ulfelder H: The effects of pregnancy upon endometriosis. Obstet Gynecol Surv 20; 709, 1965. Di Zerega GS, Barber DL, Hodgen GT: Endometriosis: role of ovarian steroids in initiation, maintenance and suppression.
et ul.
Fertil Steril 33: 649. 1980.
P. Vercellini Department of Obstetrics and Gynecology University of Milrno School of Medicine Via Commenda, 12
“L. Mangiagalli”
Milan, Italy
Case Report
International
203
1992. 31: 203-205
Federation
of Gynecology
and Obstetrics
Growth and rupture of an ovarian endometrioma P. Vercellini”, “Department Istituti
A. Ferraria,
of Obstetrics and Gynecology
Clinici di PerfeSonamento,
Milan
N. Vendolab, “L. Mangiagalli”.
in pregnancy
S.G. Carinellib University of Milano
School
of Medicineand
hDepartment of Pathology,
(Italy)
(Received April 24th. 1991) ,(Revised and accepted June 16th. 1991)
Abstract Pregnancy has long been considered to have beneficial effects on endometriosis. We describe a patient who underwent emergency exploratory laparotomy at gestation week 3.5 for rupture of an ovarian endometrioma.
Keywords: Endometriosis; pregnancy; abdominal pain.
ovarian
cyst;
Introduction
That pregnancy has beneficial effects on endometriosis is a long-standing clinical tenet, and anecdotal observations form the basis for the use of continuous high-dose progestins. We report the case of a woman in whom endometriosis developed rapidly, with an acute manifestation at week 35 of gestation. Case report
A 29-year-old primigravida came to our department at 35 weeks of gestation, reporting diffuse intermittent moderate abdominal pain. Apart from appendectomy performed at age 13 years, the history was unremarkable. The menstrual flows preceding conception were regular and not painful. Pelvic examinations and ultrasound scans performed before and during pregnancy were normal. The woman’s general condition was good, the size 0020-7292/92/$05.00 0 1992 International Federation Printed and Published in Ireland
of the uterus corresponded to gestational age. The cervix was uneffaced, posterior and 1 cm dilated. The membranes were intact. Presentation was cephalic and unengaged. The fetal heart beat was regular. Threatened preterm labor ,was diagnosed. The woman was admitted, and intravenous infusion of ritodrine was started. During the following 24 h the abdominal pain became progressively more severe and was accompanied by vomiting, no passage of feces or gas, and slight fever (37.5”C). At physical examination the abdomen was distended and very tender. The cervical status was unchanged. A diagnosis of bowel obstruction was made, and a laparotomy decided upon. On exploration the abdominal cavity was found to be tilled with chocolate-colored fluid. A cesarean section was performed and a healthy male infant weighting 2730 g delivered. At exploration of the pelvis, the cecum and two ileal loops adhered to the right ovary, which was enlarged due to the presence of a ruptured and collapsed 8 cm endometrioma. Endometriotic implants were disseminated on the sigmoid, parietal peritoneum, vesicouterine fold and pouch of Douglas. The intestinal adhesions were lysed and the cyst enucleated; the peritoneal implants were electrocoagulated. Histological examination confirmed the clinical diagnosis (Fig. 1). The postoperative course was uneventful. Seven weeks after delivery the paCase Report
of Gynecology
and Obstetrics
204
Fig. I.
Endomefriosis
Histologic
und pregnancy
preparation
of the right ovarian
stroma with intense decidual reaction (hematoxylin
endometrioma
showing a mucosal lining of endometrial
and eosin; original magnification
x IO).
type epithelium
C. cyst cavity; E. epithelium;
and
S. stroma;
0, ovarian parenchyma.
tient was menstruated normal.
asymptomatic. and the pelvic
She has not examination is
Discussion The scanty data available on behavior of endometriosis in pregnancy are contradictory and/or derived from studies of implants induced surgically in experimental animals. McArthur and Ulfelder [l] analyzed the clinical effects of pregnancy on 23 women with endometriosis and observed that the course of the disease during gestation is variable. Some patients presented marked progression of endometriosis throughout pregnancy. Furthermore, persistence of the disease after delivery was more frequent than regression. The role of steroids in the initia1n1 J Gynecol
Ohstrt
37
tion and maintenance of endometriotic implants in castrated monkeys with surgically induced endometriosis was studied by Di Zerega et al. [2] who observed that progesterone alone was capable of maintaining implant viability. Although it is impossible to know whether our patient had endometriosis before conception, pelvic examination and ultrasonography excluded the presence of ovarian cysts. The time-honored clinical precept that pregnancy has beneficial effects on endometriosis has long influenced the criteria of medical treatment and led numerous authors to advocate early marriage and childbearing as prophylactic measures to prevent development or progression of the disease. Epidemiologic studies to investigate these beliefs might yield interesting results.
Vercellini
References 1 2
205
Address for reprints:
MC Arthur JW, Ulfelder H: The effects of pregnancy upon endometriosis. Obstet Gynecol Surv 20; 709, 1965. Di Zerega GS, Barber DL, Hodgen GT: Endometriosis: role of ovarian steroids in initiation, maintenance and suppression.
et ul.
Fertil Steril 33: 649. 1980.
P. Vercellini Department of Obstetrics and Gynecology University of Milrno School of Medicine Via Commenda, 12
“L. Mangiagalli”
Milan, Italy
Case Report
