TEALE FENNING

bronwyn · Posted: Wed Jul 19, 2006 9:16 pm Post subject: Any "bubbles" on this one?

A case I was confronted with just this week:
"A 24 year old lady is found to have a 8x8cm unilateral, multiloculated, semi-solid ovarian cyst at her 19 week anomaly scan in her first pregnancy. Outline your subsequent management plan."
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Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Thu Jul 20, 2006 7:15 am Post subject:

That's a nice question and one that could well come up in some shape or form.

Let's have a think ... and use the rules / bubbles.

Introduction

Not uncommon
Difficult to manage as pregnant
Sinister causes - cancer
Common causes - teratoma / corpus luteal cyst (both unlikely on the features you gave - I think the question would be more open so these could be options)
Morbidity from potential surgery

Concept - conservative manangement if possible with surgery indicated in those with symptoms / suspicious features (she has suspicious features!)

History

Asymptomatic? If she has pain etc she may need intervention
Suspicious features - past personal or family history of cancer / borderline tumour, sudden increase in size, weight loss, nausea/vomiting

Examination

Jaundice / cachexia / pallor
Tenderness
Lymph nodes

Investigation

USS - suspicious features include septation (>3mm), ascites, abnormal contralateral ovary, multiloculated, semi-cystic/semi-solid (this sounds nasty to me!)
Ca-125 - increased in pregnancy so less reliable but may be very high

Treatment

Conservative - plan for this normally but probably not here

Medical - no role ? steriods if preterm delivery suspected i.e. surgery needed / chemotherapy delayed until after delivery if needed

Surgical - probably indicated with these features, delay until second trimester (she is already there) or 32-34 weeks, midline laparotomy, no role for laparoscopy, oophorectomy, sample omentum / washings,

Other - tertiary referral to an oncologist?

Follow-up

If conservative in puerperium - watch for torsion at this stage
If operated on - regular antenatal checks
If malignant - oncologist +/- adjuvant treatment

Political

Good few GAPs (Give Away Points) here
- Multidisciplinary
- Tertiary referral
- Counselling
- and why not throw in a leaflet or two!

Now that's my bubbling done - took me 6 minutes!

Did you come up with the same 'bubbles' and answers?

I do not think you necessarily have to deliver the fetus at laparotomy. This is the major issue but will only get you 2 marks maybe. However, I bet most of the marks will be in the other sections I have outlined. Do you agree?

It needs refining of course - have a go and add some stuff.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Nick Raine-Fenning · Posted: Thu Jul 20, 2006 7:26 am Post subject:

Just a thought - was the anomaly scan normal?

That would change everything!
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Thu Jul 20, 2006 11:07 am Post subject:

Great!
Very similar bubbles. It was only because of the bubbles that I got conservative management....I just wanted to operate!

Maybe a few marks for
* LSCS only for obstetric reasons, vaginal delivery not contra-indicated
* endometrioma in the differential

Will have a go at bubbling yours while on call tonight

PS have just finished operating on her........huge haemorrhagic corpus luteum!
_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Thu Jul 20, 2006 11:13 am Post subject:

Good points that I should have got!!

Endometrioma is definitely in the differential and may have been suggested by pre-pregnancy gynae problems including infertility.

I thought it was too big for a CL but at least I got it in my differential!

Luteoma is the other consideration - associated with hirsutism.

Bet you forgot to do washings and an omental biopsy?? Wink

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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Thu Jul 20, 2006 11:21 am Post subject:

Of course I did Laughing

I even peaked at her other ovary!

Oh, her anomaly was normal....that would have been far too many bubbles!
_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Thu Jul 20, 2006 12:00 pm Post subject:

Of course you did ... what?

Forgot or checked??
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

bronwyn · Posted: Thu Jul 20, 2006 8:22 pm Post subject:

Did it all, washings, omental biopsy and checked the other ovary Smile

_________________
Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Thu Jul 20, 2006 9:30 pm Post subject:

Good for you - knew you wouldn't let us down!

Great question to start the site off ... and with immediate clinical relevance. What more could you want!
_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997