The question
a 35 years old lady 5 weeks pregnant with moderate to severe left side abdominal pain, moderate tenderness. TVS revealed 6cm simple left ovarian cyst and intrauterine gestational sac, with
positive color doppler around the cyst and doubling BHCG.
I counseled the pt against surgical intervention as this will carry a high risk of
pregnancy loss. I kept her under observation with simple analgesics. Next
morning she was screaming of pain with severe tenderness, I took her for laparoscopY.
During laparoscopy the cyst wasn’t twisted…………
Huda Salah

The Answer (Date:    Mon, 21 Dec 2009 20:16:42 -0500  Listserv AAGL)

This is an important question. The clinical picture however, is unusual.
1. During early pregnancy ovarian cysts up to 5-6 cm diameter are rather common. Ultrasound should be able to distinguish between a corpus luteum/endometriosis and a simple follicular cyst. Because of the risk of a miscarriage we prefer to postpone surgery (unless clinicallly necessary) and to repeat the ultrasound exam a few weeks later .
2. If as in this case, the patient has acute severe pain a laparoscopy might be indicated to rule out a torsion/subtorsion. Treatment then depends on clinical judgment ; if the ovary is very mobile with a long utero-ovarian ligament or is there is any suggestion of a (sub)torsion, I shorthen this ligament with 1 stitch monocryl 3*0. If there is a 5-6 cm cyst I would puncture and drain very gently. Even if it would look like an endometrioma I would only drain.

My arguments for this are as follows
1. The cause of lateralized acute pain in early pregnancy should be an heterotopic extrauterine pregnancy, a bleeding in a corpus luteum or a torsion/subtorsion. (other causes are extremely rare, except intestinal problems )
2. Visceral pain (if not caused by infection, blood in the peritoneal cavity or ischemia) is caused predominantly by tension (eg after a bleeding in a corpus luteum) : since at the moment of surgery an eventual bleeding already has stopped I would drain in order to release the pressure.
3. Since a corpus luteum and an endometrioma not infrequently are associated, I would not do ovarian surgery especially not in the beginning of pregnancy.

Philippe R. Koninckx*,** ,Carlo de Cicco** and Anastasia Ussia**
*University of Leuven, Belgium, University of Oxford UK, Università Cattolica Rome Italy and **Gruppo Italo Belga
www.gynsurgery.org www.mondoginecologico.it .