Peripartum disseminated extrapulmonary tuberculosis simulating ovarian carcinoma

Disseminated extrapulmonary tuberculosis is an uncommon complication of pregnancy. We present a 26-year-old multiparous immigrant from Haiti who was admitted following an extramural preterm delivery. Marked ascites was confirmed by computerized tomography, which also revealed a thickened greater omentum. These findings were considered suggestive of advanced ovarian carcinoma, although extrapulmonary tuberculosis was also considered despite negative tuberculin skin test screening. Image-guided omental biopsy demonstrated caseating granulomas substantiating the diagnosis of abdominal tuberculosis, which was later confirmed by cultures. The patient responded well to antituberculosis medications. This case describes the unusual peripartum presentation of abdominal tuberculosis simulating advanced ovarian carcinoma, and demonstrates the importance of considering extrapulmonary tuberculosis when encountering ascites and omental thickening during pregnancy despite negative tuberculin skin test screening.     

Management of ovarian masses. AAGL 1990 survey.

The American Association of Gynecologic Laparoscopists (AAGL) membership was surveyed on the use of laparoscopy in the management of persistent ovarian masses in 1990. A total of 13,739 laparoscopies were performed for this indication. Ninety-six percent of the respondents performed laparoscopy for this indication on premenopausal women only. Among respondents performing laparoscopy for suspected cancer, there was a 14% conversion rate to laparotomy, compared to 9% among those who performed direct laparotomies when cancer was suspected. An overall incidence of 4 per 1,000 cases of stage I ovarian cancer was found, and about 70% of women with persistent adnexal masses were managed by laparoscopy alone. The risks to women with cancer, as well as the benefits to those without, are discussed.     

Triage of ovarian masses

Background: Triage of ovarian masses for appropriate management is important in ensuring the best outcome for patients. The Risk of Malignancy Indices (RMI) seem to represent a low cost and effective tool for triage and management of women with ovarian masses.
Aim: To review patients with an ovarian mass referred to the Gynaecological Cancer Centre at the Royal Hospital for Women, and to assess the effectiveness of the RMI in differentiating benign from malignant tumours in this group of patients.
Methods: A retrospective review of the case records of all patients with an ovarian mass referred to our centre from January 2003 to December 2005 was undertaken.
Results: Two hundred and four patients were eligible for RMI calculation. An RMI of < 200 correctly identified 83 of 108 (77%) benign ovarian tumours. An RMI of > 200 correctly identified 11 of 19 (58%) borderline ovarian tumours and 70 of 77 (91%) invasive ovarian tumours. An RMI of > 200 had a sensitivity of 84%, specificity of 77%, positive predictive value of 76% and negative predictive value of 85% in detecting both borderline and invasive ovarian tumours. The false negative rate for invasive tumours was 9%.
Conclusions: This study showed that using RMI at a cut-off of 200 for referral could have prevented 83 benign cases (41%) from being referred. We propose that the RMI could be utilised as a triage tool for referral of ovarian masses to gynaecological cancer centres.     

Transabdominal and transvaginal sonography of ovarian masses.

This chapter outlined the sonographic appearances of most ovarian tumors using both transabdominal and transvaginal sonography. The use of transabdominal and transvaginal sonography for the early detection of ovarian carcinoma seems promising and should be pursued in several institutions as clinical trials.     

Peripartum hemorrhage.

This article has reviewed the causes and potential therapies for PPH. These include both predictable and unpreventable causes and methods of differential diagnosis. Triage of therapeutic interventions and prompt diagnosis are critical in reducing morbidity and mortality caused by PPH.     

Managing ovarian masses during pregnancy

The management of adnexal masses during pregnancy can be challenging for the patient and the clinician. The specter of a possible malignancy can sway the decision for intervention versus expectant management. The etiologies of ovarian masses are reflective of the patient's age; and, therefore, benign entities such as functional ovarian cysts, benign cystic teratomas, and serous cystadenomas predominate. In the unusual cases when cancer is present, they are typically germ cell and borderline ovarian tumors, and are commonly low stage and low grade. Ultrasound is the primary modality used to detect ovarian masses and to assess the risk of malignancy. Morphologic criteria more accurately identify benign cysts compared with malignant tumors. Tumor markers are used primarily to monitor disease status after treatment rather than establish the ovarian tumor diagnosis as a result of lack of specificity, because several markers can be elevated inherent to the pregnancy itself (eg, CA-125, beta-hCG). Expectant management is recommended for most pregnant patients with asymptomatic, nonsuspicious cystic ovarian masses. Surgical intervention during pregnancy is indicated for large and/or symptomatic tumors and those that appear highly suspicious for malignancy on imaging tests. The extent of surgery depends on the intraoperative diagnosis of a benign versus a malignant tumor. Conservative surgery is appropriate for benign masses and borderline ovarian tumors. More aggressive surgery is indicated for ovarian malignancies, including surgical staging. Although rarely necessary, chemotherapy has been used during pregnancy with minimal fetal toxicity in patients with advanced-stage ovarian cancer in which the risk of maternal mortality outweighs the fetal consequences.     

Persistent ovarian masses and pregnancy outcomes

Abstract

Objective: To determine if persistent ovarian masses in pregnancy are associated with increased adverse outcomes.

Methods: This is a retrospective cohort of 126 pregnant women with a persistent ovarian mass measuring 5?cm or greater who delivered at two university hospitals between 2001 and 2009. Maternal outcomes included gestational age (GA) at diagnosis, delivery and surgery as well as miscarriage, preterm birth (PTB), ovarian torsion and hospital admission for pain. Neonatal outcomes included birth weight, respiratory distress syndrome (RDS), intra-ventricular hemorrhage (IVH), death and sepsis.

Results: A total of 1225 ovarian masses were identified (4.9%) in 24?868 patients. A persistent ovarian mass was found in 0.7%. Average GA at diagnosis was 17.8 weeks. Miscarriage rate was 3.3%. Average GA at delivery was 37.9 weeks. Of the patients, 8.5% had ovarian torsion, 10.3% had admission for pain and 9.3% had PTBs. The mean cesarean delivery rate was 46.3%. The average neonatal weight was 3273?g. There was one neonatal death in this cohort. The rate of RDS was 2.8%, IVH 0.9% and neonatal sepsis 1.9%. The most common surgical pathologic diagnosis was dermoids (37.6%). No overt malignancies were seen.

Conclusion: A persistent ovarian mass in pregnancy does not confer an increased risk of adverse pregnancy outcomes.     

Laparoscopic surgery for complex ovarian masses

STUDY OBJECTIVE: To assess the value of laparoscopy in managing complex ovarian masses. DESIGN: Retrospective, observational analysis (Canadian Task Force classification II-2). SETTING: University-based, tertiary level center for endoscopic surgery. PATIENTS: Two hundred eleven consecutive women. INTERVENTIONS: Laparoscopic surgery including ovary-preserving surgery, salpingo-oophorectomy, adhesiolysis, and pelvic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: Patients were selected on the basis of preoperative ultrasound findings. Intraoperative appearance of the tumors as well as results from frozen section examinations were compared with histologic results. Two hundred sixteen pelvic masses were benign. In 10 patients, early ovarian cancer, borderline tumors, tubal cancer, or secondary ovarian, nongynecologic pathology was managed primarily by laparoscopy and confirmed histologically. Three of these 10 women underwent standard radical open surgery within 1 week. The true nature of masses was not recognized at the time of laparoscopy in three patients with malignant findings. Patients with malignant tumors were followed for 5 years. CONCLUSION: Although most complex ovarian masses can be managed by laparoscopy, the possibility of overlooking malignancy remains, even with frozen section examination. Whether or not laparoscopy compromises clinical outcome compared with laparotomy is not fully understood. Prospective studies to address this important clinical question are urgently needed.     

Peripartum cardiomyopathy. A review

The objective of this article is to review the aetiology, epidemiology, diagnosis, clinical course, treatment and prognosis of peripartum cardiomyopathy (PPCM). The medical literature from 1966 to March 2002 was reviewed through MEDLINE. PPCM is a rare complication in pregnancy. It is seen in late pregnancy or in the early puerperium. The aetiology of this disease remains uncertain. Many possible causes have been proposed, including myocarditis, abnormal immune response to pregnancy, maladaptive response to the hemodynamic stresses of pregnancy and prolonged tocolysis. Risk factors for PPCM include advanced maternal age, multiparity, African descent, twinning and long-term tocolysis. Patients with systolic dysfunction during pregnancy are treated the same as patients who are not pregnant. The mainstays of medical therapy are digoxin, loop diuretics, sodium restriction and afterload reducing agents (hydralazine and nitrates). Due to a high risk for venous and arterial thrombosis, anticoagulation with heparin should be instituted. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be avoided during pregnancy because of severe adverse neonatal effects. The utility of immunosuppressive therapy remains ambiguous. Advances in medical therapy for dilated cardiomyopathy and cardiac transplantation have significantly improved the quality of life and survival for patients.     

Clinical use of serum c-erbB-2 in patients with ovarian masses.

The c-erbB-2 (Her-2/neu) gene product has a large extracellular domain (ECD) and part of which could be identified in the serum. We measured the serum level of c-erbB-2 ECD in 93 patients, who presented with ovarian masses, with an enzyme immunoassay test and an elevated level was found in 5.5, 16.7 and 38% of patients with benign, borderline and malignant ovarian neoplasms, respectively. This serum marker may reflect the overexpression of c-erbB-2 gene in tumor tissues, which is associated with poor prognosis. However, measurement of c-erbB-2 ECD when used alone or in combination with CA 125 is not useful in differentiating benign from malignant ovarian tumors.     

Sonographic accuracy in the diagnosis of ovarian masses

Prediction of the tissue diagnosis of ovarian masses has remained a challenge for the sonographer since many adnexal masses have nonspecific sonographic appearances. We evaluated the accuracy of the sonographic diagnosis of adnexal masses in 100 women undergoing laparotomy for ovarian masses within eight weeks of an ultrasound study. Comparison of the preoperative sonographic and final pathologic diagnoses revealed a correct sonographic diagnosis in 68% of the cases. In addition, sonography correctly identified a benign condition in 17% of the cases, though without arriving at the exact tissue diagnosis. Sonography was frankly misleading in 15% of the cases, misreading whether the lesions were benign or malignant. The identification of ovarian malignancy was correct in 24/30 patients (sensitivity, 80%), and the specificity for correctly diagnosing a benign condition was 87%. The positive predictive value of a sonographic diagnosis of an adnexal malignancy was 73%. The negative predictive value of sonography for excluding a malignancy was 91%.     

Noninflammatory ovarian masses in girls and young women

OBJECTIVE: We reviewed the presentation, treatment, and pathologic diagnoses of girls and young women less than 21 years old with noninflammatory ovarian masses that required surgery and established whether treatment had changed over time. METHODS: We retrospectively reviewed charts of all girls and young women under 21 years old with International Classification of Diseases, 9th Revision (ICD-9) codes specific for noninflammatory ovarian masses treated at our institution from June 1980 to July 1998 (n = 140). RESULTS: The median age at surgery was 15 years (range 2 days-21 years). Ovarian cysts occurred in 57.9% (81 of 140) of patients, benign tumors (including mature cystic teratomas) in 30% (42 of 140), malignant tumors in 7.9% (11 of 104), and torsed but normal ovaries in 4.3% (six of 140) of the study sample. Patients older than 15 years were more likely to have ovarian cysts and benign tumors than younger patients (P =.019). There were no malignancies among girls with neonatal cysts. The incidence of ovarian torsion was 17.8% (25 of 140). Patients with ovarian cysts, mature cystic teratomas, and normal ovaries were more likely to have torsion than those with other benign or malignant tumors (P <.001). Operative approach and surgical procedure were compared before and after July 1, 1989. Laparoscopy was performed more commonly after July 1, 1989 (P =.009). However, patient age (P <.001) rather than time of surgery (P =.83) was the most important predictive factor in a multivariate analysis for use of laparoscopy. In addition, multivariate analysis revealed that patient age (P =.02) rather than time of surgery (P =.79) was also predictive of surgeon type (gynecologist or pediatric surgeon). CONCLUSION: The most frequent cause of an ovarian mass requiring surgery in a girl or young woman under 21 years of age is an ovarian cyst, which justifies consideration of a laparoscopic approach. Patient age rather than time of surgery predicted operative approach and surgeon type. Caution should be exercised in patients over age 12 months with a complex mass on ultrasound and clinical evidence of hormonal activity, as these masses are usually malignant.     

Characteristics of persistent ovarian masses in asymptomatic women

Persistent ovarian masses have been found in a substantial proportion of 5479 self-selected asymptomatic women who were screened for early ovarian neoplasia. Each woman was scheduled to undergo three ultrasound screens (consisting of 1-12 scans) to detect regressing and non-regressing masses. A total of 14,594 screens (15,977 scans) was performed. The average interval between successive screens was 595 days (range 214-1134 days). Overall, 650 screens (4.4%; 10.1% of women) produced a positive result which became negative with successive scans (four times more frequently in pre- than naturally postmenopausal women), and 338 screens (2.3%; 5.9% of women) had a final positive result (at least one ovary that was grossly abnormal or contained a persistent mass). Biopsies were taken from 336 ovaries (89% of total, 271 women). Overall, 134 tumour-like conditions and 119 benign tumours were identified. The detection rate of tumour-like conditions was 1.5 times higher in premenopausal than naturally postmenopausal women, whereas the proportion of tumours to normal ovaries was similar in both groups. Overall, 51% of tumour-like conditions and 70% of all tumours were detected at screen 1. Four women had metastatic ovarian cancer (three at screen 1, one at screen 2; two were bilateral). Five women (0.1%) had a primary malignant tumour (two at screen 1, three at screen 2; four were stage 1a and one was stage 1b). All women are being monitored to obtain additional information about the significance of the findings.     

Peripartum Cardiomyopathy

EDITORIAL COMMENT": Cardiomyopathy is an important primary cause of indirect maternal deaths and in the last 3 published triennial reports on maternal deaths in Australia accounted for 2 of 11 deaths due to cardiovascular disease in the 1988-90 triennium (total deaths 96), 3 of 14 in 1985-87 (total deaths 86), and 2 of 14 deaths due to cardiovascular disease in the 1982-84 triennium in which the total number of maternal deaths was 94. This paper reports 3 cases of peripartum cardiomyopathy and provides valuable information concerning diagnosis, differential diagnosis and treatment. Case 1 has the anecdotal advantage of presenting the first successful pregnancy after cardiac transplantation in Australia.
Summary: Peripartum cardiomyopathy is an uncommon condition of unknown aetiology. Diagnosis requires exclusion of other causes of congestive cardiac failure and the demonstration of global ventricular dysfunction on echocardiography. Treatment consists of diuretics, vasodilators, digoxin and anticoagulants. Prognosis is related to recovery of ventricular function. The availability of cardiac transplantation has improved the outlook for those with persistent dysfunction.     

Peripartum cardiomyopathy

Objective

To determine the clinical and echocardiographic profiles of women with peripartum cardiomyopathy and ascertain the natural course of the disease.

Methods

Fifty-six women with peripartum cardiomyopathy were followed up for a mean period of 6.1 years and their clinical and echocardiographic profiles were studied as well as their outcomes.

Results

The mean ± SD age at presentation was 31 ± 5 years and mean parity was 2.6 ± 1. Of the 56 patients, 18 (32.1%) had NYHA Class II, 24 (42.9%) had NYHA Class III, and 14 (25%) had NYHA Class IV symptoms, and 21 (37.5%) and 35 (62.5%), respectively, presented with features of heart failure during pregnancy and the postpartum. During follow-up, the left ventricular ejection fraction improved from 31% ± 7.2% to 43% ± 8% (P ≤ 0.05). Nine patients (16.1%) became pregnant, with a mortality of 55.5% during pregnancy and 23.2% during follow-up.

Conclusion

Women with peripartum cardiomyopathy present with severe left ventricular dysfunction late in the pregnancy or early in the puerperium. A considerable number of women still die from this condition despite the use of angiotensin-converting enzyme inhibitors and β-blockers. A subsequent pregnancy carries a very high risk of mortality.