Management of Large Nabothian Cyst During Labor and Delivery
Large nabothian cysts that obstruct the birth canal during labor should be managed with simple drainage to facilitate vaginal delivery, as this approach provides the best outcomes for both maternal and neonatal morbidity and mortality.
Understanding Nabothian Cysts
Nabothian cysts are benign mucous retention cysts of the uterine cervix that form when cervical glands are obstructed, typically following childbirth or minor trauma. While most are small and asymptomatic, they can occasionally grow to significant sizes:
- Most nabothian cysts are <1 cm and clinically insignificant
- Large cysts (>4 cm) are rare but can cause symptoms
- Giant nabothian cysts (>8-10 cm) have been reported in case studies
Diagnosis During Labor
When a large nabothian cyst is encountered during labor:
- Visual examination will reveal a cystic mass protruding from the cervix
- The cyst may appear as a tense, bulging structure replacing part of the cervical lip
- Ultrasound can confirm the cystic nature and absence of solid components
- Differentiation from other adnexal masses is important
Management Algorithm for Large Nabothian Cysts in Labor
1. Initial Assessment
- Determine if the cyst is obstructing the birth canal
- Assess fetal status and labor progression
- Confirm diagnosis through visual examination and, if needed, bedside ultrasound
2. Management Options
For obstructing cysts: Simple drainage is the preferred approach 1
- Allows for immediate relief of obstruction
- Facilitates vaginal delivery
- Minimizes maternal and fetal risks associated with cesarean delivery
For non-obstructing cysts: Observation may be sufficient if labor is progressing normally
3. Drainage Procedure
- Sterile preparation of the area
- Simple needle aspiration of cyst contents
- Collection of fluid for potential pathologic examination
4. Post-Drainage Management
- Monitor labor progression
- Proceed with vaginal delivery if no other obstetric indications for cesarean
Evidence Supporting This Approach
The most recent and directly relevant evidence comes from a case report of a large nabothian cyst (60x70 mm) that obstructed the birth passage during labor 1. In this case:
- Simple drainage was performed to allow vaginal delivery
- The patient successfully delivered a 4130-gram baby with excellent Apgar scores
- Both maternal and neonatal outcomes were favorable
- The cyst persisted postpartum but at a smaller size (40x50 mm)
Post-Delivery Follow-Up
After delivery, the nabothian cyst should be reassessed:
- Follow-up examination at 6-8 weeks postpartum
- If the cyst persists and is symptomatic or large, definitive management options include:
Important Considerations and Pitfalls
- Diagnostic confusion: Large nabothian cysts can be mistaken for adnexal masses 3 or cervical malignancies
- Recurrence: Simple drainage may be temporary, with the cyst potentially refilling over time
- Malignancy exclusion: While rare, adenoma malignum and other cervical malignancies should be considered in the differential diagnosis of persistent large cervical cysts 1, 2
- Prolapse association: Very large nabothian cysts can present with or exacerbate uterine prolapse 4
By following this management approach, obstetricians can effectively address large nabothian cysts encountered during labor while minimizing risks to both mother and baby.