Management of Bilateral Hemorrhagic Ovarian Cysts in Pregnancy
Bilateral hemorrhagic ovarian cysts of 3.5 cm discovered incidentally on ultrasound during pregnancy can be safely managed with expectant management and follow-up ultrasound, as approximately 70% will spontaneously resolve without intervention. 1
Initial Assessment and Risk Stratification
- Size and characteristics: 3.5 cm hemorrhagic cysts are relatively small and fall below the 5 cm threshold that would raise higher concern
- Bilateral presentation: According to the literature, bilateral adnexal masses in pregnancy have been reported in up to 4% of cases, and all reported bilateral masses were benign 1
- Incidental finding: Asymptomatic cysts discovered incidentally have better prognosis than those causing symptoms
Management Approach
Immediate Management
- No urgent intervention is required for asymptomatic 3.5 cm hemorrhagic cysts
- Document the size, location, and characteristics of the cysts for baseline comparison
- Assess for any symptoms of pain, which could indicate complications such as torsion or rupture
Follow-up Plan
- Schedule follow-up ultrasound in 4-6 weeks to assess for:
- Changes in cyst size
- Resolution (expected in majority of cases)
- Development of new concerning features
Indications for Surgical Intervention
Surgery should be considered only if the patient develops:
- Severe pain suggesting torsion
- Signs of rupture with hemodynamic instability
- Rapid growth of cysts on follow-up imaging
- Development of concerning features on ultrasound suggesting malignancy
Evidence-Based Rationale
The American Journal of Obstetrics and Gynecology guidelines (2023) clearly state that approximately 70% of adnexal masses in pregnancy spontaneously resolve 1. The guidelines specifically note that bilateral adnexal masses reported in pregnancy (up to 4% of cases) have all been benign, which is reassuring for this patient.
When surgery is necessary during pregnancy, the second trimester is generally preferred as it:
- Allows time for potential spontaneous resolution
- Optimizes visualization with respect to uterine size
- Reduces risks associated with anesthesia in early pregnancy
- Minimizes risk of preterm labor compared to third trimester surgery 1
Warning Signs to Monitor
Instruct the patient to seek immediate medical attention if she experiences:
- Sudden, severe abdominal or pelvic pain
- Vaginal bleeding
- Dizziness or fainting
- Fever or signs of infection
Documentation and Communication
- Document the cysts' characteristics in the prenatal record
- Inform the patient about the benign nature of these cysts and the high likelihood of spontaneous resolution
- Discuss the plan for follow-up and indications for seeking urgent care
Key Points to Remember
- Hemorrhagic cysts are functional cysts that commonly occur during reproductive years
- The risk of malignancy in adnexal masses during pregnancy is very low (approximately 2%) 1
- Bilateral presentation of adnexal masses in pregnancy has not been associated with malignancy in published reports
- Unnecessary surgical intervention during pregnancy carries risks to both mother and fetus
By following this approach, you can provide appropriate care while avoiding unnecessary interventions that could pose risks during pregnancy.