1ST CITY CLINICAL HOSPITAL

Ovarian neoplasms and pregnancy

At the current level of development of medical science, the problems that arise during pregnancy complicated by tumor-like formations of the ovaries have not been solved. Over the past few years, there has been an increase in cases of this pathology. The incidence of ovarian neoplasms (NT) during pregnancy is 0.015–0.5%. The mutual influence of gestation and ovarian neoplasia should be considered in several aspects: what role does the high level of sex hormones play in the development of ovarian neoplasia during pregnancy, what are the features of carcinogenesis during pregnancy, how the neoplasm will affect the growth of the fetus, is it possible to prolong pregnancy until the term of a full-term or viable fetus and what is the possibility of preserving reproductive function after treatment for ovarian tumors.

Most ovarian tumors during pregnancy are physiological, the so-called retention ovarian formations (follicular, paraovarian, corpus luteum cysts), they either disappear naturally or are asymptomatic, do not increase in size, and do not lead to complications during pregnancy. If the ovarian tumor formation is benign and asymptomatic by all indications, then preference is given to dynamic observation and is not an indication for surgical treatment. The question remains debatable whether this ovarian formation is benign. Only histological examination allows one to determine the type of neoplasm and its characteristics; without it, diagnosis is impossible. All other signs are indirect and additional. These signs are very numerous, as a rule, they are not specific, but they must be followed in order to resolve the issue of surgical intervention during pregnancy. For example, confirmation of a corpus luteum cyst during pregnancy is a characteristic echographic picture with active “coronary” blood flow and a decrease in its intensity as pregnancy progresses, a decrease in the size of the cyst in the second trimester of pregnancy.

Often during pregnancy, ovarian thecal lutein cysts occur, which also do not require surgical treatment. After delivery or removal of the trophoblast, they regress within 2-4 months.

Thecallutein ovarian cyst is a retention formation of ovarian tissue, represented by atretic follicles with a layer of thecallutein cells. The appearance of a thecal lutein cyst is usually associated with trophoblastic disease or drug hyperstimulation of ovulation. The development of thecalutein ovarian cysts is often caused by exposure to high concentrations of human chorionic gonadotropin (HCG), which causes hyperstimulation of the follicles. Less commonly, the cause is a luteal hyperreaction associated with increased sensitivity of the follicles to hCG. A high level of hCG occurs in multiple pregnancies, drug stimulation of ovulation, trophoblastic disease ( hydatidiform mole or chorionepithelioma ), so thecallutein ovarian cysts are diagnosed in 25-60% of patients with trophoblast diseases. Luteal hyperreaction, associated with increased sensitivity of follicles to hCG, is usually a genetic predisposition.

The formation of thecallutein ovarian cysts also occurs during normal multiple pregnancy , gestation against the background of diabetes mellitus , hypertension , late toxicosis of pregnancy, and Rh conflict . The presence of theca lutein ovarian cysts can be detected even in newborns; giant (up to 8-12 cm in diameter) cysts can compress neighboring organs, causing intestinal obstruction .

Thecal lutein cysts of the ovaries , as a rule, with symmetrical bilateral localization. Macroscopically, the thecalutein cyst looks like a thin-walled multi-chamber formation filled with light or pale yellow liquid contents.

Diagnosis: ultrasound examination of the pelvic organs reveals echoscopic signs typical of thecal lutein cysts of the ovaries: multi-chamber structure, homogeneous contents without additional inclusions, symmetry of location, lack of blood flow. The presence of ascites is not typical for thecal lutein ovarian cysts.

Possible complications of retention ovarian formations are observed only in 8% of cases. Rupture of the capsule, torsion of the legs , malnutrition of the cyst, necrosis, bleeding are indications for surgical intervention. In these cases, the picture of an acute abdomen comes to the fore - sudden pain syndrome, hypotension, tachycardia , vomiting, pallor of the skin. It should be noted that during surgery it is very important to avoid intraoperative rupture of the tumor capsule. If there is significant growth of the ovarian cyst, pain, or suspicion of malignancy, surgical treatment is performed at any stage of pregnancy. If possible, elective surgery is performed no earlier than 14–16 weeks of pregnancy, i.e. at a time when the placenta has already acquired adequate hormonal activity, sufficient to maintain pregnancy even if a bilateral adnexectomy is performed.

The literature also remains controversial about the ability of existing ovarian cancer to reduce the rate of development during pregnancy. According to researchers, the beneficial effect of pregnancy on the course of the tumor process of this localization is associated with the lack of endocrine stimulation due to a decrease in the hormonal activity of the corpus luteum, however, tumors with estrogen and progesterone receptors have intensive growth during pregnancy due to high levels of sex hormones produced by the placenta .

Many authors draw attention to the fact that the effect of the tumor on the fetus and uterus is manifested mainly in mechanical effects. Thus, ovarian cancer in most cases is the cause of abnormal fetal position and premature birth. At the same time, during pregnancy, constant monitoring of the course of the oncological process is necessary using ultrasound and determination of tumor markers. It is worth noting that timely diagnosis of ovarian cancer in the gestational period may be hampered by biochemical markers common to cancer, characteristic of pregnancy, such as human chorionic gonadotropin (hCG), alpha-fetoprotein, carcinoembryonic antigen 125 (CA 125). In general, researchers note that pregnant women with ovarian tumors have an increased risk of miscarriage, placental insufficiency and chronic intrauterine fetal hypoxia.

At the same time, it has been proven that pregnancy does not affect the course of borderline ovarian tumors. In the case of borderline ovarian tumors, pregnancy and childbirth are not affected by a history of treatment in the form of unilateral adnexectomy, contralateral resection of the ovary and removal of the omentum. However, this fact is confirmed only in cases of stage I of the disease or in the presence of a long (2–3 years) relapse-free period.

Pathogenetically justified if a borderline tumor is suspected, adnexectomy on the affected side, ovarian biopsy of the contralateral side, omentectomy, abdominal washings and biopsy of the visceral peritoneum in at least 3-4 places, a thorough assessment of the condition of regional lymph nodes to exclude dissemination should be considered.

If an early-stage malignant tumor is suspected, the scope of surgical intervention includes unilateral removal of the uterine appendages, greater omentum, appendectomy (for mucinous tumors only) and multiple peritoneal biopsies. The material should be sent for urgent histological examination. Since the pelvic peritoneum, including the pouch of Douglas, cannot be sufficiently examined and examined during late pregnancy, some authors recommend repeated surgical intervention in the postpartum period for the purpose of restaging and assessing the state of the tumor process over time.

Ovarian cancer during pregnancy is a rare disease. Since most cases are diagnosed at an early stage, surgical treatment may be limited to preservation of the uterus and contralateral ovary.

Patients with stages IA, IB, IC, and IIA additionally undergo lymphadenectomy and platinum-based chemotherapy, although the order of treatment can be discussed. Chemotherapy should be started immediately after primary cytoreductive surgery.

The most common malignant ovarian tumors diagnosed in pregnant women are dysgerminomas (30% of all cases). Granulosa cell tumors and Sertoli-Leydig cell tumors account for up to 3% of all neoplasms. Neoplasia of the sex cord stroma during the gestational period is often diagnosed in the early stages and is characterized by slow growth and a low degree of malignancy.

Detection of malignant neoplasms of non-epithelial origin during pregnancy serves as an absolute indication for surgical intervention, which is the first step in treatment tactics. Indications for adjuvant chemotherapy are the same as for non-pregnant patients. In total, according to the literature, 6 courses of chemotherapy are carried out.

In the presence of an ovarian mass during pregnancy, the decision is made individually depending on the size and nature of the tumor, medical history and gestational age, however, there are some general points in the management of pregnant women.

The presence of ovarian tumors in the first and second trimesters of pregnancy is an indication for surgery for true or suspected ovarian tumors.

In patients with ovarian cancer associated with pregnancy in the first trimester, with a poor maternal prognosis and due to limited experience in managing this pathology, termination of pregnancy should be preferred. On the other hand, if the patient strongly desires to continue the pregnancy, starting from the second trimester, it is possible to perform surgical intervention in the amount of non-optimal cytoreduction. The optimal access in the first trimester and up to the 20th week of pregnancy is laparoscopy, from the 20th week - laparotomy. Ovarian formations discovered in the third trimester of pregnancy are removed during surgical delivery or in the postpartum period. Regardless of the stage of pregnancy, indications for surgical treatment are: suspicion of a borderline or malignant tumor, rapid growth of the tumor, and the presence of pain.

Due to the fact that ovarian cancer is characterized by an aggressive course and rapid development to late stages, childbirth must be planned before 40 weeks. Some experts emphasize that the “39 week rule” is contraindicated for this category of patients. The optimal time for delivery is 37 weeks of gestation. However, deterioration of the mother's condition may require delivery at an earlier date. In cases where cancer is diagnosed after the 30th week of pregnancy, one course of chemotherapy is administered (but not later than the 35th week). Further delivery is carried out as planned at 37 weeks of gestation. When conducting chemotherapy courses during the gestational period, it is necessary to observe a three-week interval between the last cycle of taking anticancer drugs and childbirth, which prevents complications associated with inhibition of the hematopoietic system in the mother and child (bleeding, infection, anemia). If there is a choice between premature birth and courses of cytostatics in the third trimester, it is better to choose premature birth and postpone chemotherapy courses.

According to our observations, premature birth before the 35th week causes the birth of premature, immature newborns with a high risk of mortality and the development of chronic diseases. Chemotherapy leads to stabilization of the oncological process. It becomes possible to prolong pregnancy, which undoubtedly helps to increase the degree of fetal maturity, despite the toxicity of drugs used in chemotherapy, which penetrate the placenta, but are largely retained by it and do not have a teratogenic effect in the second and third trimester.

In cases where a borderline neoplasm or cancer at the initial stage is diagnosed during pregnancy, organ-preserving operations are performed to create the possibility of preserving fertility in young patients.

According to modern information, the probability of spontaneous pregnancy after these surgical interventions ranges from 30 to 60%. If it is impossible to become pregnant naturally, assisted reproductive technologies are used. Since there is a risk of cancer developing in the remaining ovary after its pharmacological stimulation, they are trying to abandon this method. In this regard, it is desirable to obtain eggs in a natural cycle. Currently, donor eggs with a preserved uterus, as well as surrogacy, are widely used.

The decision on the tactics of pregnancy management, the timing of delivery and antitumor treatment of women with ovarian neoplasia should be made only together with an oncologist. First of all, the characteristics of each patient are taken into account, taking into account the duration of pregnancy and the stage of the disease.

Patients with ovarian tumors need to be closely monitored by an obstetrician-gynecologist and a gynecological oncologist together to resolve the issue of pregnancy management and delivery.