Primary Neonatal and paediatric Consultant Dr M Gnanabalan Operating Paediatric Surgeon Dr P Balamourugane Paediatric Pathologist Dr Seetha lakshmi

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1 Dr C K Janaki Raman DNB Pediatrics Trainee Department of Pediatrics Mehta Childrens Hospital

2 Primary Neonatal and paediatric Consultant Dr M Gnanabalan Operating Paediatric Surgeon Dr P Balamourugane Paediatric Pathologist Dr Seetha lakshmi Paediatric Radiologist Dr A Ramalingam & Dr Anand Paediatric Endocrinologist Dr Hemchand K P

3 Antenatal History of Pelvic cysts sized 40mmx28mm and 21mmx18mm. There is no history of hypothyroidism or diabetes or or Rh incompatibility PIH in the antenatal period. Mild hydramnios

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5 Female child Delivered as FTND Uneventful delivery and newborn period. Breast fed baby No abdominal distension or palpable mass Passed meconium Good growth Ultrasound repeated in 3rd month in view of antenatal findings

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7 Height 60cm (63.2 centile, SD score +0.34) Weight 6.2kg (72.1 centile and SD score +0.58) BMI 17.2 kg/m2 (69.8 centile and SD score +0.52) Her Tanner stage was A1 P1 B2 B1 Mo. No bony deformities or cafe au lait spots no mass palpable clinically, no markers of hypothyroidism No fractures or bony deformities Normal vaginal mucosa for age

8 LH 0.6 miu/ml FSH 3.5 miu/ml Estradiol pg/ml TSH 6 Alpha fetoprotein ng/ml Beta HCG 0.1IU/L

9 B2 (Tanner) Normal growth Bone age not reliable Hormones Minipuberty level range Wait and watch Breast development Complex in nature Size regressing but not satisfactory reduction Tumor markers negative Repeat USG after 2 weeks Complex ovarian cyst

10 Repeat Ultrasound after 2 weeks revealed mildly prominent uterus and persistent right ovarian cyst. (No change in size, minimal change in debris) MRI abdomen done enlarged cystic ovary (35mm x 18mm) and peripheral calcificationand hemorrhage and multiple cysts in the contralateral ovary, normally placed in the cul de sac and mobile.

11 Early breast development Growth on centiles Uterus normal on MRI No acceleration of growth Pituitary Normal on MRI screening Ovarian Cyst Complex Persistent?Calcification Laproscopy and proceed

12 child underwent Detorsion and laproscopic salphino oophorectomy on the torsed side. The resected specimen sent for HPE The Other side ovarian cyst de-roofed.

13 We present an antenatally detected complex ovarian cyst that was initially managed conservatively; operated in view of persistence complex nature proven to be benign cystic teratoma by histopathology.

14 1 in 2500 Increased with prenatal USG Risk factors: Conditions with increased HCG from placenta or mother PIH/ IDM/ Rh incompatibility Ascites and Polyhydramnios due to small bowel obstruction

15 SIMPLE CYST Anechoic COMPLEX CYST Echogenic Thick wall (>2mm) Flocculated content/ fluid debris level/ retraction clot/septation/calcifica tion Thin wall (<2mm) Follicular Torsion/Hemorrhage/t umor/follicular

16 Should you aspirate prenatally? Reveal the sex to the parents? Mode of delivery Early delivery? When to get the first Ultrasound done post natally?

17 Should you aspirate prenatally? YES NO Investigate the contents Prevent torsion Avoid surgery in neonatal period Bleeding Simple becomes complicated Infection Preterm labour Early delivery ONLY IN BILATERAL ovarian cysts, large enough so that ovarian fn preservation may be an issue Mode of delivery NVD; LSCS for obstetric reasons. Dystocia and Cyst rupture very rare When to get the first Ultrasound done post natally? Beyond two weeks

18 Is it simple or complicated? What is the Size? Is it unilateral or bilateral? Is it symptomatic or asymptomatic? Any medicines? When to refer to surgeon?

19 WAIT AND WATCH When to intervene? 1. Becomes symptomatic 2. Size >5cm 3. Persists beyond 6 months Periodic ultrasound till resolution of cysts (one in 2 weeks followed in most western centres)

20 Two schools of thought Intervene as early Be conservative Why? 1. A rare presentation of benign tumor missed SPONTANEOUS RESOLUTION OF COMPLEX CYSTS HAS BEEN REPORTED 2. Salvage the ovary if feasible 3. Laproscopy safe and simple SERIAL ULTRASOUND IF NO SATISFACTORY RESOLUTION/ INCREASE NOTED TAKE UP FOR SURGERY

21 Reference Author Sample size Key points J Korean Med science 2006 Kwak et al (Korea) 17 cysts 7 operated (6 follicular cysts, 1 serous cystadenoma) 10 followed up till resolution (8 simple and 2 complicated) Ped surgery intl 2000 Luzzato et al 27 cysts (Italy) 12 complex 10 regressed and 2 persisted Prenatal diagnosis 2008 Noche et al (france) 67 cysts 37 complex cysts 4 no torsion Oct 1992 vol C K Muller et 44 cysts 22 al Simple cysts may need surgery and complex cyst (5) resolved with no surgery Even complex cysts can resolve Even Simple cysts may be dangerous

22 In a study on 65 ovarian cysts in Austria, Mittermeyer et al reported one teratoma (out of 14 complicated cysts)* In a study on 64 ovarian cysts in Berlin, Helin et al reported one teratoma (out of 30 complicated cysts)# - Ultraschall Med 2003 Feb;24(1):21-6 # - Ultrasound Obstet Gynecol 2002; 20:

23 Antenatal ovarian cyst Minimal antenatal role. Careful post natal periodic USG mandatory Simple cyst size criteria to intervene Complex cyst very close watch and non reduction of size of cyst early surgical referral Complex cyst usually a complicated simple cyst. BUT IT CAN BE SOMETHING ELSE AS WELL! Complex cyst with coarse calcification - Is it teratoma?

24 Monitor growth and SMR if needed a GnRh stimulation test Repeat Thyroid functions Close watch on the normal ovary by periodic ultrasound