How To Deal With Gynecologic Tumors During

C-Section

Hermawan Udiyanto, dr. SpOG (K)

Divisi Onkologi, Obstetri dan Ginekologi, Fakultas Kedokteran UNS

Rumah Sakit Dr. Moewardi Surakarta 2016
Gynecologic Tumors During C-Section :

 Uterine tumor
 ovarian tumor
 Uterine tumor – C section

The management of fibroids

encountered at Caesarean section
remains a therapeutic dilemma.
 Uterine tumor – C section

 Caesarean myomectomy has traditionally been discouraged

due to fears of intractable haemorrhage and increased
postoperative morbidity, unless the myoma is pedunculated.

 A number of authors have recently shown that myomectomy

during Caesarean section does not increase the risk of
haemorrhage or postoperative morbidity.

 Selected patients and in experienced hands, myomectomy at

the time of caesarean section is a safe and effective procedure.

Lovina et al,Caesarean Myomectomy; Feasibility and safety; SQU Med J, May 2012, Vol. 12,
Iss. 2, pp. 190-196,
 The removal of intramural myoma from the pregnant
uterus was regarded as unsafe because of the
recognized difficulty in controlling blood loss

J. O. Awoleke, Department of Obstetrics and Gynaecology, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti
State P.M.B. 5355, Nigeria, Correspondence should be addressed to J. O. Awoleke; bisijacob@yahoo.co.uk .
Received 18 July 2013; Accepted 5 October 2013
  The incidence of myoma associated with pregnancy is
reported at 0.3–5%, with a majority of myomas not requiring
surgical intervention during pregnancy or delivery.

 22–32% showing increased growth.

 Katz et al. : 10–30% of women with myomas associated with

pregnancy had complications

 Caesarean section rates in women with myomas are higher,

up to 73%, mainly due to obstructed labour and
malpresentations

Lovina et al,Caesarean Myomectomy; Feasibility and safety; SQU Med J, May 2012, Vol. 12, Iss. 2, pp.
190-196,
J. O. Awoleke, Department of Obstetrics and Gynaecology, Ekiti State University Teaching Hospital, Received 18 July 2013; Accepted 5 October 2013

These tumours may be asymptomatic.

In the pregnant women with coexisting fibroids, there are :

 increased incidences of first trimester losses,
 pressure symptoms,
 pain from red degeneration (necrobiosis),
 torsion of a pedunculated variant,
 malpresentations,
 preterm rupture of membranes
 preterm labour during pregnancy,
 obstructed labour from a cervical or lower segment mass intrapartum and
retained placenta,
 subinvolution of the uterus,
 postpartum endomyometritis,
 postpartum haemorrhage in the immediate postpartum period .
  miscarriages,
 obstructed labour,
 malpresentations,
 pressure symptoms,
 pain due to red degeneration,
 preterm labour,
 preterm premature rupture of membranes,
 retained placenta,
 postpartum haemorrhage
 uterine torsion.
 .

Lovina et al,Caesarean Myomectomy; Feasibility and safety; SQU Med J, May 2012, Vol. 12, Iss. 2, pp.
190-196,
 Softening and enlargement of myoma uteri e/c increase
vascularization + increased estrogen levels of circulating

 Fast Growing e/c hypertrophy and edema, at first month -

hormonal effect, after 4 month no getting bigger.

 If the fibroids grow faster, it exceeded its blood supply -

degenerative changes occur - necrobiosis (red
degeneration) - cause pain
Documented reasons for the removal of uterine
fibroids during caesarean section include :
 the prevention of necrobiosis

 pain during pregnancy,

 to gain access to the baby in patients in whom

fibroids are obstructing the lower uterine segment

 pedunculated and anterior uterine fibroids

Recent studies - techniques to minimise blood loss at Caesarean
myomectomy including :

 Uterine tourniquet
 Bilateral uterine artery ligation,
 Electrocautery.
 uterine artery balloon catheters were placed preoperatively.
 high-dose oxytocin infusion during (i.e., after the delivery of the
baby and placenta) and after the surgery .
 combination of uterine tourniquet and high-dose oxytocin
infusion.
• A vertical male infant, weighing
2538 g with Apgar
uterine incision
scores of 4 and 9 at 1
and 5 min,
• Intraoperative
bleeding was
1600 mL
Six months after
delivery, the
patient’s myoma
had decreased to
approximately 11 cm
in size.
  Exacoustos and Rosetti :

 9 cases of CM, 3 were complicated by severe haemorrhage

necessitating hysterectomy.

 They recommended caution while making the decision to

perform this procedure

 Some authors report a higher incidence of postpartum

haemorrhage and puerperal sepsis if the fibroid is not
removed at Caesarean section.

Lovina et al,Caesarean Myomectomy; Feasibility and safety; SQU Med J, May 2012, Vol. 12, Iss. 2, pp.
190-196,
  a retrospective cohort study of 8 patients with myomas which
resulted in pregnancy complications, underwent myomectomy at
the time of Caesarean section at Sultan Qaboos University Hospital
(SQUH) between January 1999 and December 2010.
 ranging in size from 4 to 12 cms.
 Of the 8 patients studied :
 7 had anterior lower segment fibroids

 one had a posterior lower uterine fibroid

 In total, 4 were intramural fibroids (50%) and 4 were subserous.

Lovina et al,Caesarean Myomectomy; Feasibility and safety; SQU Med J, May 2012, Vol. 12, Iss. 2, pp.
190-196,
 7 of them being larger than 5 cm in diameter.
 Regarding intra-operative blood loss,
 1 patient lost 900 ml; 5 patients lost 1–1.5 litres; 2 lost 1.5–2 L,

 1 patient with a 10 x 12 cm subserous fibroid lost 3.2 L.

 None of the patients required hysterectomy.
 Neonatal outcome was good in all the patients.
 The mean gestational age at delivery was 36.75 weeks (range 33–38
weeks).
 The 5 minute Apgar score was 9–10 in all the newborns with birth
weights ranging from 2160 grams (preterm 33 weeks) to 3,000 grams.
 Kaymak et al. Compared :
 40 patients who underwent myomectomy at Caesarean section with
 80 patients with myomas who underwent Caesarean section alone.

 The mean size of the fibroids removed was 8.1 cms compared to 5.7
cms in the controls.

 No significant difference in the incidence of haemorrhage (12.5% in

the Caesarean myomectomy group versus 11.3% in the controls),
postoperative fever, or frequency of blood transfusions between the
2 groups.

 Concluded that myomectomy during Caesarean section can be

performed by experienced obstetricians without any complications.
Ortac et al. reported :
 22 myomectomies during Caesarean for large fibroids (>5 cm)
and advocate it to minimise postoperative sepsis.

Burton et al., reported :

 13 cases of myomectomy at Caesarean section, only 1 case had
intra-operative haemorrhage and they concluded it to be safe in
selected patients.
 The study group of 1,242 pregnant women with fibroids who underwent myomectomy
during Caesarean section was compared with 3 control groups:

 200 pregnant women without fibroids (Group A),

 145 pregnant women with fibroids who underwent caesarean alone (Group B), and

 51 pregnant women who underwent Caesarean hysterectomy (Group C).

 No significant differences in the mean haemoglobin change, the frequency of

haemorrhage, postoperative fever, the length of hospital stay.

 Myomectomy during Caesarean section is a safe, effective procedure not associated

with significant complications.

Lovina S M Machado, Vaidyanathan Gowri, Nihal Al-Riyami and Lamya Al-KharusiClinical and Basic Research | 195
They compared :
 47 pregnant women with fibroids who underwent Caesarean
myomectomy .

 94 pregnant women with fibroids who had Caesarean section alone.

 Myomectomy added a mean operating time of 15 minutes to the

Caesarean section.

 No patient had a hysterectomy, postpartum complications, or blood

transfusion.
J. O. Awoleke, Department of Obstetrics and Gynaecology, Ekiti State University
Teaching Hospital, Ado-Ekiti, Ekiti State P.M.B. 5355, Nigeria, Correspondence
should be addressed to J. O. Awoleke; bisijacob@yahoo.co.uk . Received 18 July
2013; Accepted 5 October 2013
 A review of 47 incidental myomectomy cases during
caesarean section ,
 procedure added 11 minutes to the time for a caesarean section,
 112 mLs to the blood loss at surgery, there were no wound
infections or serious morbidity .

 Both suggested that concomitant myomectomy with

caesarean section was safe if itwas done in carefully selected
patients.
 Subsequent documentation showed that, out of a small series of 9
patients who underwent elective myomectomy at the time of
caesarean delivery, 3 were reportedly complicated by severe
haemorrhage requiring obstetric hysterectomy .

 In another report, out of 5 cases, 4 were performed on

pedunculated fibroids and were removed without difficulty, while
the only nonpedunculated fibroid that was removed was associated
with severe hemorrhage .
 Patient selection is crucial in Caesarean myomectomy.
 Large fundal intramural fibroids should be intuitively avoided.
 Intramural myomectomy should be performed with caution.
 Fibroids obstructing the lower uterine segment or accessible
subserosal or pedunculated fibroids in symptomatic patients can
be safely removed by experienced surgeons.

The message is that what was once considered

taboo should now be reconsidered.
 Incidence : 1 in 81 to 1 in 8000 pregnancies.

 The overall incidence of malignancy in adnexal masses is 1-8%.

 Most of these are diagnosed incidentally at the time of dating or first

trimester screening ultrasound (USS).

 can be complicated by torsion, rupture, or bleeding/infection, or

labor obstruction.

 Pain due to rupture, hemorrhage into the cyst, infection, venous

congestion, or torsion

Diagnosis and Management of Adnexal Masses in Pregnancy, J Surg Tech Case Rep. 2012 Jul-Dec; 4(2): 79–85.
 A corpus luteum persisting into the second trimester accounts
for 13-17% of all cystic adnexal masses

 benign masses such as :

 dermoid cyst (7-37% incidence)

 serous cystadenoma (5-28% incidence)

 mucinous cystadenoma
 Table 1. Classification of adnexal masses in pregnancy

Functional cyst is the most common adnexal mass in pregnancy, similar to

the nonpregnant state.

Diagnosis and Management of Adnexal Masses in Pregnancy, J Surg Tech Case Rep. 2012 Jul-Dec; 4(2): 79–85.
 Conservative or surgical, depending on the size,
gestational age, available resources, and possibly
patient preference following careful evaluation.

Diagnosis and Management of Adnexal Masses in Pregnancy, J Surg Tech Case Rep. 2012 Jul-
Dec; 4(2): 79–85.
 Early in pregnancy, ovarian enlargement less than 6 cm
diameter is usually due to corpus luteum formation. Resection
of all suspected cysts at risk of rupture or undergoing torsion is
recommended.

 Cysts measuring 10 cm in diameter should be resected due to

increased risk of cancer in the large cysts,

 cysts less than 5 cm could be left alone, and indeed, most

undergo spontaneous resolution.
 Management of cysts between 5 and 10 cm in diameter
remains controversial. Some clinicians recommend
managed expectantly if they have cystic appearance.

 Intervention can be delayed until the second trimester,

usually 14-16 weeks, when access to the mass is much easier.
 Generally, there is disagreement among authors
concerning the best management of adnexal masses in
pregnancy, with some recommending observation and
others favoring surgical management.

 Most ovarian masses identified in pregnancy will

spontaneously resolve and aggressive surgical
management is not required.
 Characteristic features favorable for resolution are:
 masses that are simple by USS, less than 5 cm in diameter,

 diagnosed before 16 weeks.

 Larger masses or those with more complex morphology are less likely
to spontaneously resolve and may represent a neoplastic process.

 Similarly persistent adnexal masses into pregnancy are more likely to

be malignant or may result in complications in pregnancy, like
torsion, rupture, or obstruction of labor.
 Surgical management , when the persistent or larger ovarian mass
- at higher risk for an acute abdomen, ovarian torsion, or rupture.

 Up to 10% of persistent complex ovarian masses will ultimately be

diagnosed as malignancy

 Where cancer of the ovary is found, treatment should be

individualized and consideration should be given to the type and
stage of the cancer, women desire to continue with the pregnancy,
and the risk of modifying or delaying treatment
 supported by the fact that up to 71% of benign ovarian masses will
either decrease in size or resolve spontaneously.

 The Royal College of Obstetricians and Gynaecologists (RCOG)

guidelines stated :

 “Simple, unilateral, unilocular, ovarian cysts less than 5 cm in

diameter have a low risk of malignancy. a normal serum CA125,
can be managed conservatively.”

 The main disadvantage of delaying surgery during pregnancy is the risk of

the mass undergoing torsion, rupture, or infarction, acute abdomen, and
most importantly the risk of malignant change in case of ovarian mass.
Schmeler et al. Reviewed 59 pregnant patients from 1999 to 2003, who
underwent either surgical or observational management for an adnexal mass
of 5 cm or greater. In the study :

17 patients underwent antepartum surgery (15 laparotomies, 2 laparoscopies)

 All five malignancies (4 malignant, 1borderline) were in the antepartum

surgery group (5/17 or 29%).

 ovarian malignancy were diagnosed with stage 1 disease. One of the

surgical management patients : PROM at 23 weeks and delivered
prematurely at 28 weeks.

42 patients were observed during pregnancy with their surgery performed

intrapartum at the time of cesarean section or postpartum.

No malignancies were diagnosed on final pathology in the observational group.

No other adverse fetal outcomes were noted in either group of patients.

 Surgery is indicated when an adnexal mass that is suspicious
of malignancy.

 Traditionally, surgery for adnexal masses in pregnancy has

been performed by laparotomy , should surgical staging be
indicated.

 Disadvantages to laparotomy include :

 increased post operative recovery time,
 increased incisional pain and discomfort
 potentiating the risk of postoperative thromboembolism
 laparoscopy in pregnancy.

 In a retrospective comparative review of 88 pregnant women

undergoing surgical intervention for adnexal pathology, :
 39 patients underwent laparoscopy in the first trimester
compared to
 54 patients undergoing laparotomy (25 in the first trimester
and 29 in the second trimester).

No operative or postoperative maternal complications occurred

in either group
The advantages of laparoscopy are :

 significantly lesser operative time,

 lesser perioperative morbidity,
 earlier ambulation,
 decreased blood loss,
 reduced length of hospital stay, and
 decreased postoperative pain -faster postoperative ambulation
and return to regular activity, very important in pregnancy
because of the increased thrombotic events.

Yuen P, Ng P, Leung P, Rogers M. Outcome of laparoscopic management of persistent

Adnexal mass during the second trimester of pregnancy. Surg Endosc. 2004;18:1345–7.
Multiple observational studies have demonstrated that laparoscopic
management of adnexal masses in pregnancy is technically feasible
and should no longer be considered contraindicated in pregnancy.

Amos J, Schorr S, Norman P, Poole GV, Thomae KR, Mancino AT, et al. Laparoscopic surgery during
pregnanacy. Am J Surg. 1996;171:435–7.

Laparoscopy for an adnexal mass during pregnancy should be

undertaken by those well-trained in the art. non-urgent cases should
optimally be scheduled at 16-20 weeks.
Recommendation: “Laparoscopy is safe and effective treatment
in gravid patients with symptomatic ovarian cystic masses.
 Reedy et al. published an observational study of patients in Swedish
Health Registry, comparing the outcomes of laparotomy and
laparoscopy for the management of adnexal masses in pregnancy.

 During the 20-year span from 1973 to 1993, a total of 2181

laparoscopies and 1522 laparotomies were evaluated. This study did
not any difference in birth weight, gestational age, intrauterine
growth restriction, infant survival, or fetal malformation.
 management of incidental adnexal masses observed at the time of cesarean
section in our clinic during January 1992 to January 2005.
 The number of total live births was 35,153 and 8330 of them were by cesarean
section (23.69%).
 There were 68 cases of incidental adnexal masses greater than 5 cm
(68/8330, 0.8%). All of the masses were removed at cesarean section.
 The pathologic diagnosis of the masses were as follows: benign-benign cystic
teratoma 20 (29.4%), simple serous cyst 8 (11.8%), simple mucinous 9 (13.2%),
endometrioma 3 (4.4%), cystadenoma 14 (20.6%), and paraovarian-
paratubal cyst 13 (19.1%) and malignant-struma ovarii 1 (1.5%).
 Cystectomy procedure during cesarean section did not alter the
morbidity of the operation.
 Table 1. Demographic data of the patients

Treatment of incidental adnexal masses at cesarean section: a retrospective study.

Int J Gynecol Cancer. 2007 Mar-Apr;17(2).
Treatment of incidental adnexal masses at cesarean section: a retrospective study.
Int J Gynecol Cancer. 2007 Mar-Apr;17(2).
Table 3. Cesarean section indications
Treatment of incidental adnexal masses at cesarean section: a retrospective study.
Int J Gynecol Cancer. 2007 Mar-Apr;17(2).
recommend resection of such incidental adnexal masses at
cesarean section to avoid possible surgical procedures in future
for the patient, ( still controversial data in literature )

Management of incidental adnexal masses on caesarean section, Niger Med J. 2012 Jul-Sep;
53(3): 132–134.
 It seems reasonable to remove all ovarian masses over 10 cm in
diameter, risk of malignancy.

 Tumors 6-10 cm in diameter should be carefully evaluated for the

possibility of neoplastic disease by the use of USS or MRI or both.

 Majority of the adnexal masses diagnosed in pregnancy are benign

and will resolve spontaneously. patients should be managed
expectantly.

 If the evaluation suggests neoplasm, then surgery is indicated,

either by laparotomy or laparoscopy. Laparoscopy is safe and
feasible, and both maternal and perinatal outcomes are favorable.
RMI = U x M x s-CA 125

The RMI score (malignancy risk index) is calculated based on the s-CA 125
value, menopausal status (M), and evaluation of ultrasound (U).

Ultrasound criteria (U score)

Multilocular cyst 1
Solide areas 1
Bilateral lesions 1 Score 0–1: U=1
Ascites 1 Score 2–5: U=3

Intraabdominal metastases 1 s-CA 125 (u/ml) (the actual value is used)

Menopausal status (M score)
Premenopausal 1
Postmenopausal 3
 RRROMA (Risk of Ovarian Malignancy Algorithm)

Risk of Ovarian Malignancy Algorithm (ROMA) value ROMA adalah formula kombinasi
pemeriksaan CA125 & HE4 yang digunakan untuk mengetahui risiko malignansi pada pasien
dengan massa pelvis.

Kombinasi CA125 & HE4 lebih akurat untuk memprediksi malignansi daripada secara tunggal.
Premenopause : PI = -120 + 2.38 x LN[HE4] + 0.0626 x LN[CA125]
Postmenopause: PI = -8.09 + 1.04 x LN[HE4] + 0.732 x LN[CA125]
Risiko kanker ovarium : Predic ve Probability % = exp (PI)/[1 + exp (PI)]* 100

Cut Off ROMA

Premenopause :
ROMA7.4% = risiko nggi kanker ovarium epitelial
ROMA < 7.4% = risiko rendah kanker ovarium epitelial

Postmenopause:
ROMA25.3% = risiko nggi kanker ovarium epitelial
ROMA<25.3% = risiko rendah kanker ovarium epitelial