Case Summary:

Mrs C.A. is a 40 year old pre-menopausal woman, who was admitted to hospital
on the 28/02/10 for an elective laparotomy, due to cystic mass noted on
ultrasound (right adnexae) which was carried out as an investigation for RIF pain.

History of Presenting Complaint

3 week history of transient, dull RIF pain, local swelling and slight nausea and
menorrhagia with clots. There was no vaginal discharge, no weight loss and no
GI or urinary symptoms. She presented to A&E, where she was investigated
further, primarily via ultrasound scan, which reported a 10cm by 10cm partial
ovarian cystic mass.

Past Obstetric History:

Mrs. C.A. a premenopausal 40 year old lady, has had G0P0.

Past Gynaecological History:

Age of menarche was 13 years old. Her menstrual cycles are regular, at 26days,
with 5 days of bleeding. She has had fertility problems, and had a laparoscopy 2
years ago. There was no spillage of dye through the tubes. She has not been on
the OCP. Her last reported smear test was done 1 year previously and has been
done every year since the age of 25 and has never returned an abnormal result.

Past Surgical History:

Laparoscopy 2 years previously for investigation of similar suprapubic pain.

There were no complications from general anaesthesia.

Past Medical History:

Hypertension, Hypercholesterolaemia.

Drug History:
She is on several regular medications:-

Coversyl 4mg daily

Atorvastatin 10mg daily

Bendroflurazide 5mg daily

NKDA

Social History

Married, lives with husband.

Occupation – housewife.

Doesn’t smoke, doesn’t drink alcohol.

Family History:

None of relevance.

Systematic Enquiry:

CVS NAD

Resp NAD

GIT NAD

GU NAD

O/E

Good general condition post-op, sitting in chair, afebrile, GCS 15, normal heart
sounds, BP 125/92, pulse 88, chest clear, abdomen soft on palpation, bowel
sounds present, no lower limb oedema.

Pre-Op

She was admitted on 28/02/10, CBC U&Es, X-match 3U, anti-hypertensives as

normal until morning of surgery. NBM from midnight, consent gained, risks of
anaesthesia, trauma to baldder, uterus and risk of haemorrhage explained.

Nb cancer markers;

Ca 125 – 27.7 (norm 0-35µg/ml)

Ca 19.9 – 16.7 (norm <40µg/ml)

CEA – 10.9 (norm <5µg/ml)

Peri-Op

The laparotic right salpingo-oophorectomy, on the morning of the 01/03/10, was

done by Pfannenstein incision, a large (20cm diameter) ovarian cyst was
removed and sent for histology. There were no signs of haemorrhage or rupture,
however there was substantial torsion. Free drain was left in, PCA was given.

Post-Op

Mrs. C.A. was observed until awake. Temperature, pulse and BP were checked.
Started on 1L Hartmann’s 8hrly, and remained NBM. Urinary catheter was kept in
situ and input/output charting was done.

Day 1 – Mrs CA was well and afebrile. Abdomen was soft and bowel sounds were
normal. 50ml of blood stained serous fluid was collected. Urinary catheter was
removed and she was started on small sips of water, i.v. was retained. PCA was
removed in the afternoon and patient was supplemented with oral analgesia as
required. Patient was complaining of slight incisional pain but was relieved of RIF
pain. There was no bleeding pv.

Day 2 – Patient was mobile, opened her bowels and was passing urine normally.
Her abdomen was soft and non tender.

Day 3 – Awaiting histology results.

Case Discussion:

An ovarian cyst is a fluid-filled sac in an ovary. They can develop from the
neonatal period to postmenopause. Most ovarian cysts occur during infancy and
adolescence, which are hormonally active periods of development. Most are
functional in nature and resolve with minimal treatment. However, ovarian cysts
can herald an underlying malignant process or, possibly, distract the clinician
from a more dangerous condition, such as ectopic pregnancy, ovarian torsion, or
appendicitis. When ovarian cysts are large, persistent, or painful, surgery may be
required, sometimes resulting in removal of the ovary. With the more frequent
use of ultrasonography in recent years, the diagnosis of ovarian cysts has
become more common.

Ovarian masses are often silent and detected either when they are large, or
cause abdo extension or diagnosed on ultrasound scan. Rupture of the contents
of the ovarian cyst into the abdo cavity causes intense pain, particularly with an
endometrioma or dermoid cyst. Haemorrhage into a cyst can cause pain, or
hypovolaemic shock. PCOS is a common disorder that causes oligomenorrhoea,
hirsutism and sub-fertility.

Pre-operatively, on examination, there was some discrepancy between clinical

findings and radiological evidence. Clinically the mass was felt as a hard, solid
lesion, whereas on ultrasound a cystic mass was noted. This strengthened the
rationale for a laparotic procedure, in view of the possibility of a tumour.

Fig 1. Large ovarian cyst, as seen on Ultrasound. Taken from

http://www.obgyn.net/ultrasound/gallery/GYN_abnormal_ovarian_dermoid.jpg last
accessed 1700h on 06/02/10