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Gigantic putrid Douglas endometriotic cyst during pregnancy
20 September 2018 (online)
A 31 y/o patient 31 weeks gestation, pregnant after IVF, was presented with a mass in Douglas of 12 × 9x12 cm. Differential diagnosis, based on vag. ultrasound included endometrioma, abscess after IVF-treatment or (malignant) ovarian tumor.
In MRI radiologists saw a thick-walled cyst, 14.7 × 13.7 × 13 cm in the pelvic area, that was pushing the uterus out of the pelvis. High signal intensity in T1 imaging. The cyst was suspected to be an endometriosis cyst (endometrioma) as the patient has confirmed endometriosis. Infection parameters were elevated and hemoglobin levels reduced, which would be fitting to an abscess.
At 34 weeks gestation, transvaginal ultrasound guided biopsy was performed and 1.2 ltrs. of putrid fluid were aspirated. Prior to aspiration the patient received betamethasone. So far, pathology could not confirm endometriosis or abscess due to a lack of cells or tissue. Finegoldia magna (Peptostreptococcus magnus) was isolated via bacteriological examination, commonly found in the vagina.
The patient was treated with antibiotics and Ferinjekt.
Follow up during pregnancy showed a stable cyst of 8 × 5x7 cm. Infection parameters were declining. Management of delivery and final histology will be presented.
Endometriosis does not always regress, not even during pregnancy. The risk of complications is particularly high in the second half of pregnancy and during labor 1. One of the described risks is endometriosis cyst perforation. Reportedly 20% of endometrioma are increasing during pregnancy 2.
Complications from endometriotic cysts such as infected or enlarged endometrioma represent rare events 2.