Re: Early pregnancy with adnexal mass
From: jay kulkin (jkulkin@mindspring.com)
Sat Aug 29 15:33:12 1998
Agree with mngt thus far. Would want the mass followed by the most
competant ultrasonographer in your area. Still may be a CL cyst. Keep us
posted-
By the way-this is excellent mngt. I beleive many would have been to the OR
by now.
Jay
At 12:48 PM 8/29/98 -0500, you wrote:
>Another ER case:
>
>21 yo BF G2P1 s/p uneventful copper IUD insertion at Planned Parenthood 5/98
>presents last week to PPH as she is a week late on her menses. Urine PT + and
>patient told to go to ER to r/o ectoptic. Pt is completely asymtomatic. No
>bleeding, pain, ect. No hx of STD's or PID. Nonsmoker
>Pelvic U/S demonstrates IUD in lower uterine segment, no gestational sac, no
>free fliud in pelvis or ascites, normal left ovary, right ovary difficult to
>identify
>and 8x6x6cm right fundal complex mass appearing seperate from uterus.
>Physical exam demonstrates patient to be afebrile with normal vitals
>abdomen is completely nontender
>speculum exam: no blood or discharge. IUD string seen and IUD easily removed.
>Bimanual exam: no CMT uterus enlarged-6wk size irregular due to 6-8cm firm
>fixed nontender right adenexal/fundal mass. Left adnexal nontender no masses.
>WBC-9K
>Hgb-12
>LFT's-WNL
>Quant BHCG-87
>UA-WNL
>
>IMP: 1) Early IUP vs. Ectopic
> 2) Right Adnexal mass-asymptomatic
> DDx includes: ovarian neoplasm (benign vs. malignant) /
>degenerated
> fibroid / tuboovarian complex / hematoma /
>chronic
> hemorrhagic ectopic ?
>I elected to observe the patient overnight and and perform vag sono in my
>office in AM. Sono confirms abd sono findings. Mass appears ovarian in
>origin and is irregular with solid/cystic components and septations. Again
>nontender with vaginal imaging.
>Pt followed with serial BHCG 87, 177, 1722
>AFP, CEA, and CA125 all normal
>Patient brought back for repeat sono 1 week after presentation and a small
>normal appearring gestational sac now apparent measuring 5 week size. no fetal
>pole seen.
>Adnexal mass now measures 10x9x7cm. No free fluid noted. Pt remains
>completely asymtomatic.
>Patient informed that she appears to have an early IUP.
>The mass appears ovarian in nature and although I suspect a benign neoplasm
>due to her age, normal tumor markers, and lack of symptoms there remains the
>possibility of malignancy. She is given the option of immediate surgery vs.
>waiting until 14-16 weeks for Exp. Laparotomy assuming repeat sono next week
>confirms normal developing IUP. Informed risk of miscarriage greater in 1st
>trimester.
>Of course, I informed the patient that should this be a malignancy waiting may
>increase the chance of metastasis. Torsion precautions were also given.
>
>She elects for conservative management, however should the mass continue to
>grow she will wish to proceed with surgery.
>
>Any thoughts regarding management thus far?
>DDX?
>Role of Laparoscopy?
>
>Thanks in advance.
>
>Eric B. Jacoby, MD
>Private Practice
>Plano, TX
>
--
Jay M. Kulkin, MD MBA
Medical Director BCBS of Georgia
office 770-386-0640 ext. 17
office e mail-jkulkin@bcbs-ga.com
