Personal history Menstrual history Menarche 12 interval 30

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Personal history ไมดมเหลา ไมสบบหร Menstrual history Menarche 12 ป interval 30 วน regular duration

Personal history ไมดมเหลา ไมสบบหร Menstrual history Menarche 12 ป interval 30 วน regular duration 5 วน amount 4 pads/day ชม ไมม dysmenorrhea LMP 29มถนายน 2544

Physical examination GA: A young Thai female fully conscious , well cooperated Vital signs:

Physical examination GA: A young Thai female fully conscious , well cooperated Vital signs: BP 110/70 mm. Hg BT 36. 1 oc RR 22/min PR 78/min HEENT: No pale conjuntivae, no icteric sclera Heart: Normal S 1 S 2 , no murmur Lungs: Normal breath sounds, no adventitious sound, no crepitation

Abdomen: - palpable mass at left lumbar region, sized 6 cm. , smooth surface,

Abdomen: - palpable mass at left lumbar region, sized 6 cm. , smooth surface, movable and tender - No rebound tenderness, no guarding - No hepatosplenomegaly Uterus: fundal height 1/3 above suprapubic

Pelvic examination NIUB: normal Vagina: normal discharge Cervix: clean, os closed no cervical motion

Pelvic examination NIUB: normal Vagina: normal discharge Cervix: clean, os closed no cervical motion tenderness Uterus: 14 wks pregnancy size, no tenderness Adnexa: No mass at right side left cystic mass , sized 6 cm. , tender at connection between uterus and mass

- G 1 P 0 GA 14 wks by date - teenaged pregnancy -

- G 1 P 0 GA 14 wks by date - teenaged pregnancy - no ANC - acute abdominal pain -nausea vomitting - left cystic mass , sized 6 cm. , smooth surface, movable , tender - tender at connection between uterus and mass

Differential diagnosis gynecological -complication of ovarian tumor -Ectopic pregnancy - pedunculated myoma -Degenerated myoma

Differential diagnosis gynecological -complication of ovarian tumor -Ectopic pregnancy - pedunculated myoma -Degenerated myoma -Abruptio placentae Non gynecological -Diverticulitis -Urolithiasis

CBC UA ULTRASOUND

CBC UA ULTRASOUND

Investigation CBC WBC 81, 00 PMN 71. 2% RBC 3, 860, 000 Hb 11.

Investigation CBC WBC 81, 00 PMN 71. 2% RBC 3, 860, 000 Hb 11. 9 g/d. L MCV 83 f. L MCH 28. 2 f. L Hct 33. 6%

Urine analysis Appearance Specific gravity PH Protein Glucose Ketone Bile/urobilinogen RBC 0 WBC 0

Urine analysis Appearance Specific gravity PH Protein Glucose Ketone Bile/urobilinogen RBC 0 WBC 0 -1 yellow clear 1. 015 9 negative

Ultrasound - A single viable fetus in uterus - BPD 28 cm. HC 9.

Ultrasound - A single viable fetus in uterus - BPD 28 cm. HC 9. 8 cm. - AC ����� FL 2. 0 cm. - GA 14 wks - Mix echogenic mass , sized 10. 5 X 6. 3 cm. , left adnexa above uterus

Impression : G 1 P 0 GA 14 wks with left ovarian tumor with

Impression : G 1 P 0 GA 14 wks with left ovarian tumor with complication Twisted ovarian tumor?

Management NPO iv fluid Anti- HIV Matching/Grouping left salpingooophorectomy

Management NPO iv fluid Anti- HIV Matching/Grouping left salpingooophorectomy

Operative finding - uterus 14 wks sized ( pregnant uterus ) - normal right

Operative finding - uterus 14 wks sized ( pregnant uterus ) - normal right fallopian tube and right ovary - normal left fallopian tube - left ovarian tumor sized 10 x 8 cm. , twisted 2 rounds - no normal ovarian tissue remain, smooth surface ,

- no adhesion around left ovarian surface Content : serous, sebum, hair and some

- no adhesion around left ovarian surface Content : serous, sebum, hair and some area calcification at solid part - normal appendix

Operative diagnosis G 1 P 0 GA 14 wks with twisted left dermoid cyst

Operative diagnosis G 1 P 0 GA 14 wks with twisted left dermoid cyst

Diagnosis Left ovary: Mature cystic teratoma Left fallopian tube: partubal cyst

Diagnosis Left ovary: Mature cystic teratoma Left fallopian tube: partubal cyst

Ovarian tumors during pregnancy 36% - benign cystic teratoma(dermoid cyst ) • 25% -

Ovarian tumors during pregnancy 36% - benign cystic teratoma(dermoid cyst ) • 25% - serous cystadenoma • 13% - mucinous cystadenoma • Only 4% were malignant. • From Struyk AP ovarian tumors in pregnancy. Acta. Obstet Gynecal Scand 421 -424

Twisted ovarian cyst Incidence: 10 -15% of ovarian masses during pregnancies. • Most occur

Twisted ovarian cyst Incidence: 10 -15% of ovarian masses during pregnancies. • Most occur during early pregnancy(8 -16 wk gestation), or the puerperium, when the uterus is changing size rapidly