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DIABETES IN PREGNANCY - COMPLETE NOTES

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PART 2

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1. Gestational Diabetes Mellitus (GDM)

What is it?

Features

• Complications are similar to pre-gestational DM (pre-GDM), EXCEPT:
  • No congenital anomalies (GCA) - because GDM develops after the first trimester (organogenesis is already complete)
  • No fetal ECHO - as structural heart defects are only a risk in pre-GDM (early hyperglycemia during cardiac development)
• Follow-up and investigations: Same as pre-GDM, with the two exceptions above

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2. Diagnosis - DIPSI Criteria

Recommendations

Procedure

• No fasting required (universal screening regardless of meals)
• Give 75 gm glucose in 300 mL water (lime can be added for taste)
• Patient consumes it in 5-10 minutes
• Check 2-hour postprandial (PP) levels using a plasma-calibrated glucometer

If Patient Vomits:

• Within 30 minutes of drinking glucose - repeat test on another day
• After 30 minutes - continue the test (enough absorption has occurred)

2-Hour PP Interpretation

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3. Management of GDM

Based on 2hr PP Values:

         2hr PP Value
              |
   ┌──────────┴──────────┐
140-199 mg/dL         ≥ 200 mg/dL
   (Initial MNT)      (Immediate Insulin)
       |                     |
  MNT x 2 weeks          8U Insulin
       |                   + MNT
  [Check Metabolic        + Weight counselling
    Goals]               (No role of aspirin)

Metabolic Goals (targets to achieve)

• FBS < 95 mg/dL
• 1hr PP < 140 mg/dL
• 2hr PP < 120 mg/dL
• HbA1c < 6%
• Average capillary glucose < 100 mg/dL

If Goals MET:

• Continue MNT
• Advise 30 min walk daily
• Check 2hr PP levels: 2nd trimester = every 2 weeks, 3rd trimester = weekly, minimum = monthly

If Goals NOT MET:

• Start Metformin → then Insulin + MNT

GOI (Government of India) Treatment Guidelines:

• Diagnosed > 20 weeks → Metformin
• Diagnosed < 20 weeks → Insulin
• 2hr PP > 200 mg/dL (at any time) → Insulin

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4. Medical Nutrition Therapy (MNT)

Diet Composition

• Distributed over 3 meals + 3 snacks

Caloric Requirements

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5. Oral Hypoglycemic Agents (OHAs)

Metformin

• Recommended by GOI (Government of India)
• Used only in GDM (NOT in pre-GDM)
• Only used > 20 weeks of pregnancy
• 1st line drug
• Advantages:
  • Reduces excessive maternal weight gain
  • Reduces neonatal hypoglycemia risk
  • Reduces chances of Large for Gestational Age (LGA) fetus
  • Reduces macrosomia risk
• Preferred in obese patients
• Dose: 500 mg/day → up to 2 g/day
  • If dose needed > 2 g/day → Add Insulin
• Side effects:
  • Most common (m/c): GI side effects
  • Most dangerous: Lactic acidosis

Glyburide

• Dose: 2.5 mg/day → up to 20 mg/day
• Side effect: Increased risk of neonatal hypoglycemia

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6. Insulin in Pregnancy

Type Used

• Human pre-mix insulin 30:70
  • 30% short-acting + 70% intermediate insulin
• 1 vial = 40 IU
• Storage: 4-8°C
• Syringe reused up to 14 times

Insulin Requirement Trends

• Increases with advancing pregnancy (due to rising insulin resistance)
• Decreases during labor (patient is NPO - nothing by mouth)

Starting Insulin

• Start Human Insulin premix 30:70
• Subcutaneous injection, 30 mins before breakfast, once daily (OD)
• Dose calculated by 2hr PP levels:

Dose Titration Flowchart

• Check levels on Day 3
• If goals NOT met:
  • FBS > 95 → Add 2U insulin pre-dinner
  • 2hr PP > 120 → Add 2U before breakfast
• Recheck every 3 days
• Titrate until metabolic goals are met
• Once met: Check every 2 weeks (2nd trimester), weekly (3rd trimester)

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7. Termination of Pregnancy

• Mode of delivery: Vaginal (preferred)
• C-Section indication: Estimated fetal weight ≥ 4.5 kg

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8. Intrapartum (During Labor) Management

• Mild GDM on medical management: Skip the morning insulin dose
• Monitor blood sugar every 2 hours with glucometer
• During labor: NPO + IV Normal Saline (NS) @ 100 mL/hr

Insulin in NS Drip (500 mL NS):

• If blood glucose < 70 mg/dL (hypoglycemia) → Start IV 5% Dextrose

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9. Postpartum Management

GDM:

• Check blood sugar on Day 3 post-delivery
• At discharge → Follow up at 6 weeks with 75g 2hr OGTT
  • Normal → Confirm resolution of GDM → Advise annual 75g OGTT (due to increased risk of developing Type 2 DM)
  • Abnormal → Refer to Endocrinologist

Pre-GDM:

• Insulin requirement decreases from Day 2 of delivery
• Shifted back to OHA
• Refer to endocrinologist if needed

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PART 3 - COMPLICATIONS & SPECIAL TOPICS

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10. Maternal Complications

1. Hyperglycemia - primary problem
2. Infections (increased risk due to high glucose):
   • Asymptomatic bacteriuria
   • Candidiasis
   • Puerperal sepsis
3. Polyhydramnios (excess amniotic fluid) → can cause:
   • Preterm labor (PTL)
   • Premature rupture of membranes (PROM)
   • Cord prolapse
   • PPH (postpartum hemorrhage)
   • Subinvolution
4. Oligohydramnios - due to diabetic vasculopathy or PIH
5. Placentomegaly (Big placenta) - swelling of chorionic villi due to hyperglycemia → raises risk of PIH & placenta previa
6. Future risks: T2DM, C-section, ketoacidosis

Retinopathy Note

• Pre-gestational diabetes with retinopathy → worsens during pregnancy
• All pre-GDM females must have a baseline fundus examination

Hypoglycemia (Blood sugar < 70 mg/dL)

• 3 teaspoons glucose in 100 mL water, OR
• 6 teaspoons sugar in 100 mL water

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11. Fetal Complications - Pedersen's Hypothesis

Maternal Hyperglycemia
        ↓
Fetal Hyperglycemia
        ↓
Stimulates Fetal Pancreas
        ↓
Hyperinsulinemia
    ↙          ↘
↑ Growth    ↓ Lipolysis → Fat deposition around fetal shoulder
    ↓                 ↓
Macrosomia        ↓
         ↘       ↙
        Shoulder Dystocia

Key Fetal Risks:

• Macrosomia → Prolonged labour → Increased C-section rate
• IUGR - only if diabetic vasculopathy or PIH is present
• Increased risk of abortion - in uncontrolled diabetes
• Stillbirth due to:
  • Macrosomia → increased O2 demand → hypoxia
  • Hyperglycemia → oxidative stress → hypoxia
  • Edema of chorionic villi → decreased O2 transport → hypoxia
  • (Most common in last 2 weeks of pregnancy)
• Congenital malformations - ONLY in pre-GDM (not GDM), because organogenesis has already occurred by the time GDM develops
• Hormone for fetal growth: Insulin and IGFs

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12. Neonatal Complications

1. Neonatal Hypoglycemia (Most Important)

• Mechanism: Maternal hyperglycemia → fetal hyperglycemia → fetal hyperinsulinism
• At birth: glucose supply from mother is cut off, but insulin remains high → Hypoglycemia

2-9: Other Neonatal Complications

Important: Anemia is NOT a complication of diabetic pregnancy.

Late Complications in the Child:

• T2DM: 1-3% risk
• Obesity
• Metabolic syndrome (Syndrome X)

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13. Lung Maturity Tests

Nile Blue Sulphate Test (Principle)

• AF fetal skin cells mature at the same time as lungs
• Orange cells = Mature skin cells (stained with dye)
• Blue cells = Immature skin cells

• 50% orange cells = Lungs mature

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14. Shoulder Dystocia

Management - Mnemonic: HELPERR

Other Notes:

• Dead baby: Cleidotomy (fracture clavicle of baby)
• Symphysiotomy: Dividing pubic symphysis of mother - now Obsolete
• CONTRAINDICATED: Fundal pressure (worsens impaction)
• Each manoeuvre performed for a maximum of 30 seconds before moving to the next

Complications of Shoulder Dystocia:

• Erb's Palsy (C5, C6 injury) - most common - arm is internally rotated, adducted, and pronated ("waiter's tip" position)
• Injury to C5, C6 nerve roots

• Injury from manoeuvres

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Summary Table - Quick Recall

Medical Nutrition Therapy (MNT) in Gestational Diabetes

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What is MNT?

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Diet Composition

Notice: Carbohydrates are reduced (normally 55-60% in a regular diet) and fat is kept relatively high - this is intentional to blunt postprandial glucose spikes.

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Meal Distribution

• 3 main meals + 3 snacks throughout the day
• This is important because:
  • Spreading carbs over 6 smaller portions prevents large glucose spikes
  • Prevents prolonged fasting (which can cause ketosis/ketoacidemia, harmful in pregnancy)
  • Keeps insulin demand steady rather than in large surges

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Caloric Requirements

The reason overweight women subtract calories is to limit excessive gestational weight gain, which worsens insulin resistance and increases macrosomia risk - but never starve a pregnant diabetic woman as ketones cross the placenta and harm the fetus.

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What is the Duration of MNT Trial?

• MNT is given a trial of 2 weeks
• After 2 weeks, check if metabolic goals are met:

• Goals met → Continue MNT + 30 min daily walk
• Goals not met → Add Metformin (or Insulin if indicated)

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Additional Lifestyle Advice with MNT

• 30 minutes of moderate walking daily is advised alongside diet
• This improves insulin sensitivity
• Combined with MNT, many GDM patients can be managed without medications

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Why Carbs are 40% (Not Lower)?

• Very low carb diets in pregnancy risk ketoacidosis even at normal blood sugars (starvation ketosis)
• Fetal brain runs on glucose - complete carb restriction is dangerous
• 40% is the "sweet spot" - low enough to reduce glucose load, safe enough to prevent ketosis

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Key Takeaway

MNT is not just a "diet" - it is a structured, calculated therapeutic intervention. It is always the first step in GDM management and continues even after medications are started. It is NEVER stopped.

GDM Management Based on 2hr PP Value - Full Explanation

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The Two Pathways

              2hr PP Value (DIPSI Test)
                        |
         ┌──────────────┴──────────────┐
         │                             │
   140–199 mg/dL                  ≥ 200 mg/dL
   (Mild GDM)                    (Severe GDM)
         │                             │
    START MNT                  IMMEDIATE Insulin
    for 2 weeks                  (8 Units) + MNT
         │                      + Weight Counselling
   Check Metabolic              (No role of Aspirin)
      Goals...

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PATH 1 - 140 to 199 mg/dL

Why MNT first?

• Blood sugar is elevated but not severely so
• Diet control alone has a good chance of bringing it to target
• Avoids unnecessary medication in pregnancy

What happens after 2 weeks of MNT?

         After 2 weeks of MNT
                  |
     ┌────────────┴────────────┐
     │                         │
Goals MET                 Goals NOT MET
     │                         │
Continue MNT            Step 1: Add Metformin
+ 30 min walk daily     (500mg → up to 2g/day)
+ Monitor 2hr PP                │
                        If still not controlled
                                │
                        Step 2: Add Insulin
                                │
                          Continue MNT
                        throughout all steps

Metabolic Goals to check:

---

PATH 2 - ≥ 200 mg/dL

Why Immediate Insulin? Why not MNT first?

• Blood sugar this high cannot be controlled by diet alone
• At ≥ 200 mg/dL, the fetus is already at serious risk:
  • Macrosomia already beginning
  • Fetal hyperinsulinism already triggered
• Every day of delay = fetal harm → so insulin starts same day

Starting Dose = 8 Units

• Human premix insulin 30:70
• Subcutaneous, 30 mins before breakfast

Why 8 Units specifically?

• Based on the insulin dose table from 2hr PP:

• Since ≥ 200 falls in the highest bracket → 8U is the starting dose

What else is given alongside?

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Why "No Role of Aspirin" is Specifically Mentioned

• Prevention of preeclampsia (PIH)
• Antiphospholipid syndrome

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Complete Picture Together

DIPSI Test (75g glucose, 2hr PP)
              │
    ┌─────────┼──────────┐
< 140      140-199     ≥ 200
  │           │           │
Normal      MNT         8U Insulin
Repeat at   x 2wks      + MNT
24-28 wks      │         + Weight counselling
            Goals?       (No aspirin)
           ↙    ↘
        Met    Not met
          │       │
       Continue  Metformin
        MNT      → Insulin

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One-Line Summary

140-199 = give diet 2 weeks to fix it first. ≥ 200 = start insulin immediately, no waiting - diet alone will never be enough at this level.

5F's of Abdominal Distension (Shape/Swelling)

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The Classic Mnemonic

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5 F's

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Extended Version - "9F" or "Additional F's" (Some textbooks add)

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How to Differentiate Clinically

Fat

• Uniform distension
• Umbilicus sunken (pulled inward)
• No percussion change with position
• No fluid thrill

Fluid (Ascites)

• Umbilicus everted (pushed outward)
• Shifting dullness - dull flanks, resonant center (supine); shifts when patient turns
• Fluid thrill - tap one flank, feel impulse on other
• Puddle sign - earliest sign of ascites

Flatus

• Tympanitic (resonant) all over
• Abdomen uniformly distended
• Moves around with position changes

Feces

• Indentable, "putty-like" consistency
• Follows the line of the colon (ascending → transverse → descending)
• Usually in left iliac fossa (sigmoid)

Fetus

• Uterus felt as central pelvic-abdominal mass
• Grows upward from pelvis
• Fundal height corresponds to weeks of gestation:

12 weeks → Pubic symphysis
20 weeks → Umbilicus
36 weeks → Xiphisternum
40 weeks → Slightly below xiphisternum (lightening)

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Exam Tip

If a question says "female, abdominal distension, first thing to rule out" → always think pregnancy first before ascites or any other cause.

If question says "shifting dullness + fluid thrill" → Ascites (Fluid)

If question says "tympanitic abdomen + high-pitched bowel sounds" → Flatus / obstruction

Causes of Visible Pulsation in the Abdomen

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Two Types of Pulsation

1. Expansile Pulsation (True Pulsation)

• Pulsates outward in all directions
• Indicates the structure itself is pulsating
• Classic example: Abdominal Aortic Aneurysm (AAA)

2. Transmitted Pulsation (False Pulsation)

• Pulsation transmitted from aorta to an overlying structure
• The structure itself is not pulsating - just receiving the beat
• Example: A solid mass (like pancreatic cyst) sitting over the aorta

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Causes - Organized

A. Vascular Causes (Most Important)

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B. Transmitted Pulsation (from Aorta)

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C. Hepatic Pulsation (Special Case)

Exam point: Pulsatile liver = Tricuspid Regurgitation until proven otherwise

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D. Epigastric Pulsation

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E. Other Causes

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Clinical Differentiation

Expansile vs Transmitted

Place both hands on either side of mass:

Expansile (AAA):
  ← hands pushed apart on both sides →
  TRUE pulsation

Transmitted (overlying mass):
  Both hands move UP together (not apart)
  FALSE / transmitted pulsation

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Epigastric Pulsation - Quick Rule

Epigastric pulsation
        │
   ┌────┴────┐
Increases    Decreases
on lying     on sitting
flat         forward
   │              │
Normal /        RV
Aortic       enlargement

If pulsation increases on lying flat and decreases on leaning forward → likely aortic If pulsation better felt in epigastrium + increases on inspiration → likely RV hypertrophy

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Most Important for Exams

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OVARIAN CANCER - COMPLETE NOTES

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1. OVARIAN CYSTS

Functional Ovarian Cysts

• Most common (m/c) type of ovarian cyst
• Occur due to hormonal disturbances
• Mostly temporary - resolve spontaneously on their own
• No specific treatment required in most cases

Types of Functional Cysts

Why Theca Lutein cyst in molar pregnancy? Molar pregnancy produces massive amounts of hCG → overstimulates theca cells → multiple bilateral cysts. They are the LARGEST functional cysts.

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2. FEATURES OF OVARIAN CANCERS

• Present late (hence screening is NOT routinely done in the general population)
• Symptoms are vague: Nausea, vomiting, loss of appetite, bloating - often dismissed as IBS
• Adnexal mass found on examination
• IOC (Investigation of Choice): TVS (Transvaginal Sonography)

This is why ovarian cancer has a poor prognosis - it is the "silent killer." Most patients are Stage III or IV at diagnosis.

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3. BENIGN vs MALIGNANT ADNEXAL MASS

USG Features of Malignancy (Red Flags):

• Thick septa (>3 mm)
• Papillary excrescences (projections from inner wall)
• Solid component within the cyst
• Mixed echogenicity
• Vascularity on Doppler
• Ascites
• Enlarged para-aortic lymph nodes
• Matted bowel loops

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4. MANAGEMENT OF OVARIAN CYST

              Patient with Ovarian Cyst
                         │
          ┌──────────────┴──────────────┐
          │                             │
   Reproductive age group         Extremes of age
          │                             │
       Cyst size              ┌─────────┴──────────┐
          │                   │                    │
   ┌──────┼──────┐      Post-menopausal        Pre-pubertal
   │      │      │            │                    │
3-5cm  5-7cm  >7cm     Check CA-125          Check AFP,
   │      │      │       ≥35 IU?              hCG, LDH
   │      │      │            │                    │
Wait & Follow Surgery    Surgery after        Surgery after
watch  up   (high risk   further              investigations
       USG  torsion/     investigations
            rupture)

Key Notes on CA-125:

• Limited value in reproductive age because CA-125 rises in many benign conditions:
  • Fibroid, PID, Genital TB, endometriosis, even menstruation
• In reproductive age: CA-125 >200 IU = significant
• In postmenopausal women: any rise in CA-125 ≥35 IU is significant (fewer false positives)

Risk of Malignant Transformation:

• Postmenopausal: 30%
• Premenopausal: 7%

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5. OVARIAN PATHOLOGIES IN PREGNANCY

Management of Ovarian Cyst in Pregnancy:

         Ovarian cyst in Pregnancy
                    │
       ┌────────────┴────────────┐
       │                         │
  Asymptomatic               Symptomatic
       │                  (Rupture/Torsion)
 ┌─────┴──────┐                  │
 │            │           Remove cyst
1st T       2nd T         immediately
 │            │        (regardless of GA)
Wait &     Malignant
watch      features on
 │         USG OR >10cm
m/c =           │
Corpus        Surgery
Luteum
(resolves
spontaneously)

NOTE: Removal in 1st T is C/I
→ ↓ Progesterone → Abortion

Why wait in 1st trimester? The corpus luteum produces progesterone which maintains the pregnancy until the placenta takes over (~10-12 weeks). Removing an ovarian cyst in the 1st trimester risks removing the corpus luteum → progesterone drops → abortion.

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6. RISK FACTORS FOR OVARIAN CANCER

Incessant Ovulation Theory

Risk Factor Table

Protective Factors

Why does OCP protect? It suppresses ovulation → fewer total ovulations in lifetime → less surface trauma to ovarian epithelium.

Why does breastfeeding protect? Prolactin suppresses GnRH → anovulation during breastfeeding period.

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7. GENETIC SYNDROMES

Lynch Syndrome (HNPCC)

• Gene: MLH1 / MSH2 (mismatch repair genes)
• Most common associated cancer: Colorectal cancer > Endometrial cancer (60-70% risk)
• Risk of ovarian cancer: 20%

BRCA1

• Highest risk of ovarian cancer: 40%
• Also increases endometrial cancer risk
• Prevention: TAH + BSO (Total Abdominal Hysterectomy + Bilateral Salpingo-Oophorectomy) after family completion - ideally at 35-40 years of age

BRCA2

• Risk of ovarian cancer: 15%
• More associated with breast cancer than BRCA1

Hereditary vs Sporadic Ovarian Cancer

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8. WHO CLASSIFICATION OF OVARIAN TUMORS

              OVARIAN TUMORS
                    │
    ┌───────────────┼───────────────┐
    │               │               │
Epithelial      Germ Cell       Sex Cord Stromal    Metastatic
  (90%)         (5-15%)            (3-5%)
  m/c            2nd m/c           3rd m/c

Most Common Overall:

• m/c ovarian tumor (all types): Serous cystadenoma
• m/c ovarian tumor in reproductive age: Dermoid cyst
• m/c ovarian cancer: Serous cystadenocarcinoma

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9. EPITHELIAL OVARIAN TUMORS

Types:

1. Serous tumors (m/c)
2. Mucinous tumors
3. Brenner's tumor
4. Endometrioid tumor
5. Clear cell tumor

General Features of Epithelial Tumors:

• m/c age: 60 years
• m/c bilateral
• Worst prognosis due to non-specific symptoms (nausea, vomiting, IBS, weight loss)
• HPE hallmark: Psammoma bodies (calcified concentric rings)
• Mutations:
  • Low grade: KRAS, PTEN mutations
  • High grade: p53 mutation

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10. SEROUS vs MUCINOUS TUMORS

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11. PSEUDOMYXOMA PERITONEI

• Peritoneum filled with mucinous material ("jelly belly")
• Causes:
  • Appendix cancer: most common cause
  • Mucinous ovarian tumor (metastatic)
  • Mucocele of appendix
• Bad prognosis due to high recurrence rate
• Treated surgically with cytoreduction + HIPEC (heated intraperitoneal chemotherapy)

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12. BRENNER'S TUMOR

• Mnemonic: "We BUST"
• HPE: Walthard cell nest + Coffee bean nuclei (nuclear grooving)
• Always benign
• Always solid (not cystic)
• Always unilateral (100%)
• Lined by transitional epithelium (resembles bladder lining)

Coffee bean nuclei (central grooving) is seen in two tumors:

1. Brenner's tumor
2. Granulosa cell tumor

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13. ENDOMETRIOID vs CLEAR CELL TUMOR

Key Notes:

• m/c ovarian tumor associated with endometriosis: Clear cell > Endometrioid
• m/c ovarian tumor associated with endometrial cancer: Endometrioid > Granulosa cell
• Solid ovarian tumors: Brenner's & Fibroma

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14. GERM CELL TUMORS (GCT)

Types:

1. Teratoma:
   • Benign: Mature cystic teratoma (Dermoid cyst)
   • Malignant: Immature teratoma
   • Monodermal: Struma ovarii (all thyroid tissue)
2. Dysgerminoma
3. Yolk sac tumor (Endodermal sinus tumor)
4. Embryonal carcinoma
5. Choriocarcinoma
6. Mixed type

General GCT Features:

• m/c in young girls (10-30 years)
• Usually unilateral
• Better prognosis if diagnosed early (compared to epithelial tumors)

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15. TUMOR MARKERS - GCT

Exam trick: AFP is NEVER seen in dysgerminoma. hCG is NEVER seen in yolk sac tumor. These negatives are frequently tested.

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16. DERMOID CYST (Mature Cystic Teratoma)

Features:

• m/c ovarian tumor in reproductive age
• m/c ovarian tumor in pregnancy
• m/c ovarian cyst to undergo torsion
• Usually unilateral (bilateral in only 10% cases)
• Contains all 3 germ cell layers (ectoderm is most common component: hair, skin, teeth, sebaceous glands)
• Mostly benign

Structure:

• Rokitansky protuberance - a raised prominence (plug) inside the cyst from which hair, teeth, and other structures arise
• This is the most common site of malignant transformation

Malignancy Risk:

• Risk: 0.2-2% (very low)
• m/c type of malignancy: Squamous cell carcinoma
• m/c site: Rokitansky protuberance

USG Findings:

1. Tip of iceberg sign - echogenic component obscures deeper structures (like an iceberg, only tip visible)
2. Dot and dash appearance - hair shafts and sebaceous material create characteristic pattern

Contents:

• Sebaceous material (yellow, oily)
• Hair (white/yellow)
• Teeth (hyperechoic on USG)
• Bone

Management:

• Cystectomy (preferred) - removes cyst, preserves ovary; especially important in young patients (risk of torsion is high so needs removal)
• Oophorectomy - if family is completed

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17. DYSGERMINOMA

Features:

• 2nd most common GCT
• Usually unilateral (bilateral in 15-20%)
• Highest risk of bilaterality among GCTs
• Best prognosis among all GCTs
• Only radiosensitive ovarian tumor (very important exam point)
• m/c ovarian cancer in dysgenetic gonads (Turner syndrome, Swyer syndrome)
• m/c ovarian cancer in pregnancy

Gross Appearance:

• Fleshy, solid, lobulated, tan/pink color

HPE (Histopathology):

• Nests of clear cells separated by fibrous septa
• Lymphocyte infiltration in the septa (characteristic finding)
• Resembles testicular seminoma (they are counterparts of each other)

Tumor Markers:

• LDH, hCG, PLAP
• AFP is NEVER elevated (key exam point)

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18. YOLK SAC TUMOR (Endodermal Sinus Tumor)

Features:

• Most malignant GCT
• Worst prognosis - rapidly progressive
• Presents with acute abdomen (due to rapid growth)
• 100% unilateral - never bilateral

Tumor Marker:

• AFP (Alpha-fetoprotein) - most important marker
• Also: LDH, α1-antitrypsin
• hCG is NEVER elevated

HPE:

• Schiller-Duval body (Glomeruloid body)
• Appearance: central capillary surrounded by tumor cells, contained within cystic spaces
• Resembles a primitive kidney glomerulus under microscope

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19. OCCURRENCE SUMMARY - GCTs

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MASTER COMPARISON TABLE - Quick Recall

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Management of Ovarian Cyst - Full Flowchart

                    OVARIAN CYST DETECTED
                        (IOC: TVS)
                             │
            ┌────────────────┴────────────────┐
            │                                 │
   REPRODUCTIVE AGE                    EXTREMES OF AGE
            │                                 │
        Cyst Size                   ┌─────────┴──────────┐
            │                       │                    │
   ┌────────┼────────┐        POST-MENOPAUSAL        PRE-PUBERTAL
   │        │        │               │                    │
 3-5cm   5-7cm    >7cm          CA-125 ≥35 IU?     AFP/hCG/LDH
   │        │        │               │              raised?
   ▼        ▼        ▼               ▼                    │
Wait &   Follow   Surgery        Surgery              Surgery
Watch    up USG   (torsion/      after further        after
                  rupture        investigations       investigations
                  risk)

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Key Decision Points Explained

Reproductive Age - Why Size Matters?

Post-Menopausal - Why CA-125?

• After menopause, ovaries should be quiet - any cyst is suspicious
• CA-125 ≥ 35 IU in this age group is significant (few false positives post-menopause)
• If raised → operate

Pre-Pubertal - Why AFP/hCG/LDH?

• Ovarian cyst in a child is most likely a Germ Cell Tumor
• GCTs produce AFP (Yolk sac tumor), hCG (Choriocarcinoma), LDH (Dysgerminoma)
• Any raised marker → operate immediately

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Important Notes

• Malignant transformation risk: Post-menopausal = 30% | Pre-menopausal = 7%
• CA-125 in reproductive age is unreliable (rises in Fibroid, PID, TB, endometriosis) - only >200 IU is significant in this group
• In pregnancy + 1st trimester → wait and watch (removing cyst risks progesterone loss → abortion)
• If symptomatic at any age (torsion/rupture) → immediate surgery regardless of age or size

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Complete Explanation of the Flowchart

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Step 1 - First Question: Is she Symptomatic?

Symptomatic (torsion/rupture)  →  Operate IMMEDIATELY
                                   (no matter what trimester)

Asymptomatic                   →  Go to Step 2

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Step 2 - Asymptomatic: Which Trimester?

1st Trimester - WAIT & WATCH

Key Rule: Removal of ovarian cyst in 1st trimester is absolutely contraindicated unless there is an emergency.

---

2nd Trimester - Best time to operate if needed

Why 2nd trimester is the safest time for surgery in pregnancy?

• Organogenesis is complete (less teratogenic risk from anaesthesia)
• Placenta has taken over progesterone (no abortion risk)
• Uterus not yet too large to obstruct the surgical field
• Risk of preterm labour from surgery is lowest

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Symptomatic Branch - Always Operate

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Summary in One Line per Step

• Symptomatic (any trimester) → Operate NOW
• 1st trimester + asymptomatic → Wait, watch, do NOT touch
• 2nd trimester + suspicious/large → Operate
• 2nd trimester + normal → Monitor