AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 43 CASE REPORT African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | Large Adnexal Tumour in a Young Woman Presenting with Cardiac- related Signs and Symptoms BACKGROUND Adnexal tumours are a broad spectrum of gynaecologic conditions with the spectrum spanning from benign functional cysts to malignant neoplastic processes. Benign ovarian tumours are usually asymptomatic or have local symptoms like pelvic pain or irregular menstrual cycles. Unusually large adnexal tumours can have varying degrees of systemic effects, owing to pressure symptoms and displacement of vital organs. Cardiovascular compromise can occur via mechanical compression of the inferior vena cava or elevation of the diaphragm and direct pressure on thoracic organs . The resulting physiologic imbalances may take the form of lower limb oedema, decreased cardiac preload, lessened ventricular compliance, and respiratory failure. The report of this case demonstrates the systemic impact of a very large benign ovarian tumour in a young woman, highlighting the interaction between gynecological disease and cardiovascular physiology. We describe the diagnostic investigations and the importance of multidisciplinary management between gynaecology, internal medicine and anaesthesiology to provide the best possible outcome. CASE REPORT A 21 year old nulligravid woman attended the emergency department with a seven-month history of progressive abdominal distension. In addition, she also reported early satiety, increased fatigue, and unintentional weight loss during this time. She had no relevant medical history, prior hospitalisation or surgery, and no family history of malignancy. The patient is a student who is sexually active, and has been using injectable contraceptives as birth control. On physical examination she appeared cachectic with distinct muscle wasting and loss of subcutaneous fat. Her blood pressure was 151/121 mmHg and her pulse rate was 140 bpm. Her respiratory rate was 24 breaths per minute and her temperature was normal. She had bilateral pitting oedema from her feet extending into the mid-thigh juncture where the indentation was clearly visible. On cardiovascular examination, she had sinus tachycardia with no added sounds, and no murmurs, rubs or gallops could be heard. The assessment of her respiratory system revealed the presence of increase effort of breathing accompanied by the use of accessory muscles and intercostal retractions. She had decreased lung sounds with absence of any abnormal sounds. On abdominal examination she had massive distension, which was tense and dull nature with a positive fluid thrill indicating ascites. Her pelvic examination was otherwise unremarkable. Ultrasound examination revealed a very large cyst filling the wholeabdomenextendingup fromthepelvis to theepigastrium. On chest X-Ray she had an increased cardio-thoracic ratio with severe compressions over the mediastinum, tracheal deviation to the left, and bilateral basal consolidation of the lungs indicative of atelectasis. Echocardiography showed partially impaired left ventricular performance with an ejection fraction of 43 %, moderately extensive circumferential pericardial effusion, the deepest portion of which was 1.5 cm with no features of a tamponade and raised pulmonary pressures of 37mmHg. Since there was no tamponade imminent, decision was made to not drain the effusion, as this is an invasive, highly technical procedure with risk for infection. The origin of the tumour was not clearly delineated on ultrasoundexaminationduetothehugesizeofthecyst.Contrast- enhanced computed tomography (CT) of the abdomen and pelvis showed a unilocular cystmeasuring approximately 27 cm x 3O cm x 40 cm originating from the right ovary with bilateral hydronephrosis due to ureteral compression. In addition, there were also compression of the lung fields and a pressure effect on the right atrium. The pelvis had evidence of free fluid, compatible with ascites. A CT pulmonary angiogram, done to rule out possible pulmonary embolism due to respiratory distress, showed no thromboembolic disease. Other special investigations showed a mild normocytic anaemia with a haemoglobin of 10 g/dL and haematocrit of 29.3%. Renal function was normal with creatinine of 61µmol/l and urea of 8.2mmol/l in spite of bilateral hydronephrosis. Her liver function tests were normal with a albumin of 35 g/dl. Her lactate dehydrogenase (LDH) level was mildly elevated at 298 U/L (140-280 U/L), alpha-fetoprotein level was normal at 5.2 ng/mL, beta-human chorionic gonadotropin was undetectable and cancer antigen 125 (Ca-125) was only slightly elevated at 47 U/mL (0-35 U/ml). Initial medical management included intravenous Thapelo Matlou 1 , Leon C Snyman 1 , Salome Bothma 2 1 Department Obstetrics & Gynaecology, University of Pretoria and Kalafong Provincial Tertiary Hospital, Pretoria, South Africa 2 Department Internal Medicine, University of Pretoria and Kalafong Provincial Tertiary Hospital, Pretoria, South Africa CORRESPONDENCE: L Snyman | Email: leon.snyman@up.ac.za Large Adnexal Tumour in a Young Woman Presenting with Cardiac-related Signs and Symptoms ABSTRACT Adnexal tumours constitute a wide range of conditions that are frequently faced in gynecological practice, and this include benign cysts, as well as malignant tumours. Although the majority of ovarian tumours are asymptomatic or have localized symptoms, very large adnexal tumours may have systemic effects because of their size and location. This report describes a rare case of a young woman with a very large adnexal tumour presenting with predominantly cardiovascular-related symptoms. A 21 year old nulligravid woman presented to our emergency department with progressive history abdominal distension, swelling of the lower limbs, and cardiorespiratory distress due to an adnexal tumour noted intra op to be measuring 30 x 40 cm. Initial investigations revealed a tumour originating from the pelvis extending to the epigastrium. Further investigations revealed cardiovascular compromise tumour with an ejection fraction of 43% on echocardiogram. A multidisciplinary team consisting of gynaecological oncologists, physicians and anaesthetists were involved in the management of the patient. Fertility sparing surgery was performed and serial echocardiograms post-operatively showed improvement in the patient’s cardiovascular status.