Antenatally detected abdominal cyst: Does cyst size and nature determine postnatal symptoms and outcome?

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Highlights

  • Diagnostic accuracy from the antenatal USS can be as high as 67 to 80%.

  • Cyst from different aetiologies may demonstrate different intrauterine growth characteristics.

  • Maximum cyst diameter greater than 37 mm in-utero is predictive of persistence postnatally.

  • Cyst size was not predictive of postoperative symptoms or the need for surgery.

Abstract

Background

The outcome of antenatally detected fetal intra-abdominal cysts is highly variable and challenging to predict. Antenatal ultrasound scans may be of value in predicting postnatal outcome.

Aims

To report antenatal and postnatal course of fetal intra-abdominal cysts identified on antenatal ultrasound and establish the value of cyst dimensions for predicting outcome.

Study design

Retrospective observational study.

Subjects

All intra-abdominal cysts diagnosed in a single centre between 2013 and 2019.

Outcome measures

Cyst characteristics were recorded from radiological reports and postnatal diagnosis and outcomes documented. Growth characteristics were identified to distinguish different diagnosis. The maximum antenatal diameter of all cysts was identified and the best cut-off diameter to predict whether a cyst would persist postnatally or require surgery was identified. Best cut-off values were identified using Youden index.

Results

Of the 38 cysts identified on antenatal ultrasound, 24 (63%) persisted postnatally, 8 required surgery (21%) and 4 (11%) were not considered an intra-abdominal cyst postnatally. Ovarian cyst and duplication cyst may have different growth characteristics. In the prediction of cysts persisting postnatally, the area under the ROC curve (AUC) was 0.81 (95% CI, 0.66–0.95). Two cut off values were identified, 37.5 mm (50% sensitivity, specificity 100%, Youden's index 0.50) and 28.5 mm (sensitivity 65%, specificity 85%, Youden's index 0.50). In the prediction of surgery, no optimal diameter was found; AUC was 0.57 (95% CI, 0.34–0.81).

Conclusions

Maximum antenatal cyst diameter is useful for the prediction of whether a cyst will persist postnatally but not for the prediction of surgery.

Introduction

Advances in ultrasound technique have enabled more detailed assessment of fetal anomalies during antenatal screening [1,2]. This has facilitated earlier and more accurate detection of fetal anomalies including intra-abdominal cysts [3,4]. Cystic lesions within the fetal abdomen mainly arise from the developing gastrointestinal and genitourinary tract [5]. They represent a wide range of pathologies the commonest being ovarian, duplication and hepatobiliary cysts [6]. The evolution of such anomalies is highly variable. A proportion of intra-abdominal cysts regress during pregnancy or after birth, resolving without any clinical significance [7]. Nevertheless, some cysts can persist after birth, cause symptoms or complications, thus necessitating surgical intervention [8]. Relatively little data exists regarding the outcome and management of fetal intra-abdominal cysts. Thus, predicating the likeliest outcome remains challenging.

Features on antenatal ultrasound scans (USS), including the origin, size and morphology of a cyst, may be predictive of outcome [6,9,10]. Small, intra-parenchymal, unilocular cysts appear most likely to spontaneously resolve, whereas the likelihood of regression is seemingly reduced in larger, complex cysts [9,10]. Furthermore, cysts reaching larger diameters are at higher risk of complications (such as ovarian torsion, haemorrhage or bowel obstruction), thus increasing the risk of surgical intervention.

Knowledge of an intra-abdominal cyst's likely evolution can inform plans for antenatal follow-up and postnatal management, optimising the site of delivery and ensuring prompt perinatal review. Furthermore, it is important that prospective parents are counselled with regard to the expected outcome and the possibility of surgical intervention after birth [11]. Further research detailing the predictive value of antenatal USS may provide valuable data to inform prognostic counselling. This study aims to report the antenatal and postnatal course of fetal intra-abdominal cysts identified on antenatal USS and in particular, establish the value of cyst dimensions for predicting outcome.

Section snippets

Methods

A retrospective review of all fetuses with an intra-abdominal cyst outside the urinary tract seen at the joint Fetal Medicine and Paediatric Surgery Clinic at our Centre for Reproductive Health, between October 2013 and November 2019, was conducted. This is a tertiary referral unit receiving cases from the local population and specialist tertiary regional referrals to the fetal medicine department. All cases where an intra-abdominal cyst was the most likely diagnosis or could not be excluded

Results

During a 6-year period, 46 cystic lesions were identified on antenatal USS (Fig. 1). The final antenatal diagnosis in 8 cases was not an intra-abdominal cyst. One medical termination of pregnancy (MTOP) was recorded (an intra-abdominal cyst of unknown origin). The remaining cohort comprised 37 intra-abdominal cysts identified on the antenatal USS of 10 male (27.8%) and 26 female fetuses (72.2%). A single cyst was observed in all but one fetus where 2 intra-abdominal cysts of unknown origin were

Discussion

The evolution of intra-abdominal cysts is highly variable; predicting which will regress spontaneously and which will cause symptoms or complications necessitating surgery is challenging [6]. Uncertainty regarding the outcome of a cyst can complicate prognostic counselling offered to prospective parents and the planning of antenatal follow-up and postnatal management.

This study aimed to describe the antenatal and postnatal course of intra-abdominal cysts, diagnostic certainty antenatally and

Conclusion

In conclusion, the diagnostic accuracy of antenatal USS in this study seemed to be high. Characteristic growth profiles appear to separate ovarian from duplication cysts, with duplication cysts presenting earlier. The findings of this study also suggest that overall, cyst diameter on antenatal USS is predictive of persistence postnatally, but not surgery. The reliability of statistical results in this study was limited by the small sample size of certain subgroups. Thus, further research will

CRediT authorship contribution statement

Sarah Lewis:Methodology, Formal analysis, Investigation, Writing - original draft, Writing - review & editing.Jane Walker:Conceptualization, Investigation, Writing - review & editing.Merrill McHoney:Conceptualization, Methodology, Formal analysis, Investigation, Writing - review & editing.

Declaration of competing interest

None.

Acknowledgments

Thank you also to the staff at the Fetal Medicine Clinic for kindly assisting with the identification of cases and to Dr. Margaret McDougal for providing guidance on statistical analysis.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

References (19)

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    This discrepancy may be explained by the exclusion of urinary tract anomalies which usually do not necessitate surgical intervention in the postnatal period. The predictive value and diagnostic accuracy of prenatal ultrasound imaging in identifying the origin of fetal abdominal cysts has been previously reported [1,2,4,7,15,22]. In a of series of 71 patients, Ozyunca et al. reported a positive predictive value of 75% in the identification of a clear organ of origin for an abdominal cyst, with an overall sensitivity of 88.1%, specificity of 73.1%, and false positive rate of 5% [4].

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