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Jędrzejewski G. i inni – Ovarian ultrasonography in newborn and neonates
Vol. 7/2008 Nr 3(24)
Endokrynologia Pediatryczna
Pediatric Endocrinology
Ovarian Ultrasonography in Newborns and Infants
Morfologia ultrasonograficzna jajników u noworodków i niemowląt
Grzegorz Jędrzejewski, 2Beata Kulik-Rechberger, 1Paweł Wieczorek
1
Department of Pediatric Radiology, Medical University, Lublin
Department of Paediatric Propedeutics, Medical University, Lublin
1
2
Adres do korespondencji:
Grzegorz Jędrzejewski, Zakład Radiologii Dziecięcej AM w Lublinie, ul. Chodźki 2, 20-093 Lublin,
tel: (81) 7418447, e-mail: [email protected]
Key words: ovarian cysts, ultrasonography, newborns, infants
Słowa kluczowe: torbiele jajników, ultrasonografia, noworodki, niemowlęta
STRESZCZENIE/ABSTRACT
The common use of ultrasonography caused that the detection rate of ovarian cysts in newborns and infants has risen
significantly. The visualization of cysts poses a dilemma how to cope with them. The aim of this study was to evaluate
ovaries in newborns and infants using ultrasound examinations and to assess the incidence of ovarian cysts. Material
and methods. Pelvic ultrasound examination was carried out in 34 newborns and 42 infants, using a linear transducer
with a sector format. The sizes of the ovaries was assessed in three dimensions, and then the volume was calculated.
Results. In the group of 29 newborns with visable ovaries, the cysts (follicles 10 mm and grater in diameter) were
detected in 7 girls (24.1% of patients): in 3 girls unilateral cysts and in 4 girls bilateral ones. In the group of 33 infants
with visable ovaries, cysts were observed in 4 girls (12.1%). In 3 of them we dealt with unilateral cysts. The volume
of the ovaries with cysts in newborns ranged between 2.7-12.8 cm3, and in infants between 3.7-6.1 cm3. In the case of
one girl cyst was removed in a surgical treatment because of its intracystic hemorrhage properties. In other girls cysts
resolved spontaneously in a few months of observation. Pediatr. Endocrinol. 7/2008; 3(24):65-70.
Powszechne używanie ultrasonografii w diagnostyce sprawia, że obecnie częściej wykrywa się cysty jajników u noworodków i niemowląt. Obecność cyst zwykle budzi dylemat jak należy w takim przypadku postępować. Celem pracy była ocena ultrasonograficzna jajników u noworodków i niemowląt i określenie częstości występowania torbieli
jajników. Materiał i metody. Badania ultrasonograficzne miednicy mniejszej wykonano u 34 noworodków i 42 niemowląt, z użyciem głowicy liniowej 5–7,5 MHz, z sektorowym odwzorowaniem obrazu. Wielkość jajników oceniano w 3 wymiarach, a następnie obliczano ich objętość. Wyniki. W grupie 29 noworodków z uwidocznionymi jajnikami, torbiele (pęcherzyki o średnicy 10 mm i większej) obserwowano u 7 dziewczynek (24,1% badanych), przy czym
u 3 dziewczynek cysty były jednostronne a u 4 obustronne. W grupie 33 niemowląt z uwidocznionymi jajnikami, torbiele obserwowano u 4 dziewczynek (12,1%), u 3 z nich jednostronne. Objętość jajników z obecnością cyst u noworodków wynosiła od 2,7 do12,8 cm3, u niemowląt od 3,7 do 6,1 cm3. U jednego dziecka cystę usunięto chirurgicznie
ze względu na jej krwotoczny charakter. U pozostałych dziewczynek torbiele ustąpiły samoistnie w ciągu kilku miesięcy obserwacji. Endokrynol. Ped. 7/2008; 3(24):65-70.
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Praca oryginalna
Pelvic ultrasound appears to be a routine
gynaecological examination. Normal values for
ovarian measurements in adults have been revised
over the past decades. Less is known about ovaries
in children, especially in newborns and infants. In
these patients ultrasound examinations are made
mainly to exclude congenital malformations. During
abdomen and pelvic ultrasound examinations small
cystic lesions in ovaries that made doctors and
parents concerned are usually detected accidentally
[1-3]. According to Strickland [4], small simple
cysts found accidentally in childhood should be
considered as normal findings. The controversial
issue seems to be the size of follicles, which
may be named the cyst. Cohen and co-authors
[1] apply the term of the cyst to all cystic lesions
in an ovary, regardless of their size. They noted
ovarian cysts in 84% out of 98 investigated patients.
The majority of authors [4-6] claim that the cyst
should have 9-10 mm and more in diameter. They
are usually functional, which is a consequence of
follicular growth and atresia [4]. In the case of
large cysts it is recommended to carefully assess
the size, shape, localization, walls of the cyst and
its internal structure. To make the diagnose more
reliable, the urinary and digestive systems should
also be assessed [5]. The incidence of cystic lesions
increases the ovarian volume [3].
The aim of this study was to evaluate ovaries
in newborns and infants during ultrasound
examinations, assess the incidence of ovarian cysts
as well as to follow their natural history.
Material and methods
Pelvic ultrasound was performed in 76 girls. The
patients were divided into two groups. The first group
consisted of 34 newborns, girls born in time and
premature ones, whose corrected age did not exceed
four weeks. The second group consisted of 42 girls
aged between four weeks to 12 months (mean 3,5±2,1
month). Pelvic ultrasound was performed using a
linear transducer with a sector format. The sizes of
the ovaries were assessed in three dimensions, and
then the volume was calculated. Girls with ovarian
cysts had regular ultrasound review in 2-4 week
periods. The observation lasted up to 24 weeks.
Results
The ovaries were visualized in 29 out of 34
girls from the first age group. In 10 girls the
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Endokrynol. Ped., 7/2008;3(24):65-70
ovaries consisted of small follicles, up to 2 mm in
diameter. In 12 girls bigger follicles were found,
with a diameter ranging from 3 to 10 mm [Fig.1].
The cysts (follicles grater than 10 mm in diameter)
were observed in 7 girls, which represents 24% of
patients. The diameters of the cysts ranged from
11 to 38 mm. In 3 girls the cystic lesions were
unilateral in 4 girls – bilateral. The presence of
cysts made ovaries bigger. In Table I we present
mean measurements of ovaries in the group of
newborns, with follicles up to 10 mm (n=22), and
with cysts (n=7).
In the second group which consisted of 42 girls
the ovaries were not visible in 9 cases. Ovarian cysts
were found in 4 girls (12,1%), unilateral ones in 3 of
them. The diameters of the cysts ranged from 12 to
29 mm. The characteristic sign in those ovaries was
a small amount or the lack of normal ovarian tissue.
In the rest 29 girls ovaries were assessed as normal.
In 6 cases ovaries consisted of small follicles, up to
2 mm in diameter. In 23 girls bigger follicles were
traced, with a diameter ranging from 3 to 10 mm. In
one infant the so-called „daughter cyst” sign which
corresponded with a smaller ovarian follicle laying
inside the ovarian cyst was found [Fig. 2]. The mean
measurements of ovaries are shown in Table II.
The intracystic hemorrhage, which indicated
dense content of the cyst, occurred in one infant,
with the presence of the cyst pedicle [Fig. 3]. In this
girl, after 6 weeks, cystectomy was performed. In
other children spontaneous regression of the cysts
occurred during observation, which lasted to 24
weeks.
Discussion
Normal ovaries in newborns and infants
are difficult to visualize during abdominal
ultrasound due to their small volume [1, 2]. In our
examinations we could not find the ovaries in 17%
of newborns and in 21% of infants. Few articles
refer to the ovarian size and structure in a small
girls. Sanfilippo and co-authors [2] found that the
mean volume of ovaries in newborns was 0.3-0.9
cm3. Moreover, Cohen at al. [1] reported that the
mean volume of ovaries among girls up to the age of
3-month-old was 1.06 cm3, among girls aged 4-12
months it was 1.05 cm3, and among girls aged
13-24 months – 0.67 cm3. In our experience in
newborns the mean volume of ovary with a follicle
up to 10 mm is 0.6 cm3. In infants aged between
1 to 12 months it is 0.9 cm3. Small follicular ovarian
Jędrzejewski G. i inni – Ovarian ultrasonography in newborn and neonates
cysts were frequent findings during ultrasound
examination, both in newborns and infants. Ovarian
cysts were found in 7 newborns and in 4 infants,
which represents 24,1% and 12,1% of patients with
visualized ovaries respectively. In newborns the
diameter of cysts ranged between 11 and 38 mm and
in infants between 11 and 29 mm. The prevalence
of cysts greater than 9 mm in diameter was similar
to that observed by Cohen and co-authors [1], who
noted such cysts in 18% of girls. The incidence of
cyst lesions increased the ovarian volume. In our
study, the volume of ovaries with cysts in the first
age group ranged between 2.7-12.8 cm3, and in the
second age group between 3.7-6.1 cm3.
As other investigators [6], we found that
ultrasound appearance of an uncomplicated
ovarian cyst is round, homogeneous, anechoic
and has thin walls. Mesenteric cysts, urachal cyst,
hydrometrocolpos, enteric duplication cystic and
giant meconium pseudocysts are the structures of
similar appearance [5, 7]. Teratomas are other rare
lesions which may be confused with ovarian cysts
[3]. Complex cysts, especially those resembling
solid mass or cystic mass with a retracting clot, may
be impossible to differentiate from a neoplasm [7].
Sometimes it is difficult to establish the origin of
the cyst, especially in the case of a very large cyst
[5]. According to the most frequent occurrence in
an ovary, it is important to eliminate the ovarian
origin of the cyst [3]. The specificity of a diagnosis
is improved by the visualization of normal ovarian
tissue around the cyst, or a „daughter cyst” along
the cyst wall [3, 8]. Small cysts are usually confined
to the adnexae, larger cysts can be completely intraabdominal because of the small neonatal pelvis
and the presence of long cyst pedicles [3]. Ovarian
cysts can therefore be mobile and may vary in
positions. We found such a cyst, filled with echoic
content and changing the positions during following
examinations in one of the examined girls.
The majority of ovarian cysts are asymptomatic,
or the symptoms are nonspecific [9], which was
also confirmed in our study. The cysts observed in
our examinations did not exceed 4 cm in diameter.
A large cyst may cause urinary tract obstruction,
bowel obstruction, thorax compression, with
pulmonary hypoplasia and even sudden death of a
child [7, 9]. Symptoms may appear in the case of
bleeding, torsion and rupture. Such complications
usually occur in cysts having more than 5 cm in
diameter [4, 10, 11]. The most frequent, which may
cause bleeding, rupture or peritoneal adhesions,
is the torsion of the cyst [10]. Hemorrhagic cysts
reveal the fluid-blood level, thickening of the walls
or solid component filling the whole cyst [3, 6].
In children with ovary cyst the management
should be primarily pointed to preserve the ovary.
It depends on the size of cyst and their ultrasound
appearance [9]. Because even cystectomy results
in the loss of normal ovarian tissue, in the case
of uncomplicated cysts a conservative approach
is proposed. Regular ultrasonography alone is
recommended if the cysts are less than 5 cm in
diameter. Usually spontaneous regression of
these cysts can occur. In the case of larger cysts,
aspiration of the cyst should be considered. In the
case of recurrent or complicated cysts or surgical
treatment should be taken into consieration. Cysts
diagnosed antenatally may be aspirated in utero if
there are signs of thoracic compression [11].
Conclusions
An understanding of the normal physiology
of the ovary is essential to prevent inappropriate
intervention. Simple cysts with a diameter up to 10
mm should be considered as normal findings which
require no intervention. Most of these cysts, despite
larger sizes, usually resolve spontaneously.
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Endokrynol. Ped., 7/2008;3(24):65-70
Table I. The measurements of ovaries with follicles up to 10 mm in diameters (A), and with cysts (B – follicles bigger than 10 mm in
diameter) in newborns
Tabela I. Wymiary jajników z pęcherzykami o średnicy do 10 mm (A) i z torbielami (B – pęcherzyki przekraczające 10 mm) u noworodków
Newborns
Length
mm
Width
mm
Thickness
mm
Volume
cm3
Mean ±SD
median
min-max
Mean ±SD
median
min-max
Mean ±SD
median
minmax
Mean ±SD
median
min-max
A (n=22)
13,9±6,3
12
7-24
7,8±3,6
6,5
4-15
7,4±3,15
6
4-13
0,6±0,7
0,25
0,1-2,7
B (n=7)
29,7±6
29,5
20-38
20,5±4,25
19
16-27
19,4±4,3
18,5
15-26
6,4±3,7
4,8
2,7-12,8
Table II. The measurements of ovaries with follicles up to 10 mm in diameter (A), and with cysts (B - follicles bigger than 10 mm in
diameter) in infants
Tabela II. Wymiary jajników z pęcherzykami o średnicy do 10 mm (A) i z torbielami (pęcherzykami przekraczającymi 10 mm –B) u
niemowląt
Infants
Length
mm
Width
mm
Thickness
mm
Mean ±SD
median
min-max
Mean ±SD
median
min-max
Mean ±SD
median
min-max
Mean ±SD
median
min-max
A (n=29)
16±5,4
14
8-28
9,4±3
9,5
5-17
9,3±3,05
9
5-16
0,9±0,85
0,53
0,052,7
B (n=4)
25±2,9
25
21-29
17,6±2,6
17
16-26
17,4±2,3
17
15-26
4,3±1,2
3,75
3,7-6,1
Fig. 1. Normal ovary in 6 month old girl, with follicles up to 10 mm in diameter.
Ryc. 1. Prawidłowy jajnik u 6 miesięcznej dziewczynki, z pęcherzykami o średnicy do 10mm.
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Volume
cm3
Jędrzejewski G. i inni – Ovarian ultrasonography in newborn and neonates
Fig. 2. The “daughter cyst sign” in 3 month old girl
Ryc. 2. Obraz „torbieli w torbieli” u 3 miesięcznej dziewczynki
Fig. 3. Hemorrhagic cyst in 9 month old girl
Ryc. 3. Torbiel krwotoczna u 9 miesięcznej dziewczynki
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