A series of physiological changes such as loss of appetite, nausea and vomiting during pregnancy are similar to the symptoms of early gastric cancer. Clinicians tend to diagnose that they are normal physiological pregnancy or hyperemesis gravidarum. Even if individual pregnant women have prominent reactions and their symptoms are not relieved for a long time, they are mostly regarded as individuals differences or chronic gastritis, which induce delays in diagnosis. The patient had been waken up in the morning with nausea, no vomiting, and poor appetite for a long time, and had not aroused the doctor's alertness until the appearance of ascites. Compared with the symptoms of the primary tumor, the symptoms of secondary ovarian cancer are often more obvious, such as pelvic mass, abdominal distension, ascites, anemia, weight loss, etc. Clinically, about one-third of ovarian cancer patients are diagnosed with secondary symptoms for the first diagnosis . In order to protect the fetus from being affected, the use of gastrointestinal barium meal, CT and other radiological examinations during pregnancy is limited. Most invasive examinations such as gastroscopy and abdominal puncture are difficult for pregnant women to accept, which often delays the diagnosis. Because the early symptoms of gastric cancer are indistinguishable, and the clinicians are inexperienced in rare cases, the early symptoms are easily overlooked. Once the secondary symptoms appear, the clear diagnosis is mostly late.
The types of ovarian tumors are complex and changeable. Therefore, for pregnancy with ovarian tumors, clinicians must consider not only the distinction between benign, malignant and borderline, but also primary and metastatic, which is very difficult. It is clinically differentiated from ovarian physiological cysts, endometriotic cysts, and ovarian epithelial cystadenoma.
The patient found a unilateral ovarian cyst with a diameter of <5cm since 6+4 weeks of pregnancy, which was mistaken for a simple ovarian cyst. Ovarian tumors during pregnancy are mostly benign, and about 70% can resolve spontaneously in the second trimester . The ultrasound examination was not standardized during pregnancy, which delayed the diagnosis and treatment. The detection of the patient found that the ovarian tumor had progressed unilaterally to bilateral, with uneven echoes, and rapid growth in volume in a short time (2 weeks), cystic to solidified, with abundant blood flow signals and low blood flow resistance, and a large amount of ascites, all suggest the possibility of ovarian malignancy . Therefore, ovarian tumors during pregnancy need to be reviewed regularly and closely followed up. The diagnosis should be further confirmed by magnetic resonance imaging (MRI). MRI has been widely used in obstetrics. It has a higher resolution for soft tissue lesions and can more clearly show the relationship between lesions and surrounding organs. It has become another important auxiliary examination method besides ultrasound. It has sensitivity and specificity in the diagnosis of malignant tumors in pregnancy .
Gastroscopy biopsy pathological examination is the basis for the diagnosis of this patient, and it is also a key point in the diagnosis of the disease. Although gastroscopy may have adverse effects such as allergic reactions, arrhythmia, local injury and bleeding, premature birth, etc., it is not a contraindication to pregnancy examination. If a pregnant woman has persistent gastrointestinal symptoms for a long time, it cannot be explained by normal pregnancy reactions or malignant lesions indicated by imaging examination, gastroscopy can be performed . Patients should be fully communicated to reduce their concerns and improve compliance. In order to find out the reason, it is necessary to perform invasive cavity puncture. The patient underwent The ultrasound-guided catheter drainage of ascites was performed with strict aseptic operation on the patient. Routine ascites and cytology of ascites sediment are helpful for differential diagnosis.
The detection values of AFP and CA125 in the patient were elevated, but it was little clinical significance because AFP and CA125 also increased during pregnancy. Studies had reported that the changes of CEA, CA199, HE4, and LDH values were not significantly related to pregnancy, and could assist pregnancy-related ovaries tumor diagnosis.
When malignant tumors in pregnancy occur in different periods, the treatment principles are also different. In the first trimester, the mother’s health is generally given priority. It is not recommended to continue the pregnancy. It is preferred to actively treat malignant tumors after the termination of the pregnancy. In the second trimester, the severity of the disease and the periods of the gestational week must be considered, then the pregnancy should be continued or terminated. In the third trimester, the gestational time should be appropriately extended to improve the survival probability of the fetus, and it is more common in premature babies . In this case, considering the poor prognosis of the pregnant woman and the patient’s expectation for the fetus, the fetal lung maturity was promoted and pregnancy was terminated as soon as possible when the survival probability of fetal survival was high. Cesarean section and complete staging of ovarian malignant tumors were performed at 28+5 weeks of gestation. Follow-up found that the newborn was alive and the growth and development were normal. The treatment of ovarian malignant tumors requires a comprehensive assessment of the tumor (degree of malignancy), pregnant women and their families (the physical condition of the pregnant women, the expectation of the pregnant women and their family members for the fetus), the fetus (gestational age, survival ability), the hospital's critically ill newborns and critically ill pregnant women's ability and other factors [11, 12].
Stage IV gastric cancer in pregnancy with bilateral ovarian metastasis, T3N1M1, has a very poor prognosis, and the patient's survival time is less than 4 months. Changes in hormones and immunosuppressive status during pregnancy promote tumor occurrence and development. The tissue type is highly malignant, which easily spreads to distant lymph nodes and involves vascular . Treatments of radiotherapy and chemotherapy during pregnancy is limited. The patient did not undergo a pre-pregnancy health checkup, which led to the deterioration of the gastric cancer appeared before pregnancy. The key to improving the prognosis of patients is early detection, early diagnosis and early treatment, which is precisely the difficulty faced by clinicians.