Bartholins Cyst management and Pregnancy

Jane was a 21 y/o BF G3P2A0 family member who presented to L&D in obvious discomfort. She was 37+5d along in her pregnancy and had a C/C of point tenderness along her left labial fold x 3-4 days that was making it difficult to walk around without pain. Pain level was 7/10 with ambulation. She showed minimal improvement with cool/warm compress to area and percocet use. She was also hesitant to use percocet. She had significant pain with intercourse, denied bleeding, any leaking of fluid or changes in vaginal discharge. +PMHx of STI(Chlamydia), Txed as part of prenatal W/U. Upon pelvic evaluation a large 4 X 3 cm fluctuant cystic mass was noted along the left labia majora border of the vulva consistent with a Bartholins cyst. Bartholins glands allow small amounts of mucous to lubricate the external genitalia. They can be the result of a functional block, infection (STI) or other bacteria, or from localized edema. It was very tender to palpation. The cyst was not actively draining and was erythematous. Jane's V/S were stable, Tmax 99. The CNM I was working with consulted with OB physician on her management. Upon review of her condition the Obstetrician decided to send her home without I&D and have her continue sitz baths, percocet for pain, cool/warm compresses to area for pain relief. Increase rest, but activity was OK as tolerated. No ABX initiated. F/U in clinic in 48hrs or prn.
Physician did not want to perform any elective procedure while she was pregnant. Patient was sent home with discharge instructions. Jane was one of the CNM's centering patients so they had a great rapport. She was in a great deal of discomfort that I thought could be remedied by small I&D and placement of word catheter to allow for controlled drainage of fluid. OB did not want to have the cyst draining with the possibility of the baby being delivered. Highly likely cyst would start to spontaneously start to drain on its own. On the other hand I did not want to see cyst burst and rupture during childbirth while the baby was coming out of birth canal. Risk for bleeding is also increased due to pregnancy. Infection may be a concern for pre-term labor, although she was already 37 weeks. Neither approach is wrong, judgement call.