Managing Ovarian Masses During Pregnancy

Management of a persistent adnexal mass in pregnancy: what is the ideal surgical approach?

STUDY OBJECTIVE

To compare short-term and pregnancy-related outcomes of laparoscopy with laparotomy for management of a persistent second-trimester adnexal mass.

DESIGN

Retrospective cohort study of pregnant women at 14 weeks or more of gestation undergoing laparoscopy or laparotomy for management of an adnexal mass (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Women of reproductive age with a persistent adnexal mass at 14 weeks or more of gestation.

INTERVENTION

Removal of adnexal mass via laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Between 1990 and 2008, 101 pregnant women underwent treatment of a persistent adnexal mass at 14 weeks or more of gestation at our institution. Fifty women underwent laparoscopy, and 51 underwent laparotomy. Similar demographic and adnexal mass characteristics were identified between the 2 surgical groups. Eight patients in the laparotomy group experienced postoperative complications, compared with none in the laparoscopy group (p < .02). Mean surgical estimated blood loss and length of hospital stay were significantly less in the laparoscopy group compared with the laparotomy group: 17.5 mL vs 100 mL (p < .001) and 0.7 days vs 2.78 days (p < .001), respectively. There were no observed differences in pregnancy-related outcomes between the 2 groups.

CONCLUSION

Minimally invasive surgery is a reasonable approach to management of a second-trimester adnexal mass in gravid women. Laparoscopy enables a shorter hospital stay, decreased blood loss, and fewer postoperative complications without seeming to have a negative effect on pregnancy-related outcomes. While these findings are reassuring, larger studies are encouraged to continue to evaluate this issue.

Evaluation and management of adnexal mass in pregnancy

With widespread use of ultrasound in early pregnancy, incidental adnexal masses are detected frequently. This article reviews the differential diagnosis, appropriate evaluation, and current treatment options for adnexal masses in pregnancy. With the increased sophistication of ultrasound, observation has become a more viable option. However, for those masses suspicious for malignancy, at risk for torsion, or clinically symptomatic, surgical management is warranted. With increasing numbers of successful laparoscopic procedures reported in pregnancy, laparoscopy appears to be a safe option with trained and experienced providers.

A woman with salt-wasting congenital adrenal hyperplasia presenting with a mucinous ovarian cystadenoma during pregnancy

Women with congenital adrenal hyperplasia (CAH) caused by steroid 21-hydroxylase deficiency show reduced fertility, especially with the salt-wasting form. A 27-year-old pregnant woman with this disease underwent laparotomy and oophorectomy to remove a multilocular ovarian tumor at 14 weeks of pregnancy. This proved to be a mucinous cystadenoma. Toward the third trimester, she presented with marked elevations of 17α-hydroxyprogesterone and plasma renin activity. Careful management of endocrine and body fluid homeostasis allowed her to give birth to a healthy female infant with normal external genitalia. This case illustrates endocrinological parameters during pregnancy in a woman with classical salt-wasting CAH.

Paratubal borderline tumor incidentally found during cesarean section: case report and review of literature

Diagnosis of a gynecologic malignancy during cesarean section is quite rare. We report a case of a 39-year-old, nulliparous woman who underwent elective cesarean section during which a paratubal cyst was noticed and removed. The pathology revealed serous borderline tumor. Subsequent staging laparotomy was done 23 days after cesarean section. She was diagnosed with stage IC paratubal serous borderline tumor and underwent no further therapy. For the time being 15 months have passed from the staging laparotomy and she is currently free of disease recurrence. This case presented the importance of the evaluation of adnexa during cesarean section together with a short review of the literature on the rare paratubal borderline tumors and the role of fertility-sparing, conservative surgery in their management.

Heterotopic triplets: tubal ectopic and twin intrauterine pregnancy. A review of obstetric outcomes with a case report

INTRODUCTION

Heterotopic triplets hardly take place, but nowadays the extended use of assisted reproductive technologies is increasing the ectopic pregnancies rate and subsequently the heterotopic pregnancies, leading to a potentially dangerous condition for the woman and the intrauterine pregnancy.

MATERIAL AND METHODS

Fourteen cases previously reported in the literature of patients presenting an intrauterine twin pregnancy which became complicated by a tubal ectopic pregnancy have been reviewed. The case of a patient following a homologous intrauterine insemination treatment, resulting in live birth of both twins, is also described.

CONCLUSION

Although the diagnosis of heterotopic triplets with tubal ectopic is challenging, a timely surgical treatment will preserve intrauterine gestation with a great chance of a successful obstetric outcome for both twins.

Laparoendoscopic single-site surgery for exteriorization and cystectomy of an ovarian tumor during pregnancy

Herein, we describe a surgical approach for management of a pregnant woman with an ovarian tumor using laparoendoscopic single-site surgery with exteriorization. We assessed both the feasibility and cosmetic outcome. The operation lasted 25 minutes, and the estimated blood loss was negligible. No perioperative or postoperative complications developed, and the patient was discharged on postoperative day 2.

[French recommendations for ovarian cancer management during pregnancy]

Evaluation of the fetus using prenatal ultrasound has resulted in increased detection of asymptomatic adnexal masses during pregnancy. Such masses are rarely malignant (1/10 000 to 1/50 000 pregnancies), but the possibility of borderline or cancer must be considered. It is a common assumption by both patients and physicians that if an ovarian cancer is diagnosed during pregnancy, treatment necessitates sacrificing the well-being of the fetus. However, in most cases, it is possible to offer appropriate treatment to the mother without placing the fetus at serious risk. The care of a pregnant woman with cancer involves evaluation of sometimes competing maternal and fetal risks and benefits. These recommendation approaches attempt to balance these risks and benefits; however, they should be considered advisory and should not replace specific interdisciplinary consultation with specialists in maternal-fetal medicine, gynecologic oncology, and pediatrics, as well as imaging and pathology, as needed. Second level ultrasound including Doppler is needed. MRI is not often necessary, and CA 125 is of low contribution. We suggest surgery be performed after 15 SA for ovarian masses which (1) persist into the second trimester, (2) are greater than 5 to 10 cm in diameter, or (3) have solid or mixed solid and cystic ultrasound characteristics. During antepartum surgical staging and debulking, homolateral salpingo-oophorectomy and peritoneal cytology and exploration are necessary. Women found to have advanced stage epithelial ovarian cancer should consider having completion of the debulking of the reproductive organs at the conclusion of the pregnancy. If chemotherapy is indicated, we recommend delaying administration, if possible, after the delivery or at least after 20 SA in order to minimize the potential fetal toxicity.

Squamous cell carcinoma arising in a dermoid cyst of the ovary in pregnancy

BACKGROUND

A rare complication of mature cystic teratoma of the ovary is malignant transformation, mostly being squamous cell carcinoma (SCC). Due to small case series, there are no established standard surgical and postoperative procedures.

CASE

A 41-year-old pregnant woman presented with a right ovarian tumour. At 14 weeks of gestation, laparotomy with oophorectomy was performed. Histology revealed a pT1a poorly differentiated SCC with lymphovascular invasion. She delivered a healthy infant at 39 weeks of gestation. Nine weeks after delivery, she underwent complete surgical resection and was staged pT1a, pN0 (0/40) pMx, G0. No further treatment was given and 37 months later she is still free of disease.

CONCLUSION

For this rare entity complete surgical resection seems to be a safe treatment.

Pelvic masses

Pelvic masses develop commonly in women of all ages and states of health. Despite the variety of masses that exist, general guidelines for diagnosis and management allow most masses to be treated in a generalist setting. This article is intended to guide non-obstetric and non-gynecologic physicians through diagnosis and treatment of nonmalignant pelvic masses. It includes information on physical examination, appropriate imaging techniques, laboratory tests, and variations in treatment for adolescents and pre- and postmenopausal women. It also addresses referral guidelines for suspected malignant masses.

Benign disorders of the ovary

Most ovarian disorders are benign, with the majority being functional ovarian cysts and benign neoplasms. Imaging can often aid in diagnosis and risk assessment. Benign ovarian disorders are frequently incidental findings, but they may cause symptoms from hormonal overproduction, mass effects, or torsion. In addition to symptoms, any ovarian abnormality can raise the specter of malignancy. Knowledge of the cause, presentation, and natural history of these benign ovarian disorders helps providers counsel and treat patients appropriately.

Ovarian cancer during pregnancy: analysis of 15 cases

GOAL

Our goal was to analyze and describe cases of ovarian cancer in pregnant women treated at our hospital.

METHOD

Retrospective study based on clinical histories from patients diagnosed and treated at our hospital for ovarian cancer and pregnancy from 1987 to 2005.

RESULTS

Fifteen cases of ovarian cancer were diagnosed among pregnant women; the ratio is 0.11/1000 deliveries. Among them, 66.6% of patients were asymptomatic, and 86.6% had been diagnosed via ultrasound. Of the diagnosed tumors, 40% were malignant epithelial tumors, 26.6% of them were of low malignant potential. The 20% were germinal cell tumors. Of these primary ovarian malignancies, the 59.9% were stage I. The remaining 20% were metastatic tumors. Forty percent of the total were treated conservatively (salpingo-oophorectomy) and 60% with hysterectomy and bilateral salpingo-oophorectomy. Chemotherapy was administered to 66.6% of the patients, in two cases during pregnancy. Eighty percent of the newborns were healthy and presented no sequelae or malformations. Global survival at 5 years was 76%.

CONCLUSIONS

Ovarian cancer is rare in pregnant women. Most malignant ovarian neoplasias in pregnant women are at early stages and are associated with good prognosis both for the mother and for the neonate.

Adnexal Masses in Pregnancy: Diagnosis and Management

The widespread use of ultrasound in obstetrics has led to an increase in the diagnosis of asymptomatic adnexal masses in pregnancy. Ultrasound is an accurate and safe method for diagnosing the etiology of an adnexal mass and distinguishing benign from malignant pathology. The management of an adnexal mass in pregnancy is controversial. Historically, it was recommended that any adnexal mass be removed electively in the second trimester to exclude malignancy and prevent complications such as torsion, rupture, and obstruction of labor. More recent recommendations have limited surgical intervention in pregnancy to symptomatic adnexal masses and those that are highly suggestive of malignancy. Surgery in pregnancy is associated with an increased risk of adverse pregnancy outcomes. However, laparoscopy appears to be a safe alternative to laparotomy for benign masses when performed by experienced surgeons.

Learning objectives

To list the differential diagnoses of adnexal masses in pregnancy

To interpret ultrasound images of adnexal masses and distinguish benign from malignant masses

To describe the management options for adnexal masses in pregnancy, including the indications and options for surgical intervention.

Metastatic primitive neuroectodermal tumor of the ovary in pregnancy

Primitive neuroectodermal tumor (PNET) is a small round tumor belonging to the PNET/Ewing's sarcoma family. We hereby report a case of PNET of the ovary, which was detected at the second trimester of pregnancy. Chemotherapy was administered and a healthy baby was delivered by cesarean section. After the pregnancy, the mother was found to have metastatic disease. Chemotherapy was continued, but she died due to progressive disease 13 months after the initial diagnosis. In this case report, we discuss chemotherapy options during pregnancy and the importance of multidisciplinary approach to unusual presentations of rare tumors