Adnexal Masses in Pregnancy: Surgery Compared With Observation

Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review

Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.

Pregnancies complicated by adnexal masses: a case series

INTRODUCTION

Adnexal masses>or=5 cm in diameter are rare during pregnancy.

MATERIALS AND METHODS

We present our experience on six pregnant women with adnexal masses diagnosed and operated during pregnancy and/or at the time of cesarean section.

RESULTS

Carefully selected cases with a unilateral mass and a solid component with normal tumor marker result can be followed until term and adnexectomy can be performed during cesarean section. On the contrary, gross adnexal masses, even with normal tumor marker levels should be operated when diagnosed, but these women might deliver small for gestational age infants.

CONCLUSION

By depending upon restricted criteria according to tumor markers, ultrasound or other radiological imaging techniques, some patients with an adnexal mass carrying an important risk factor for malignancy may be overlooked.

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.

Evaluation and Management of Adnexal Masses During Pregnancy

An increase in the incidence of adnexal masses uncovered during pregnancy has occurred concurrently with the adoption of near universal use of prenatal ultrasound. The majority of these masses resolve by the second trimester. Persistent masses continue to be at risk for significant sequelae such as torsion, rupture, and obstruction of labor. These events may result in the need for emergent surgical intervention with increased risk of adverse outcome for both mother and fetus. In addition a small risk of cancer exists and extended delay in diagnosis should be avoided. As such, surgical excision of persistent adnexal masses should be entertained at approximately 16 to 20 weeks of gestation. In the approximately 5% of cases in which an adnexal masses proves to be a malignancy, appropriate staging may be safely performed. In selected cases, chemotherapy should at least be entertained.

An unusual case of primary fallopian tube carcinoma in pregnancy

Fallopian tube carcinoma is the rarest of all female genital tract malignancies. It usually occurs in postmenopausal women and is associated with infertility. We present the first reported case of it occurring as a primary tumor in a young primigravida. It presented as a large, rapidly growing adnexal mass at 9 weeks of gestation which was removed and found to be a papillary serous carcinoma of the fallopian tube. The patient continued the pregnancy to term and delivered a live healthy infant by ventouse. A staging laparotomy in the postnatal period showed no spread of tumor, and in view of her age and desire for further pregnancies, her uterus and other ovary and tube were conserved. She remains tumor free 2 years following detection. We discuss the incidence, progress, management, and survival rates of this rare gynecological malignancy.