Evaluation and Management of Adnexal Masses During Pregnancy

Ultrasound Features and Clinical Outcome of Patients with Ovarian Masses Diagnosed during Pregnancy: Experience of Single Gynecological Ultrasound Center

(1) Background: The number of adnexal masses detected during pregnancy has increased due to the use of first-trimester screening and increasingly advanced maternal age. Despite their low risk of malignancy, other risks associated with these masses include torsion, rupture and labor obstruction. Correct diagnosis and management are needed to guarantee both maternal and fetal safety. Adnexal masses may be troublesome to classify during pregnancy due to the increased volume of the uterus and pregnancy-related hormonal changes. Management should be based on ultrasound examination to provide the best treatment. The aim of this study was to describe the ultrasound features of ovarian masses detected during pregnancy and to optimize and personalize their management with the expertise of gynecologists, oncologists and sonographers. (2) Methods: Clinical, ultrasound, histological parameters and type of management (surveillance vs. surgery) were retrospectively retrieved. Patient management, perinatal outcomes and follow-up were also evaluated. (3) Results: according to the literature, these masses are most frequently benign, ultrasound follow-up is the best management, and obstetric outcomes are not considerably influenced by the presence of adnexal masses. (4) Conclusions: the management of patients with ovarian masses detected during pregnancy should be based on ultrasound examination, and a centralization in referral centers for ovarian masses should be considered.

Paratubal Cystectomy in a Pregnant Woman Using the Single-Incision Laparoscopic Surgery (SILS) Technique

Introduction

The proliferation of prenatal ultrasound has enhanced the detection of adnexal masses during pregnancy. The presentation necessitates a clear approach to investigation and treatment that balances both maternal and fetal risk. Laparoscopy is a safe approach to surgical management in the pregnant patient, and SILS may contribute to minimising perioperative complications. Case Presentation. We present the case of a 21-year-old female in her second trimester of pregnancy presenting with a large 20 cm right adnexal cyst. We proceeded with laparoscopic cystectomy via the SILS technique. There were no intraoperative complications, and she recovered well postoperatively.

Conclusion

Laparoscopic resection of adnexal lesions is safe during pregnancy and should be favoured over the open approach. SILS minimises incision sites and has potential for reduction in perioperative morbidity.

Paracentesis of an Ovarian Cyst During Second-Trimester Pregnancy

A common issue is that modern obstetricians are required to manage ovarian cysts during pregnancy. Most lesions are benign and will spontaneously resolve, with a few exceptions. Management practices include conservative observation or surgery. Asymptomatic women with an ovarian cyst larger than 5 cm should undergo serial ultrasounds up to 16 weeks of pregnancy and, if the mass does not regress, further management with imaging or surgery is to be considered. This article presents a case of an ovarian cyst sized 21 cm in a second-trimester pregnancy and its management. Paracentesis was performed due to persisting symptoms. The procedure was performed with no complications for the mother and no adverse effects for the fetus. The patient was discharged in good health.

Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass

During routine antenatal ultrasound examinations, an ovarian mass can be found incidentally. In clinical practice, the differential diagnosis between benign and malignant ovarian masses is essential for planning further management. Ultrasound imaging has become the most popular diagnostic tool during pregnancy, with the recent development of ultrasonography. In non-pregnant women, several methods have been used to predict malignant ovarian masses before surgery. The International Ovarian Tumor Analysis (IOTA) group reported several scoring systems, such as the IOTA simple rules, IOTA logistic regression models, and IOTA assessment of different NEoplasias in the adneXa. Other researchers have also evaluated the malignancy of ovarian masses before surgery using scoring systems such as the Sassone score, pelvic mass score, DePriest score, Lerner score, and Ovarian-Adnexal Reporting and Data System. These researchers suggested specific features of ovarian masses that can be used for differential diagnosis, including size, proportion of solid tissue, papillary projections, inner wall structure, locules, wall thickness, septa, echogenicity, acoustic shadows, and presence of ascites. Although these factors can also be measured in pregnant women using ultrasound, only a few studies have applied ovarian scoring systems in pregnant women. In this article, we reviewed various scoring systems for predicting malignant tumors of the ovary and determined whether they can be applied to pregnant women.

Adnexal masses in pregnancy: An updated review

Adnexal masses in pregnancy are not commonly encountered. The majority of these masses are discovered incidentally during routine follow-up. However, some of these masses become symptomatic due to their size, location, and impingement of adjacent structures. Several diagnostic modalities can be utilized for the detection of adnexal masses with different sensitivity and specificity rates. The differential diagnosis of adnexal masses discovered during pregnancy is broad and includes both benign and malignant lesions. The management of such lesions has been a subject of debate for years with no consensus regarding the best management plan. Tumor size, site, and the trimester of mass detection are all crucial in management. In this account, we review adnexal masses discovered in pregnancy, the diagnostic modalities utilized for detecting these lesions, their differential diagnosis, and management strategies.

Adnexal Masses in Pregnancy

Importance

Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Objective

The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy.

Evidence Acquisition

This was a literature review using primarily PubMed and Google Scholar.

Results

Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy.

Conclusions and Relevance

Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Sonographic features of ovarian tumors in pregnant women before surgical intervention and chemotherapy

The problem of ovarian tumor differential diagnosis is solved using comprehensive ultrasound examination at different levels of efficiency. However, ultrasound imaging is an operator-dependent technique due to subjective interpretation of results. The study was aimed to assess the ultrasound signs of benign and malignant ovarian germ cell tumors (OGCTs) in pregnant women in order to determine the feasibility of surgical treatment and chemotherapy. The study was carried out using the logistic regression models. A group of 199 pregnant women with benign and malignant OGCTs were enrolled. Of them, 183 patients had benign, and nine patients had malignant tumors. In order to assess menstrual function and fertility, seven pregnant women were enrolled, who had previously received treatment for malignant OGCTs. Pre-operative assessment results were compared with morphological assessment data. Organ-preserving surgical treatment was performed (unilateral adnexectomy); if necessary, the patients received cisplatin-based chemotherapy. Perinatal outcomes were assessed. The median observation time between the malignant OGCT detection and the end of the study was 66 months (12–240 months). It was found that comprehensive ultrasound examination and logistic regression models (sensitivity 100%, specificity 92.3%, overall accuracy 92.8%) enabled differential diagnosis of benign and malignant OGCTs. The number of unnecessary surgical procedures in patients with benign OGCTs was been limited, the pregnancy and childbirth outcomes were improved. Nine pregnant women received organ-preserving surgical treatment for malignant OGCTs, and three patients received chemotherapy after surgery, which allowed the patients to realize their reproductive potential.

Surgical Management of Adnexal Masses in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

The incidence of adnexal masses in pregnancy is 1% to 6%. Although surgery is often indicated, there are no definitive management guidelines. We aimed to investigate the optimal approach to surgical management of adnexal masses in pregnancy on the basis of a meta-analysis of previous studies.

DATA SOURCES

We performed a systematic review using MEDLINE, Embase, Cochrane Library, and Clinicaltrials.gov from inception to July 17, 2020.

METHODS OF STUDY SELECTION

There were no restrictions on study type, language, or publication date. Comparative and noncomparative retrospective studies that reviewed operative techniques used in surgery of adnexal masses in pregnancy were included. Meta-analyses were performed to assess outcomes. This study was registered in the International Prospective Register of Systematic Reviews (CRD42019129709).

TABULATION, INTEGRATION, AND RESULTS

Comparative studies were identified for laparoscopy vs laparotomy and elective vs emergent surgery (11 and 4, respectively). Elective surgery is defined as a scheduled antepartum procedure. For laparoscopy vs laparotomy, the mean maternal ages and gestational ages at time of surgery were similar (27.8 years vs 27.7 years, p = .85; 16.2 weeks in laparoscopy vs 15.4 weeks in laparotomy, p = .59). Mass size was larger in those undergoing laparotomy (mean 8.8 cm vs 7.8 cm, p = .03). The most common pathologic condition was dermoid cyst (36%), and the risk of discovering a malignant tumor was 1%. Laparoscopy was not associated with a statistically increased risk of spontaneous abortion (SAB) or preterm delivery (PTD) (odds ratio [OR] 1.53; 95% confidence interval [CI], 0.67-3.52; p = .31 and OR 0.95; 95% CI, 0.47-1.89; p = .88, respectively). The mean length of hospital stay was 2.5 days after laparoscopy vs 5.3 days after laparotomy (p <.001). The decrease in estimated blood loss in laparoscopy was not statistically significant (94.0 mL in laparotomy vs 54.0 mL in laparoscopy, p = .06). Operative times were similar in laparoscopy and laparotomy (80.0 minutes vs 72.5 minutes, p = .09). Elective surgery was associated with a decreased risk of PTD (OR 0.13; 95% CI, 0.04-0.48; p = .05). Noncomparative studies were identified for laparoscopy and laparotomy. Laparotomy had more SABs and PTDs than laparoscopy (pooled proportion = 0.02 vs 0.07 and pooled proportion = 0.02 vs 0.14, respectively).

CONCLUSION

Laparoscopy for the surgical management of adnexal masses in pregnancy is associated with shorter length of hospital stay and similar risk of SAB or PTD. Elective surgery is associated with a decreased risk of PTD.

Ovarian Cancer and Pregnancy-A Current Problem in Perinatal Medicine: A Comprehensive Review

The frequency of concomitant adnexal tumors in pregnancy is reported to be at 0.15-5.7%, while ovarian cancer complicates 1 in 15,000 to 1 in 32,000 pregnancies, being the second most common gynecologic cancer diagnosed during pregnancy. The aim of this review is to discuss the problem of ovarian cancer complicating pregnancy and the current recommendations for diagnostics and treatment, with an emphasis on the risk to the fetus. A detailed analysis of the literature found in the PubMed and MEDLINE databases using the keywords "ovarian cancer", "ovarian malignancy", "adnexal masses", "ovarian tumor" and "pregnancy" was performed. There were no studies on a large series of pregnant women treated for ovarian malignancies and the management has not been well established. The diagnostics and therapeutic procedures need to be individualized with respect to the histopathology of the tumor, its progression, the gestational age at the time of diagnosis and the mother's decisions regarding pregnancy preservation. The multidisciplinary cooperation of specialists in perinatal medicine, gynecological oncology, chemotherapy, neonatology and psychology seems crucial in order to obtain the best possible maternal and neonatal outcomes.

Extraovarian dysgerminoma in a pregnant woman: an extremely rare finding

Extraovarian germ cell tumors are very rare and their occurrence during pregnancy is exceptional. In this case report an abdominal mass was shown by ultrasonography, during a routine monitoring of a 26-year-old pregnant woman. The patient was left under radiological control in the following months in order to bring the pregnancy to term. A few months after the delivery, the patient underwent surgery and a diagnosis of extraovarian (abdominal) dysgerminoma was made. To the best of our knowledge, there are only 3 other case reports describing an extra-gonadal dysgerminoma occurring during pregnancy. The aim of this study was to report an extremely rare tumor, whose management can be challenging first because this neoplasm has some differences from its ovarian and testicular counterparts. Furthermore, the occurrence during pregnancy makes the multidisciplinary approach mandatory since 3 distinct but not independent entities are involved (tumor, mother and fetus).

Borderline ovarian tumors in pregnancy

Borderline ovarian tumors (BOTs) are common in women in their reproductive years. In more than one-third of patients tumors are detected at the age of 15–29, the average age at initial diagnosis is 40. The study was aimed to improve methods for BOTs diagnosis in pregnancy and to determine the possibilities of organ preservation treatment. A group of 300 pregnant women with various tumor-like formations and ovarian tumors was examined. Of them, 25 patients had borderline epithelial tumors (22 patients had serous and 3 patients had mucinous tumors). Ultrasound examination together with blood serum CА-125, sFas, VEGF and IL6 level assessment were performed prior to surgery. The results obtained were compared with the results of morphological studies. Organ preservation and radical surgical treatment were carried out, and chemotherapy, if necessary. Perinatal outcomes were studied when performing the cross-comparison. It was discovered, that ultrasonography and logistic regression analysis made it possible to distinguish between benign ovarian tumors, BOTs and malignant ovarian tumors. The levels of VEGF above the 500 pg/ml, IL6 above the 8.1 pg/ml and CА-125 above the 300 U/ml indicated the high probability of malignant ovarian tumors in pregnant women. Only the morphological study of ovarian tissue, obtained regardless of surgical methods, ensured understanding of the ovarian tumor’s true nature during pregnancy. At the same time, in three pregnant women with ovarian tumors, the morphological examination revealed some tissue areas common both for BOTs and malignant ovarian tumors. Thus, the predominance of the tumor early stages, relatively mild course and, favorable prognosis in patients with BOTs make it possible to use gentle surgical treatment making it possible to preserve menstrual function and fertility.

Adnexal masses in pregnancy: an updated review on diagnosis and treatment

Adnexal masses are not common in pregnancy. They are often discovered incidentally during routine ultrasound examinations. In general, 24%-40% of the cases are benign tumors; up to 8% are malignant tumors. Adnexal masses are usually asymptomatic, but sometimes can be responsible for abdominal or pelvic pain. Transvaginal and transabdominal ultrasound is essential to define the morphology of pelvic masses and to distinguish between benign and malignant cases. Magnetic resonance imaging can be a complementary examination when ultrasound findings are equivocal and a useful additional examination to better define tissue planes and relations with other organs. Patient counseling can be challenging because there is no clear consensus on the management of adnexal masses during pregnancy. Treatment options consist of observational management (in case of asymptomatic women with reassuring instrumental findings) or surgery (via laparoscopy or laparotomy). Surgery can be offered as a primary tool when cancer is suspected or when acute complications such as ovarian torsion occur.

Pregnancy and Cancer: the INCIP Project

PURPOSE OF REVIEW

Cancer diagnosis in young pregnant women challenges oncological decision-making. The International Network on Cancer, Infertility and Pregnancy (INCIP) aims to build on clinical recommendations based on worldwide collaborative research.

RECENT FINDINGS

A pregnancy may complicate diagnostic and therapeutic oncological options, as the unborn child must be protected from potentially hazardous exposures. Pregnant patients should as much as possible be treated as non-pregnant patients, in order to preserve maternal prognosis. Some approaches need adaptations when compared with standard treatment for fetal reasons. Depending on the gestational age, surgery, radiotherapy, and chemotherapy are possible during pregnancy. A multidisciplinary approach is the best guarantee for experience-driven decisions. A setting with a high-risk obstetrical unit is strongly advised to safeguard fetal growth and health. Research wise, the INCIP invests in clinical follow-up of children, as cardiac function, neurodevelopment, cancer occurrence, and fertility theoretically may be affected. Furthermore, parental psychological coping strategies, (epi)genetic alterations, and pathophysiological placental changes secondary to cancer (treatment) are topics of ongoing research. Further international research is needed to provide patients diagnosed with cancer during pregnancy with the best individualized management plan to optimize obstetrical and oncological care.

A rare case of paratubal cystadenoma during pregnancy

Paratubal cysts (PTCs) are generally incidentally detected in pregnancy. However, paratubal cystadenomas in pregnant women are very rare cases who are reported individually. An unusually giant case of paratubal cystadenoma in a pregnant woman is presented here. A 27-year-old woman presented to our department for a routine pregnancy checkup. A giant cystic mass accompanying a 17-week gestation was detected on examination. During laparotomy, a huge right-sided PTC was resected. Histopathological evaluation revealed a benign cystadenoma originating in the ipsilateral paratubal space. PTCs are often denoted as being benign. Neoplastic transformation or malign potential will change the course of follow-up and the patients' prognosis. Treatment with surgical excision in the second trimester can safely prevent such associated adverse conditions. In conclusion, gynecologists should be careful for causes of adnexal masses in a woman with an intrauterine pregnancy. PTCs also tend to show accelerated growth patterns during pregnancy.

Rare causes of acute abdomen in pregnancy: “ultrasound to the rescue”. A review of two cases

Acute abdomen in pregnancy poses special challenge to the pregnant woman, her unborn infant, and the attending physician. The problems are multifactorial, as the physiological changes in pregnancy mask some of the clinical signs that can be elicited in making accurate diagnosis. Some diagnostic modalities are not feasible in pregnancy because of their effects on the fetus. Another dilemma is that two lives are at stake. It becomes even more challenging when one is faced with rare causes. For these reasons, the choice of diagnostic modality becomes critical. The chosen diagnostic modality should not only be readily available, non-invasive, least hazardous to the mother and fetus, but should also provide adequate information to enable accurate diagnosis. Ultrasonography provides such an opportunity and should be utilized whenever the need arises. We present two cases of acute abdomen in pregnancy managed at Abubakar Tafawa Balewa University Teaching Hospital: one was seen in the third trimester and the other in the first trimester, each with its peculiar presentation. The review is meant to alert obstetricians on the critical role of ultrasound in enhancing accurate diagnosis in the face of a complex clinical condition like acute abdomen in pregnancy.

Management of gynecological cancers during pregnancy

The diagnosis of a gynecological malignancy during pregnancy is rare but not uncommon. Cancer treatment during pregnancy is possible, but both maternal and fetal interests need to be respected. Different treatment plans may be justifiable and multidisciplinary treatment is advised. Clinical trials are virtually impossible, and current evidence is mainly based on small case series and expert opinion. Individualization of treatment is necessary and based on tumor type, stage, and gestational age at time of diagnosis. Termination of pregnancy is not necessary in most cases. Surgery and chemotherapy (second trimester and onwards) are possible types of treatment during pregnancy. Radiotherapy of the pelvic area is not compatible with an ongoing pregnancy. This article discusses the current recommendations for the management of gynecological malignancies (cervical, ovarian, and vulvar cancers) during pregnancy.

Evaluation of the Diagnostic Accuracy of Serum D-Dimer Levels in Pregnant Women with Adnexal Torsion

We aimed to evaluate the diagnostic accuracy of serum D-dimer levels in pregnant women with adnexal torsion (AT). The pregnant women with ovarian cysts who suffered from pelvic pain were divided into two groups; the first group consisted of the cases with surgically proven as AT (n = 17) and the second group consisted of the cases whose pain were resolved in the course of follow-up period without required surgery (n = 34). The clinical characteristics and serum D-dimer levels were compared between the groups. Patients with AT had a higher rate of elevated serum white blood cell (WBC) count (57% vs. 16%, p = 0.04) and serum D-dimer levels (77% vs. 21%, p < 0.01) on admission in the study group than in the control group. Elevated D-dimer and cyst diameter larger than 5 cm yielded highest sensitivity (82% for each); whereas the presence of nausea and vomiting and elevated CRP had the highest specificity (85% and 88%, respectively). This is the first study that evaluates the serum D-dimer levels in humans in the diagnosis of AT, and our findings supported the use of D-dimer for the early diagnosis of AT in pregnant women.

Decidualized endometrioma masquerading as ovarian cancer in pregnancy

OBJECTIVES

To identify the sonographic features of decidualized endometriomas in patients treated at a single institution and to determine whether sonographic findings can distinguish these lesions from malignant ovarian tumors during pregnancy.

METHODS

We conducted a retrospective cohort study that included pregnant women with a histologic diagnosis of decidualized endometrioma between January 1, 2005, and December 1, 2012, and had an ovarian cyst or mass seen preoperatively on obstetrical sonography. Sonographic characteristics of these masses were retrospectively evaluated using the International Ovarian Tumor Analysis Group definitions for adnexal masses.

RESULTS

Seventeen patients with 22 adnexal masses were included in our study. Nine of 22 lesions (41%) were classified as unilocular solid, and 14 of 22 (64%) had solid components, of which 12 of 14 (86%) had substantial blood flow. Septations were present in 8 of 22 masses (36%). Cyst sizes varied from 30 to 120 and 32 to 270 mm at the initial and follow-up scans, respectively. Eight patients had no follow-up scans and underwent surgery within 3 weeks of diagnosis. The other 9 patients (14 masses), had follow-up scans and underwent surgery from 3 to 34 weeks after their initial scans. Eight of these masses showed no notable change in size or appearance, and 1 became smaller.

CONCLUSIONS

There were no characteristic sonographic features identified to distinguish decidualized endometrioma from ovarian malignancy. However, lesions showing no change in size over 4 weeks or lacking solid components and vascularity are more likely to be benign rather than malignant and may justify delaying surgery until delivery or postpartum.

Cancer treatment in pregnant women

In general, strategies for the treatment of cancer in pregnancy should not differ significantly from the treatment regimens in non-pregnant women. However, this is difficult due to either the effects of anticancer drugs on the developing foetus or the possibility of long-term complications after the exposure to drugs and radiation. The decision about the introduction and continuation of treatment in the event of pregnancy should be preceded by a detailed analysis of the potential benefits and risks. There are no data to suggest that pregnancy termination alters the biological behaviour of the tumour or patient prognosis in the presence of appropriate antineoplastic therapy. All patients should be given appropriate advice and informed that there are insufficient scientific data to determine any generally accepted consensus. It is very important to always respect the will of the patient, and the moral judgment of the physician should have no impact on the decisions taken by the woman. If the woman decides to undergo active treatment and maintain her pregnancy, it is necessary to carry out consultations with experts in the field appropriate to the type of cancer. This paper presents a basic review of the literature on the targeted therapies currently used in selected cancers diagnosed during pregnancy: breast cancer, cervical cancer, Hodgkin's disease, melanoma, thyroid cancer, ovarian cancer, and colorectal cancer.

Management of adnexal masses in pregnancy: our experience from a tertiary referral perinatal centre in South India

PURPOSE

Adnexal masses in pregnancy are often incidentally detected during sonography and most resolve spontaneously by early second trimester. This study aimed to look at the prevalence and management of adnexal masses in pregnancy at a tertiary care referral perinatal hospital.

METHODS

This is a retrospective study of all women with adnexal masses (excluding ectopic gestations and non-gynaecological lesions) identified pre-pregnancy or during pregnancy (antepartum/intrapartum) from January 2006 to August 2013 at the study institute.

RESULTS

The study identified 252 women (0.6, 95 %, CI: 0.5, 0.7) with adnexal masses and mean (SD range) age of 27.1 (4.21, 18-39) years. Majority (80 %) of the masses were diagnosed incidentally. 170 (67.5 %) women were offered conservative management and cysts resolved in half of them. 87 (34.5 %) women had adnexal surgery and 15.1 % were operated during the antepartum period because of persistent abdominal pain or suspicious sonographic findings. Three (1.2 %) malignancies and five (2.0 %) borderline ovarian tumours were diagnosed on histopathological examination. 16 (6.3 %) women were lost to follow-up antenatally. Pregnancy carried to term in 175 (69.4 %) women. Perinatal mortality rate was 31.1/1,000 total births (caused by prematurity). Complications encountered were torsion (7.1 %), malignancy (1.2 %), rupture (0.4 %) and infection (0.4 %).

CONCLUSION

Although conservative management was appropriate in the majority of cases, the study identifies the need to standardize diagnosis, investigations and management for a better evaluation of outcomes.

Gynecologic malignancy in pregnancy

Gynecologic malignancy during pregnancy is a stressful problem. For the diagnosis and treatment of malignancy during pregnancy, a multidisciplinary approach is needed. Patients should be advised about the benefits and risk of treatment. When selecting a treatment for malignancy during pregnancy, the physiologic changes that occur with the pregnancy should be considered. Various diagnostic procedures that do not harm the fetus can be used. Laparoscopic surgery or laparotomy may be safely performed. The staging approach and treatment should be standard. Systemic chemotherapy during the first trimester should be delayed if possible. Radiation therapy should preferably start postpartum. Although delivery should be delayed preferably until after 35 weeks of gestation, termination of pregnancy may be considered when immediate treatment is required. Subsequent pregnancies do not increase the risk of malignancy recurrence.

Surgical intervention for adnexal masses during pregnancy

We aimed to evaluate the influence of surgical intervention on gestational and neonatal outcomes in women who underwent elective surgery in the second trimester of gestation because of an adnexal mass. We retrospectively reviewed the hospital records of women who underwent elective surgery for adnexal masses in the second trimester of gestation between 2006 and 2012. The ages of the women ranged between 17 and 33 years. Eight women underwent a laparotomy, and one woman, who aborted on the day of the operation, underwent a laparoscopy. Dermoid cysts, cystadenoma and borderline ovarian tumours were present in four, two and two of the women, respectively. Eight women had no complications after surgery and delivered healthy newborns at term. We concluded that elective surgery on an adnexal mass in the second trimester of gestation is safe for both the mother and the fetus.

Squamous cell carcinoma arising in an ovarian mature cystic teratoma complicating pregnancy

Mature cystic teratomas of the ovary (MCT) are usually observed in women of reproductive age with the most dreadful complication being malignant transformation which occurs in approximately 1% to 3% of MCTs. In this case report, we present a patient with squamous cell carcinoma which developed from a MCT during pregnancy. The patient was treated conservatively without adjuvant chemotherapy and was followed without evidence of disease for more than 60 months using conventional tools as well as positron emission tomography-computed tomography following the initial surgery. We report this case along with the review of literature.

Transvaginal ovarian cystectomy for adnexal torsion during pregnancy

Ovarian torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of ovarian torsion that was managed by transvaginal ovarian cystectomy in a 27 week gravid patient.

Adnexal masses in pregnancy

Adnexal masses are often seen in the gravid patient. With current advances in technology, an increased number of adnexal masses are incidentally discovered on antenatal screening ultrasonography examinations. Sonography is the first-line imaging modality for any adnexal mass. However, further evaluation with magnetic resonance imaging (MRI) may be critical for diagnosis. For example, MRI can determine whether a mass contains fat, which can be useful in the diagnosis of a teratoma. Characteristic features of nonneoplastic and neoplastic ovarian lesions seen on sonography and MRI will be discussed. Radiologic features that help distinguish benign from malignant neoplasms will be described. Additional lesions specific to the gravid state must be considered in the differential diagnosis when appropriate, such as hyperstimulated ovaries, hyperreactio luteinalis, theca lutein cyst, and luteomas.

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.

Acute abdomen caused by adnexal torsion in the first trimester of pregnancy: a case report

INTRODUCTION

Adnexal torsion is a rare cause of acute abdominal pain during pregnancy. The clinical and laboratory findings are non-specific. In this paper we present a case of adnexal torsion in the first trimester of pregnancy.

CASE OUTLINE

On admission, the patient presented signs of acute abdomen.The pain started few hours prior to admission, and was predominantly localized, occasionally irradiating to the central parts of the lower abdomen, accompanied by nausea and vomiting. Ultrasound revealed viable intrauterine pregnancy and right adnexal mass with small amount of free fluid in the Douglas pouch. After short preoperative evaluation, laparotomy and adnexectomy were performed. Surgery and postoperative followup were uneventful, and histopathology reported torquated corpus luteum cysts.

CONCLUSION

The diagnosis of adnexal torsion during pregnancy is difficult, and occasionally remains a diagnostic dilemma. Surgery is inevitable, must be prompt, and comprises adnexectomy.

Ovarian endometroid adenocarcinoma in pregnancy

Background. Ovarian cancer is very rare in pregnancy. It is mainly of epithelial origin, low grade and low malignant potential. Case report. We presented a patient in which ultrasound confirmed the presence of clearly limited tumor in the left ovary when she was eight weeks pregnant. The results of 4D Color Doppler showed a central type of tumor vascularisation with resistance index (IR) less than 0.5. The Consultancy Board in Gynecology of the Institute for Oncology and Radiology of Serbia decided to remove the patient's left adnexa and intensively monitor the pregnancy period. The operation (Adnexectomia lateralis sinistra) was performed at 18th week of gestation. Histopathological analysis showed adenocarcinoma invasivum, endometroid well-differentiated type (histological grade I, nuclear grade 2). In 37th week of gestation, the patient gave birth to a male child by cesarean section. In the next 3 years the patient had no subjective interference, laboratory tests and ultrasonographic findings were normal. Conclusion. Ovarian cancer in pregnancy is usually asymptomatic and diagnosed during routine clinical and ultrasound examination. The color Doppler technique have particular importance in the diagnosis of pathological blood supply in tumors and in indication of malignant ovarian mass.

[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.

Adnexal torsion during pregnancy: report of four cases and review of the literature

Adnexal torsion is a rare cause of acute abdominal pain during pregnancy. It is frequently associated with ovarian stimulation for in vitro fertilization (IVF) or with ovarian masses, mainly of functional origin. The clinical, laboratory and imaging findings are non-specific. The authors present four cases with adnexal torsion diagnosed during the first trimester of pregnancy. The clinical picture, the mode of diagnosis, and the therapeutic approach are discussed. In two cases, the adnexa was removed, because there was extensive hemorrhage and ischemia. In the other two cases, unwinding of the adnexa was carried out and the ovary was preserved. The diagnosis of adnexal torsion is difficult, especially during pregnancy, and occasionally remains a diagnostic dilemma. It necessitates a prompt surgical intervention, because any delay leads to irreversible ovarian necrosis, so that adnexectomy is ultimately required.

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.

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.