Managing Ovarian Masses During Pregnancy

Practical Tips for Reporting Adnexal Lesions Using O-RADS MRI

The Ovarian-Adnexal Reporting and Data System (O-RADS) MRI risk stratification system provides a standardized lexicon and evidence-based risk score for evaluation of adnexal lesions. The goals of the lexicon and risk score are to improve report quality and communication between radiologists and clinicians, reduce variability in the reporting language, and optimize management of adnexal lesions. The O-RADS MRI risk score is based on the presence or absence of specific imaging features, including the lipid content, enhancing solid tissue, number of loculi, and fluid type. The probability of malignancy ranges from less than 0.5% when there are benign features to approximately 90% when there is solid tissue with a high-risk time-intensity curve. This information can aid in optimizing management of patients with adnexal lesions. The authors present an algorithmic approach to the O-RADS MRI risk stratification system and highlight key teaching points and common pitfalls. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

The safety and effectiveness of elective laparoscopic surgery for benign ovarian cysts during pregnancy-Comparison with emergency surgery

AIM

Relatively small benign ovarian cysts are conservatively managed in early pregnancy. However, emergency surgery is required should acute abdomen occur. Our study aimed to examine and compare the outcomes of benign ovarian cysts treated with elective laparoscopic surgery or emergency surgery during pregnancy.

METHODS

From 2004 to 2017, we treated 135 pregnant patients (110 elective and 25 emergencies) with benign ovarian cysts at our tertiary perinatal center and compared their surgical and perinatal outcomes.

RESULTS

There was no significant difference in cyst diameter (7.6 ± 2.5 vs. 6.8 ± 2.1 cm), but cysts <6 cm were significantly more common in emergency (36%) than in elective (15%) cases. Mature teratomas were significantly more common in elective cases (89% vs. 52%) but corpus luteum cysts were more common in emergency cases (0% vs. 32%). The rates of laparoscopic surgery (98.2% vs. 52.0%) and ovarian conservation (99.1% vs. 80.0%) were significantly higher, and post-surgical hospitalization (4.6 ± 1.3 vs. 9.8 ± 10.5 days) was significantly shorter in elective than in emergency cases. There was no significant difference in the gestational age for delivery (38.9 ± 1.9 vs. 38.4 ± 2.7 weeks), preterm birth rate (12% vs. 20%), or birth weight (2939 ± 469 vs. 3019 ± 510 g).

CONCLUSIONS

We cannot state that an emergency surgery during pregnancy is rarely required for small benign ovarian cysts. However, the surgical outcomes were significantly better for elective than for emergency surgery, with no difference in perinatal outcomes. If a benign ovarian cyst is found early in pregnancy, elective laparoscopic surgery may be considered with adequate informed consent.

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.

Age‐dependent phenotypes of ovarian endometriomas

Purpose

To analyze the characteristics of the ovarian endometrioma (OE) across the life span of a woman. In the past, the OE has traditionally been viewed as a single, monolithic disease. Today, there are emerging data indicating that OE phenotypes differ according to the age of the woman.

Method

A narrative review of original articles on OE indexed by PubMed.

Results

When appearing in infancy and early adolescence, OE may be the consequence of endometrial cells retrogradely shed with neonatal uterine bleeding. The post‐menarcheal variant, manifesting itself during full adolescence, is singularly frequent in the presence of vaginal or uterine outflow obstructive anomalies. The typical and most frequent adult phenotype is characterized by increasing fibrosis and a tendency to progress; its mere presence exerts a detrimental effect on the surrounding healthy ovarian tissue. In postmenopause, an old lesion may be reactivated in the presence of exogenous or endogenous estrogens, or even be produced ex novo; rarely, it can spread to a variety of organs and structures and even degenerate causing malignancies.

Conclusions

Given the existence of these variants, it is important to agree on management guidelines that take into consideration these different phenotypes.

Traditionally, ovarian endometriomas are considered rightfully as one subtype of endometriosis that is different from other subtypes. Beyond that, it is considered as a monolithic disease entity. In this review, we synthesized published data and argue that this subtype actually has age‐dependent phenotypes, and as such, management should be ideally tailored to achieve the best results.

World Federation for Ultrasound in Medicine Review Paper: Incidental Findings during Obstetrical Ultrasound

Although the prevalence of incidental findings revealed during an obstetric ultrasound examination is low, the findings may include adnexal and cervical masses, uterine or urinary congenital malformations, free fluid in the pouch of Douglas or tortuous vessels (varices). Adnexal masses are the most common finding and vary in imaging characteristics. They are mainly unilateral, cystic masses with a low risk of malignancy that are treated conservatively. The International Ovarian Tumor Analysis scoring models may be helpful in differentiating benign from malignant masses. For those masses >5 cm, follow-up is recommended, and resection could be considered to avoid risk of torsion, rupture and hemorrhage, which may compromise pregnancy outcome. Uterine masses such as fibroids are commonly diagnosed early in the first trimester and should be followed up during pregnancy to evaluate any changes. Transabdominal and transvaginal ultrasound is the first-line test for the diagnosis of such incidentalomas; however, magnetic resonance ultrasound may have a useful role in excluding malignancy potential. As a result of their low frequency and the lack of good evidence, there are no specific guidelines on the management of incidentalomas detected at obstetric scans. Their management should follow the related general guidelines for ovarian, cervical and uterine masses, with individualized management depending on the pregnancy status.

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.

Biliary cystadenoma masquerading as an adnexal cyst in pregnancy

The aetiological diagnosis of cystic masses detected on routine ultrasound during pregnancy can be challenging. Unless approached cautiously with a detailed history and adequate use of imaging techniques, misdiagnosis of these cystic masses are not uncommon. Cystic masses diagnosed during pregnancy are mostly of ovarian origin; however, other non-ovarian cystic masses are also detected incidentally or at laparotomy/laparoscopy. We report a rare case of ruptured biliary cystadenoma in a pregnant woman diagnosed at emergency laparotomy. She was taken up for surgery with a provisional impression of ruptured adnexal cyst. However, the cyst was found to be arising from the liver and the histology of the cyst wall was reported as biliary cystadenoma.

Juvenile granulosa cell tumor in pregnancy: case series and literature review

BACKGROUND

Pregnancy complicated with juvenile granulosa cell tumor (JGCT) is very rare; thus, the experience on clinical diagnosis and management is limited.

CASES

Two patients presented with abdominal pain, two were incidentally discovered, one by ultrasonography, and one during a caesarian section. One case received an emergency caesarian section because of tumor rupture at 38th week's gestation, the rest were treated at full term and no abnormalities were detected in the newborns. Three cases received further staging surgery, two of which received postoperative adjuvant chemotherapy. No patient had recurrent disease after a follow-up period spanning from 13 to 57 months.

CONCLUSION

In the absence of emergency, surgery can be delayed without affecting the fetus. More research is needed to determine the value of chemotherapy in FIGO stage I patients.

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.

Characteristics of ovarian endometrioma during pregnancy

AIM

During pregnancy, the ovarian endometrioma generally decreases in size and occasionally ruptures. We evaluated (1) whether and how ovarian-endometrioma size changes from the first trimester to the postdelivery period, and (2) the type of endometrioma more likely to rupture during pregnancy.

METHODS

During an 18-year period (2000-2018), ultrasound in the first trimester revealed ovarian endometrioma in 149 pregnant women at our tertiary institute. Among these, we subjected 138 endometriomas in 145 patients to expectant management (wait-and-watch approach during pregnancy). We compared the cyst sizes in the first trimester and the postdelivery period, and defined a >1 cm diameter size-change as a significant increase/decrease. We analyzed four patients with rupture and characterized the predictors of rupture.

RESULTS

A comparison of cyst sizes in the first trimester and the postdelivery period revealed that the size of 94 (68%), 37 (27%), and 7 ovaries (5.0%), respectively, decreased, remained unchanged, and increased; in 56 ovaries (40%), apparent cysts were no longer present. Of the 145 patients, four (2.8%) required emergency surgery for cyst rupture. Adhesion to the surroundings, an increase in cyst size, large size (diameter of ≥6 cm), and compression due to the enlarged uterus in late pregnancy were factors clinically related to rupture.

CONCLUSIONS

Approximately two-thirds of ovarian endometriomas decreased in size during pregnancy (40% disappeared), 27% remained unchanged, and only 5% increased in size. However, 2.8% of pregnant women with endometrial cysts experienced rupture. We characterized risk factors for rupture; however, clinical application requires further evaluation.

Approaches to the Diagnosis and Management of Ovarian Cancer in Pregnancy

Ovarian cancer is one of the most common gynecological cancers diagnosed in pregnancy. Its management is often very problematic due to the proximity of the adnexa to the developing fetus and chemotherapy-related toxicity risk. Tumor markers and imagining studies play important roles in diagnosis, help differentiate benign masses from malignancy and allow to plan the treatment. Due to the physiological changes that occur in pregnancy, levels of tumor markers can be altered and reduce their diagnostic value. We review current recommendations for the management and treatment of ovarian cancer in pregnant patients considering gestational age at diagnosis, tumor histology, stage of the disease, risk of obstetrical complications, and patient’s preferences.

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.

Decidualization of an ovarian endometrioma complicated by a sigmoid fistula during pregnancy: a case report

BACKGROUND

During pregnancy, the discovery of adnexal masses remains frequent. Such masses are mostly benign. Ovarian endometrioma is a rare etiology. The diagnosis may be difficult in some situations, such as decidualization. It may be asymptomatic or result in complications for which magnetic resonance imaging is needed.

CASE PRESENTATION

We describe an unusual case of decidualization of an ovarian endometrioma complicated by a sigmoid fistula during a 7-week, 1-day pregnancy in a Arabic patient aged 38 years who developed acute pelvic pain with fever. She had a medical history of unexplored secondary dysmenorrhea. The diagnosis was suspected on the basis of magnetic resonance imaging findings. The management was based on surgery, during which exploration revealed a mass at the expense of the left ovary being very adherent and fistulized to the sigmoid. We performed adnexectomy followed by digestive ostomy. The result of pathological study with immunohistochemistry led to a diagnosis of decidualization of an ovarian endometrioma altered by infection.

CONCLUSION

Decidualization of an ovarian endometrioma can lead sometimes to unexpected complications. The decision to provide surgery must be made with caution without delaying treatment in the event of a deep suspicion of malignancy and/or complication. The particular and exceptional complication discovered in our patient is the fistulization to the sigmoid.

Management of adnexal masses' torsion during pregnancy

With the increased use and quality of ultrasound in pregnancy, adnexal masses are being encountered with greater frequency. Most of the time such masses are asymptomatic. It can be discovered in an emergency. Surgical intervention may cause risks to the mother and her fetus, while observation without intervention may also lead to unfavorable complications, such as ovarian torsion or the development of a tumor. Therefore, the management requires a balance between the maternal and fetal risks. We report two cases of torsion of adnexal masses during pregnancy, and we provide a brief literature review on the management and prognosis of this condition in pregnancy.

The Case of a Serous Borderline Ovarian Tumor in a 15-Year Old Pregnant Adolescent: Sonographic Characteristics and Surgical Management

OBJECTIVE

This study aimed to describe a rare case of a serous borderline ovarian tumor (BOT) diagnosed during pregnancy in a 15-year old adolescent.

RESULTS

The suspect of BOT was raised at a transvaginal ultrasound scan in early first trimester (at 5 weeks of amenorrhea), due to the presence of a moderately vascularized irregular papilla in the context of a unilocular low-level right ovarian cyst. The patient and her parents required termination of pregnancy, irrespective of the diagnosis of an ovarian lesion. After termination of pregnancy, the patient underwent laparoscopic enucleation of the ovarian mass, omentectomy, and peritoneal biopsies. No intra-abdominal spillage of the ovarian mass occurred, and the surgical specimens were put in an endobag and extracted transvaginally. Final pathological examination confirmed the diagnosis of a serous borderline ovarian tumor. The patient of free of disease after 8 months of follow-up.

CONCLUSION

Although rare, borderline ovarian tumors can be diagnosed in an adolescent during pregnancy. The combination of specific sonographic assessment and minimally invasive conservative surgery appears as a very effective approach in this type of patient.

KEY POINTS

· BOTs can occur in pregnant adolescents.. · Transvaginal ultrasound is crucial to suspect BOT.. · Laparoscopic conservative treatment is feasible..

Cytoreductive surgery for advanced stage ovarian cancer in the second trimester of pregnancy-a case report and literature review

RATIONALE

Advanced stage ovarian cancer is rarely encountered in pregnant women, due to the high number of ultrasound imagistic studies performed during this period. The clinical course of patients diagnosed with advanced stage ovarian cancer is similar in pregnant and nonpregnant women.

PATIENT CONCERNS

We present the case of a 27-year-old woman initially submitted to emergency surgery for ovarian cyst torsion in the ninth week of gestation, at that moment ovarian cystectomy being performed.

DIAGNOSES

The histopathological studies demonstrated the presence of a moderately differentiated epithelial ovarian cancer.

INTERVENTIONS

Although the interdisciplinary team decided for staging surgery followed by platinum-based chemotherapy beginning from the second trimester of pregnancy, both the patient and her family refused this strategy and opined for total hysterectomy en bloc with bilateral adnexectomy. Surprisingly, intraoperatively both ovaries had a tumoral aspect, whereas peritoneal carcinomatosis nodules were found in the Douglas pouch. Therefore, the neoplastic process was staged as a IIIC epithelial ovarian cancer, a total hysterectomy with bilateral adnexectomy, Douglas pouch peritonectomy, omentectomy, pelvic and para-aortic lymph node dissection being performed.

OUTCOMES

The patient was discharged in the sixth postoperative day and was confined to the oncology service in order to be submitted to the standard taxanes and platinum based chemotherapy.

LESSONS

Although ovarian cancer has been rarely reported during pregnancy, this diagnostic should be taken in consideration whenever persistent adnexal masses are encountered.

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.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Pregnancy]

OBJECTIVE

To determine the place of imaging, tumour markers, type of treatment and surgical route, follow-up, delivery mode, and re-staging in case of BOT during pregnancy, in order to provide guidelines.

METHOD

A systematic bibliographical analysis on BOT during pregnancy was performed through a PUDMED search on articles published from 1990 to 2019 using keywords « borderline ovarian tumour and pregnancy ».

RESULTS

Pelvic ultrasound is the gold standard and first-line examination for the detection and characterization of adnexal masses during pregnancy (grade C). Pelvic MRI is recommended from 12 gestational weeks in case of indeterminate adnexal masses and should be concluded by a diagnostic score (grade C). Gadolinium injection should be minimized because of proven risk to the fetus and should be discussed on a case-by-case basis after patient information (grade C). In the absence of data in the literature, it is not possible to recommend the use of any tumour marker for the diagnosis of BOT during pregnancy. In case of a surgical treatment of BOT during pregnancy, there is insufficient evidence to recommend either a cystectomy or an oophorectomy. For BOT, the laparoscopic approach should be preferred during pregnancy if it is feasible (grade C). Surgical route and type of surgery should be chosen after taking into account the tumour size, the obstetrical term, and the subsequent desire for pregnancy, following discussion in a multidisciplinary meeting. In the absence of sufficient data in the literature, it is not possible to make any recommendation on the follow-up of a BOT suspected during pregnancy. There is not enough evidence in the literature to change obstetrical management for delivery in patients with BOT. In case of incomplete staging of a BOT treated during pregnancy, restaging can be discussed as for non-pregnant patients (grade C).

CONCLUSION

The diagnosis of BOT occurring during pregnancy remains rare despite systematic screening of adnexal masses in the first trimester of pregnancy and an increasing maternal age. There is limited data in the literature concerning the management of BOT during pregnancy. All decisions must be taken after discussion in a multidisciplinary meeting.

Ultrasound features and clinical outcome of patients with malignant ovarian masses diagnosed during pregnancy: experience of a gynecological oncology ultrasound center

OBJECTIVE

The number of women diagnosed with ovarian masses during pregnancy has increased in recent years and the management of these women can be controversial. We aim to describe ultrasound characteristics and clinical outcomes of patients with malignant ovarian masses diagnosed during pregnancy.

METHODS

Patients with a histological diagnosis of malignant ovarian mass detected during pregnancy who underwent pre-operative ultrasound by experienced ultrasound examiners between December 2000 and November 2017 were included in this retrospective observational study. Ultrasound characteristics of the masses were described using International Ovarian Tumor Analysis terminology. Patients with ovarian masses but without histopathological reports were excluded. Results are presented as absolute frequency (percentage) for nominal variables and as median (range) for continuous variables. Results A total of 22 patients were included in the analysis. The median age was 32.5 (range 23-42) years and median gestational age at diagnosis was 13.5 (range 4-30) weeks. Eight (36.4%) patients had a serous/endocervical-type borderline tumor, seven (31.8%) patients had a primary epithelial ovarian carcinoma, five (22.8%) patients had a metastatic tumor to the ovary, and two (9%) patients had a mucinous borderline tumor. At ultrasound, mucinous borderline tumors were multilocular (1/2, 50%) or multilocular-solid (1/2, 50%) lesions. Serous/endocervical-type borderline tumors were unilocular-solid (3/8, 37.5%) or multilocular-solid (5/8, 62.5%) masses and all had papillary projections. Most invasive epithelial ovarian cancers were multilocular-solid masses (5/7, 71.4%). All metastatic tumors appeared as solid masses. No patients with borderline tumors had a cesarean section due to disease, whereas most patients with epithelial ovarian carcinomas (4/7, 57.2%) and with ovarian metastases (3/5, 60%) had a cesarean section due to disease. No neonatal complication was reported for patients with borderline tumors or epithelial ovarian carcinomas, whereas two of three newborns of patients with metastatic tumor died of the disease.

CONCLUSION

At ultrasound, morphological features of malignant ovarian masses detected during pregnancy are similar to those described in non-pregnant patients. The likelihood of undergoing cesarean section increases with malignant disease in the ovary.

Giant Ovarian Mucinous Cystadenoma Complicating Term Pregnancy

Huge ovarian cyst are found in less than 1% of all ovarian cyst in pregnancy and are associated with poor feto-maternal outcome. A 28 years old G2P1 with history of normal vaginal delivery 3 years back was referred from local health post with complains of intermittent pain abdomen at 29 weeks. Her scan showed huge ovarian cyst of 18.9×17.6 cm with multiple thick septation. Woman was conservatively managed till term and elective surgery was planned however she presented in labour with breech presentation at 39 weeks and 4days. Emergency lower segment caesarian section along with left sided salpingo-oophorectomy was done along with delivery of 2.5 kg healthy female baby. Histopathology was suggestive of mucinous cystadenoma of ovary. Although antepartum removal of ovarian cyst has been recommended to ensure good pregnancy outcome, expectant management and timed intervention can be adopted for pregnancy with huge ovarian cysts. Keywords: mucinous cystadenoma; ovarian cyst; pregnancy.

Complex US adnexal masses during pregnancy: Is pelvic MR imaging accurate for characterization?

OBJECTIVE

To retrospectively evaluate the accuracy of pelvic magnetic resonance (MR) imaging for the characterization of complex sonographic adnexal masses discovered in women during pregnancy.

STUDY DESIGN

The study population comprised 31 pregnant women (median age: 32 years (range: 19-42); mean gestation age of 16 weeks) referred to our institution for MR imaging for characterization of an adnexal mass discovered incidentally during routine ultrasound (US) for other indications. The population comprised of 31 women, with 36 adnexal lesions (mean size: 103mm [range: 20-290]), of which 27 were benign and 9 were malignant masses. Prospective US and MR reports were reviewed to determine the presence of a benign or malignant lesion. Two radiologists (R1 and R2) blinded to the final outcome, retrospectively evaluated the MR images using the criteria based on the A_DNEXMR-S_CORE and classified the lesion as benign or malignant. The reference standard was surgical pathology or at least a 1-year imaging follow-up.

RESULTS

Prospective US and MR imaging correctly identified the diagnosis in 27/36 (75%) (95% confidence interval (CI): 58.9%-86.2%) and in 32/36 (88.9%) (95% CI: 74.6%-95.6%) of lesions, respectively. MR imaging with A_DNEXMR-S_CORE allowed a correct diagnosis in 32/36 (88.9%) (95% CI: 74.6%-95.6%) of lesions for R1 and in 30/36 (83.3%) (95% CI: 68.1%-92.1%) of lesions for R2. The sensitivities and specificities of MR imaging using the MR A_DNEXMR-S_CORE were 100% (95% CI: 70.1%-1000%) for both readers and 85.1% (95% CI: 67.5%-94%) and 77.7% (95% CI: 59.2%-89.4%) for R1 and R2, respectively. No malignancy was classified as benign using MR criteria. The reproducibility between the two readers was almost perfect, with a kappa of 0.914.

CONCLUSION

MR imaging is highly accurate for the characterization of complex adnexal masses incidentally discovered during pregnancy.

CLINICAL RELEVANCE

MR imaging can accurately characterize adnexal masses in pregnancy and could be useful in opting for expectant management until delivery.

Ovarian cancer in pregnancy

Although the occurrence of ovarian masses in pregnancy is relatively common, the majority of them is functional and resolve spontaneously; nevertheless, ovarian cancer is the fifth most common malignancy diagnosed in pregnancy. If malignancy is suspected, treatment should be decided on the basis of gestational age, stage of the disease and patient preferences. In early stage, ovarian cancer surgery may be planned preferably after 16 weeks of pregnancy, and chemotherapy can be administered from the second trimester if indicated as in non-pregnant patients. In advanced-stage disease, when complete cytoreduction is not achievable, neoadjuvant chemotherapy could be administered even in pregnancy. Chemotherapy should be a combination of carboplatin and paclitaxel in epithelial ovarian cancer patients and a combination of cisplatin, vinblastin and bleomycin in non-epithelial ovarian cancer. The outcome of patients with ovarian cancer diagnosed in pregnancy is similar to non-pregnant patients, and stage of the disease is the most important prognostic factor.

A huge ovarian mucinous cystadenoma causing virilization, preterm labor, and persistent supine hypotensive syndrome during pregnancy

Mucinous cystadenoma (MC) of the ovary is an unilateral, multilocular cystic benign epithelial tumor. Supposed to be hormone responsive, MC reaches huge sizes during pregnancy. Aortocaval compression is common during pregnancy, especially when the pregnant woman is in the supine position. However, the compression recovers with a change in position. The authors report the first case of a huge mucinous cystadenoma of the ovary complicating pregnancy and causing virilization, premature labor, and persistent supine hypotensive syndrome.

Comparison of Adnexal Mass in Women Undergoing Mass Excision During the Antepartum Period and Cesarean Section

OBJECTIVES

The frequency of adnexal masses in pregnant women ranges from 0.1% to 4%. Selecting the right approach to manage the subsequent intervention remains one of the most controversial challenges among gynecologists. Our aim in this cross-sectional study was to clarify the clinical-pathological differences among the adnexal masses that are excised during either the antepartum period or cesarean section (CS).

METHODS

In this study, we assessed 11,000 pregnancy cases referred to the Qaem Hospital in the Mashhad University of Medical Sciences, Iran, between 2010 and 2014. In total, 53 pregnant women with adnexal masses (other than non-gynecological mass and ectopic pregnancy) were selected for further investigation. We divided patients into two groups (group A and group B). Patients of group A had a diagnosed tumor that was excised antepartum while patients in group B had a mass taken out during CS. We then assembled data based on maternal age, parity, gestational age, surgery type, delivery mode, size and location of the tumor, complications, presentations, histopathological diagnosis, and ultrasonography findings for further analysis.

RESULTS

The major proportion of masses (62.3%) were excised during CS whereas the remainder (37.7%) were removed antepartum. The mean size of the detected tumor for benign and malignant cases was 10.0 cm and 13.8 cm in group A, and 8.0 cm and 9.3 cm in group B, respectively. There was a statistically significant difference observed between patients in the two groups regarding the benign/malignant status of the mass (p = 0.008), its size (p = 0.019) and simplicity/complexity (p = 0.004).

CONCLUSIONS

The rate of malignant tumors was considerably higher in women who had antepartum mass excision compared to those with mass resection during CS. Also, tumors were larger (and more complex) in patients in group A compared to group B.

Laparoscopic surgery for treating adnexal masses during the first trimester of pregnancy

OBJECTIVE:

To evaluate the feasibility and safety of laparoscopic surgery for treating adnexal masses during the first trimester of pregnancy.

STUDY DESIGN:

An observational study of a prospective collection of data of all pregnant women who underwent laparoscopic surgery for adnexal masses during the first trimester of pregnancy between January 1999 and November 2012 at the Obstetrics and Gynecology Department of the Italian Hospital of Buenos Aires, Buenos Aires, Argentina was performed.

RESULTS:

A total of 13 women were included. The median (range) gestational age at the moment of surgical procedure was 7 weeks (range: 5-12 weeks). The main indication of surgery was cyst torsion in four cases (30.7%) and rupture of ovarian cysts in four cases (30.7%). Other indications included persistent ovarian cyst in three patients (23%) and heterotopic pregnancy in two cases (15.3%). Neither surgical complications nor spontaneous abortions occurred in any of the cases and the post-operative period was uneventful in all the cases. No cases of intrauterine growth retardation, preterm delivery, congenital defects, or neonatal complications were registered.

CONCLUSION:

The treatment of complicated adnexal masses by laparoscopic surgery during the first trimester of pregnancy appears to be a safe procedure both for the mother and for the foetus. Additional research on a larger number of cases is still needed to support these conclusions.

Minimally Invasive Management of Ovarian Cysts During Pregnancy Using Ethanol Sclerosis

Traditionally, the management of symptomatic ovarian cysts in pregnancy has been limited to laparoscopy or laparotomy with the associated morbidity. However, in select patients requiring intervention, the risks of surgery may be minimized with sclerotherapy. We present the first case report, to our knowledge, of ethanol sclerosis of an ovarian cyst during pregnancy. A description of the surgical technique to complete such a procedure is provided as well as a brief review of the current literature with respect to the use of sclerotherapy for the management of ovarian cysts.

Cancer and pregnancy: an overview for obstetricians and gynecologists

A relatively rare occurrence, pregnancy-associated cancer affects approximately 1 in 1000 pregnancies. Optimizing treatment of the cancer and minimizing harm to the fetus are often dependent on the extent of disease, treatment options required, and the impact on the pregnancy as well as the gestational age of pregnancy. When malignancy is diagnosed, the obstetrician-gynecologist plays a key role in the diagnosis, initial evaluation, and coordination of patient care. Furthermore, the obstetrician-gynecologist may be asked to assist in fertility planning for young women with a new diagnosis of cancer and may be responsible for addressing questions about family-planning needs and the safety of future pregnancy. Therefore, the purpose of this article was to provide the obstetrician-gynecologist with a relevant overview of the current literature regarding concurrent pregnancy and cancer diagnoses, management options, including maternal and neonatal outcomes, as well as the future needs of young women diagnosed with cancer who desire fertility preservation.

Diagnosis of emergencies/urgencies in gynecology and during the first trimester of pregnancy

Several surgical and/or medical emergencies/urgencies may occur in gynecologic patients and in pregnant women during the first trimester. Particularly, ectopic pregnancies, ruptured or hemorrhagic ovarian cysts, ovarian or adnexal torsions, threatened or inevitable miscarriages, phlogistic gynecological disorders, complications involving the uterine fibroids, endometriosis, and spontaneous uterine rupture are possible acute complications. The diagnosis is suspected on the basis of symptoms (acute pelvic and/or abdominal pain, with or without vaginal bleeding or discharge, until acute abdomen with peritonitis), by means physical evaluation (abdominal, pelvic, and bimanual gynecological examinations), by means of transabdominal (TAS) and/or transvaginal (TVS) sonography, and laboratory tests. However, the diagnosis is often not that simple, especially when the symptoms and clinical signs are minimal, and ultrasound (US) examination is not diriment. The differential diagnosis of abdominal/pelvic pain is broad and includes primarily gastrointestinal and urogenital disorders. Generally, TAS should usually be used in conjunction with TVS for evaluation of the female pelvis. If the US examination is not conclusive, CT or MRI, especially in pregnant patients, should be considered.

Heterotopic pregnancy following IVF-ET: successful treatment with salpingostomy under spinal anesthesia and continuation of intrauterine twin pregnancy

The extended use of assisted reproductive technologies is increasing the heterotopic pregnancies, leading to a potentially dangerous condition for the intrauterine pregnancy and the mother. We report a case of unruptured heterotopic pregnancy following IVF-ET at 6 weeks of gestation and the patient was treated with salpingostomy under spinal anesthesia. The intrauterine twin pregnancy course was uneventful with the delivery of healthy babies at 34th week by Cesarean section.

Management and outcome of ovarian malignancy complicating pregnancy: an analysis of 41 cases and review of the literature

OBJECTIVE

The aims of this study are to summarize our experience of managing ovarian malignancy complicating pregnancy, to discuss the maternal and fetal outcomes, and to review the literature concerned.

METHODS

Forty-one patients with ovarian malignancies complicating pregnancy at Peking Union Medical College Hospital between 1990 and 2012 were retrospectively reviewed.

RESULTS

Of the 41 patients, malignancies included epithelial ovarian cancers (13/41, 31.7 %), epithelial borderline ovarian tumors (12/41, 29.3 %), ovarian malignant germ cell tumors (10/41, 24.4 %), sexcord stromal tumors (3/41, 7.3 %), metastatic ovarian tumors (2/41, 4.9 %), and primary ovarian choriocarcinoma (1/41, 2.4 %). The median overall survival was 30 months (range 3-165), with an overall mortality rate of 24.4 %. The pregnancy outcomes included termination in the first trimester (8/41, 19.5 %), full-term vaginal delivery (7/41, 17.0 %), full-term cesarean section (17/41, 41.5 %), and therapeutic cesarean section for premature birth (9/41, 22.0 %). One preterm newborn died, and the remaining 32 survived in healthy status. All patients underwent surgery, and those who deliberately delayed radical surgery had gloomy prognosis. Two patients received chemotherapy during pregnancy, and 24 patients started chemotherapy after pregnancy termination.

CONCLUSIONS

Management priority should be given to the malignancy of ovarian tumors at any stage of pregnancy. Surgical intervention is the main treatment modality, and delaying of radical surgery is not recommended for patients with suspicion of high malignancy. Early diagnosis and appropriate treatment could offer satisfactory prognosis.

Cystically degenerated leiomyoma of the rectosigmoid managed laparoscopically at 13 weeks of gestation

The safety of laparoscopic management of adnexal masses in pregnancy has been documented. Herein we report laparoscopic removal during pregnancy of a cystically degenerated leiomyoma of the sigmoid colon, which had been mistaken for an adnexal mass. When smooth muscle gastrointestinal tumors are observed, it is important that they be characterized with appropriate markers so that postoperative treatment can be individualized to the patient.

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.

Acute abdomen due to ovarian congestion: a fallopian tube accompanied by a paratubal cyst, coiling tightly round the ovary

We experienced an unreported rare case with an adnexal mass causing severe acute abdomen during pregnancy. A 30-year-old Japanese pregnant woman was transported to our hospital for her right lower abdominal pain at 30 weeks of gestation. Magnetic resonance imaging and ultrasound demonstrated a cyst measuring 3-4 cm in diameter adjacent to the right ovary, and a parovarian cyst was considered to be the most probable diagnosis. We strongly suspected torsion of the ovarian pedicle or fallopian tube in conjunction with her clinical symptoms. Laparotomy revealed that the elongated right fallopian tube accompanied by a paratubal cyst was coiling tightly 2.5 times round the right ovary, causing apparent congestion and enlargement of the right ovary. Soon after we released the congested right ovary from the coiling of the fallopian tube, the congestion subsided. The postoperative course was favorable, and pregnancy and delivery were uneventful.

Largest Serous Cystadenoma in the first Trimester treated Laparoscopically: A Case Report

We report the first case of a giant serous cystadenoma approximately 7.5kg in weight in a 28-year old primigravida at 8 weeks of gestation which was successfully excised laparoscopically. Postoperatively, she had a quick recovery and she was discharged on post op day 3 with an intact pregnancy and no complications. This is the largest ovarian cyst in early pregnancy that has been ever reported from our hospital. We also believe this cyst to be the largest cyst in early pregnancy ever reported in the literature that has been managed by Laparoscopy.

Laparoscopic management of fallopian tube torsion at 35 weeks of gestation: case report

Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.

The role of 3-dimensional power Doppler imaging in the assessment of ovarian teratoma in pregnancy: a case report

Background. Conventional sonography is the primary imaging tool for these pregnant women who present with an ovarian teratoma. In some cases, however, sonography diagnosis is difficult. We report a case of ovarian teratoma during pregnancy diagnosed by three-dimensional Power Doppler. The cyst was removed via laparotomy without fetal or maternal complications. Three-dimensional ultrasound with multiplanar view can better discriminate a benign ovarian teratoma from complex ovarian lesions or malignant tumors. Its role is significant especially during pregnancy as it may assist in determining which patients are requiring surgery and which are not. The results of three-dimensional sonography and magnetic resonance (MR) were equal but the role of MR imaging is limited in early pregnancy. Conclusions. Three-dimensional technique is a reliable diagnostic modality for preoperative assessment of an ovarian teratoma as it can be performed during the first trimester of pregnancy.