Management of adenxal mass during pregnancy

1. Management of
adenxal mass during
pregnancy
Prof. Aboubakr
Elnashar
Benha University Hospital,
Egypt
elnashar53@hotmail.com
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2. Adnexa: appendages of an organ
Adnexal mass: lump in tissue near the
uterus, usually in the ovary or fallopian tube
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3. Contents
Incidence
Causes
Characters
Diagnosis
Management
Conclusion
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4. Incidence
Increase detection rate
Routine U/S in early pregnancy:
4%
At CS: 0.5%
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5. Causes
I. Ovarian
1. Simple cyst
2. Haemorrhagic cyst
3. OHSS
4. Endometrioma
5. Luteoma
6. Brenner tumour
7. Epithelial tumours:
Serous and mucinous
Endometrioid
Clear-cell carcinomas ABOUBAKR ELNASHAR

6. 8. Germ cell tumours:
Mature and immature teratomas
Dysgerminomas
Endodermal sinus tumours
Embryonal carcinomas
9. Sex cord-stromal tumours:
Fibrothecomas
Granulosa cell
Sclerosing stromal
Sertoli-Leydig cell tumours
10. Metastatic tumours:
Krukenberg
Lymphoma
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7. II.Tubal
Hydrosalpinx
Heterotopic pregnancy
IV. Paratubal cyst
III. Fibroid
Pedunculated or located in the broad lig
IV. Non-gynaecological
Mesenteric cyst
Appendix mass
Diverticular disease
Pelvic kidney
Urachal cyst
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8. 3 Characters
1. Nearly all are benign
Ovarian cancer:
0.004–0.04%.
Most are borderline with a low malignant potential
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9. 2. High possibility of regression
-Ovarian cysts:
Most are undetectable at 14 w (mostly C.Luteum)
Simple (<5 cm), hemorrhagic, OHSS: 90-100%
-Ovarian mass:< 6cm: 95%
>6cm: 60%
-Persistent: 75% are complex
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10. 3. Complications
Depend on size, gest age
1. Rupture
2. Haemorrhage
3. Torsion (up to 5%)
4. Obstructed labour
5. Fetal malpresentation
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11. Diagnosis
1. Bimanual examination
2. US
3. MRI
4. Color Doppler
5. CT
6. Tumor markers
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12. 1. Bimanual examination:
detected if it is at least 5 cm
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13. 2.US:
• Abd &TV
• Diagnostic in most cases (> 90%)
• Types:
I. Simple cyst
II. Low level echo cyst
III. Complex cyst
IV. Solid
•Complex (Solid–cystic): more likely to be malignant.
Purely solid or purely cystic: more likely to be benign.
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14. ovary
uterus
Unilocular, thin-walled, anechoic
I. Simple ovarian Cyst
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15. Unilocular
Thin-walled
 Anechoic
Follicular cyst ABOUBAKR ELNASHAR

16. Simple cysts
Corpus luteal or follicular cyst
Haemorrhagic cysts
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17. Massively enlarged
ovaries
Thin-walled septation
Ascites may be present
OHSS
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18. Hydrosalpinx
Tubular-shaped
structure
Anechoic content
Incomplete
septum
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19. II. Low-level echo cysts
Endometrioma 95%
Hemorrhagic cyst 50%
Teratoma 18%
Malignant Neoplasm 12%
Patel et al (Radiology. 1999;210:739-745.)
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20. Anechoic with lacelike internal
echoes within cyst
HemorrhagicC.
Corpus Luteum
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21. Low-level echo cysts + Characteristic
Features
Endometrioma
Hyperechoic wall foci (in 35%)
Hemorrhagic cyst :
Lacelike internal echoes (in 40%)
Teratoma
Regional bright echoes ( in 97% )
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22. Diffuse ‘ground glass’ pattern due to
presence of old bloodEndometrioma
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23. 1-Dermoid Cyst
The commonest 36%
2-Endometriotic cyst 5%
3-Malignant Cyst 1-3%
III. Complex cyst
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24. Dermoid
Complex mass solid
and cystic ( fat, bone)
Fill in Pattern
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25. Malignant cyst
• Wall thickening
• Wall nodularity
• Septations > 3 mm
• Papillary projections
• Solid component:
the most significant predictor of
malignancy
• Ascites:
positive predictive value of 95% for
malignancy (Brown et al , 1998)
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26. U/S echogenic mural nodule in cystic
mass.
Papillary serous Cystadenom
Few small papillae
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27. Mucinous
Cystadenocarcinoma
Solid areas Many
papillary. P
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28. IV. Solid Adnexal Masses
•Subserous Fibroid
Luteoma of pregnancy
Ovarian Fibroma
Dysgerminoma
Gonadal stromal tumors
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29. At 16 weeks' gestation with R
adnexal solid mass Leiomyoma
or ovarian mass.
A
B
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30. 3. MRI:
Indications:
Suspicious
Poorly visualized
Inadequately localized
Disadvantages:
More expensive
More time consuming than US
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31. • Advantages:
1. Safely used in pregnancy {lack of ionising
radiation compared with CT}.
2. Good at defining endometriotic& dermoid
cysts
3. Superior resolution when compared with CT
4. Create images in several planes
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32. MRIT1 a mass with high signal
intensity (arrow).
MRIT2: Mass arising from R Ovary with
preserved morphology.
Septate U
UOvary
MRIT1 Fat -saturated
U
Dermoid Cyst
MRI
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33. Endometrioma
T2 MRI
Very low
signal
intensity
TI MRI High
signal
intensity
TI MRI
Fat -
saturated
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34. MRI: Right ovarian Mucinous cystadenoma 30 w.ABOUBAKR ELNASHAR

35. MRI Mass originating from right lateral
wall of uterus Leiomyoma
A
B
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36. 4. Colour flow Doppler
•{Malignant lesions are vascular
Benign lesions demonstrate little or no blood flow}.
Malignant lesions:
Resistance and pulsatility indices < 1
•Benign conditions (endometriomas, corpus luteal
cysts& other benign complex ovarian masses)
have the same picture
•{increased pelvic vascularity in pregnancy}: overlap of
these indices in both benign& malignant lesions:
Doppler imaging unreliable.
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37. 5. CT
Has little place in pregnancy in
modern obstetrics
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38. 6. Tumour markers
•In the non-pregnant state:
a. CA125
most reliable serum marker for epithelial ovarian carcinoma as
it is raised in over 75% of cases.
b. Serum alphafetoprotein (AFP)& beta-hCG
useful in the preoperative evaluation& management of ovarian
germ cell tumours.
c. Serum inhibin levels:
can be detected in women with granulosa cell tumours of the
ovary and mucinous carcinomas.
d. Serum lactate dehydrogenase:
Raised in ovarian dysgerminomas
{rarity of this neoplasm} data regarding this association are
sparse.
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39. During pregnancy:
a. Serum AFP, BhCG& inhibin levels:
all raised {placental synthesis}: its use is limited.
b. Serum CA125 levels:
elevated during pregnancy {decidual cell production, with
levels rising as pregnancy progresses}.
Some researchers have suggested using a cut-off level of 112
U/ml as the upper limit of normal, compared with 35 U/ml in
the non-pregnant state.
The usefulness of this marker in pregnancy is still restricted
and if an ovarian mass is thought to look suspicious, further
evaluation with MRI may be preferable.
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40. Management
•Depends on:
1. Size
2. Sonographic appearance
3. Symptoms
A. Observation
B. Aspiration
C. Surgery
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41. A.Observation
• Simple cysts <5 cm:
No further evaluation
Rescanning if pelvic pain{Majority resolve spontaneously}
• Complex cysts:
US/4W{determine whether the cyst is becoming larger}.
In the majority of cases, resolve during the course of the
pregnancy.
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42. •Adnexal masses that undergo torsion:
Usually:
Dermoids or cystadenomas.
During 1st trimester or immediate puerperium (up to
14 d)
On the right side.
•Dermoids <6 cm
Can be managed conservatively
{1. unlikely to grow significantly in pregnancy
2. risk of complications e.g. torsion is low}
Rescan in the postnatal period to determine further
management
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43. Why The New Conservative Concept?
1. Torsion is rare till postnatal
2. Most malignancy are Border line or LMP
3. MRI cane differentiate most malignancy.
4. Surgery: PTL in10% at 2nd trimester
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44. B. Aspiration:
•Indications
Persistent, simple, unilocular cysts, >10 cm
Causing pain or thought to be increasing the risks of
fetal malpresentation or obstructed labour
•Timing
after 14 w {minimise disturbance to the corpus
luteum}.
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45. •Method
1. Transvaginally or abdominally
2. US guidance
3. Fine needle (>20 gauge).
4. Local anaesthesia for the skin
5. Antibiotic
6. Fluid aspirated: for cytology
7. Rescan to determine recurrence
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46. •Complications
1. Well tolerated& without short or long-
term complications.
2. Recurrence
33–50%
Further aspirations can be required during
the rest of the pregnancy.
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47. C. Surgery
•Indication depend on:
1. Degree of suspicion of malignancy
2. Development of complications.
• Timing:
after 14 weeks gestation
{minimise the risk of fetal loss due to miscarriage,
although this risk is very small. Pregnancy is
dependent on the corpus luteum during the first
trimester & much less so after 12 w}.
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48. • Approach:
1. Laparotomy
2. Laparoscopy
skill-dependent
more time consuming than open surgery.
performed during 2nd trimester
an ‘open’ method (Hasson) {avoid uterine injury from
the primary trocar introduction}.
•Tocolytics:
not routinely necessary, but
if uterine irritability: tocolytic regimens can be
employed.
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49. •Adnexal mass discovered at CS:
The most common lesions:
Dermoid cysts
Paratubal cysts
Cystadenomas
Endometriotic cysts
Corpus luteal cysts.
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50. Management:
1. Simple cysts <5 cm: left alone
2. Simple cysts>5 cm or complex cysts: cystectomy.
3. After cyst removal contents should be inspected:
any signs of malignancy (solid excrescences):
Oovarectomy or,
if available, rapid frozen section.
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51. Precaution:
1.Avoid intra-abdominal contamination.
2.The contralateral ovary should be examined & if
indicated, biopsied accordingly.
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52. Ovarian Cyst
Simple cyst < 5 cm.
No further
action
No increase in size
Rescan 6 weeks
postnatal
Complex or
simple cyst > 5 cm.
Rescan in 4 weeks
MRI in suspicious US
Resolution
Sever pain/
torsion/pressure
symptoms
Rapid increase in size or
High ? Malignancy
Surgery
Aspiration if simple cyst
Clinical Algorithm For The Management
Of Ovarian Cysts In Pregnancy
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53. Conclusions
•The majority of ovarian cysts are benign and resolve
spontaneously
•Ovarian cancer is extremely rare & thus most of
these cysts can be managed conservatively.
•Unless there is a suspicion of malignancy or there is
a significant cyst complication, such as torsion,
surgery is not indicated.
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54. •MRI is a safe & useful tool when ultrasound provides
an inconclusive answer.
•Surgery is done through laparoscopy or laparotomy
depending on operator experience & patient
preference.
•Aspiration is only indicated in simple cyst, causing
pain or thought to be obstructing the birth canal.
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55. Tumors Unique to Pregnancy
1. Luteomas:
may be virilizing
2. Theca-lutein cysts:
can be large and appear complex.
seen in: pregnancies with inordinately high hCG
secretion e.g.
gestational trophoblastic disease
Twins
other situations with increased placental mass.
3. OHSS:
caused by:
-ovulation-induction therapy
-spontaneously {mutation in the FSH receptor}
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56. Management
I. Surgery: Resection
1. suspected of rupture or torsion
2. capable of obstructing labor
3. >10 cm {increased risk of cancer in large cysts}.
4. contain septae, nodules, papillary excrescences,
or solid components
,
II. Observation:
Cysts 10 cm or less and simple
N.B. 5- to 10-cm cysts who are observed have been
reported to require emergency exploration for
rupture, torsion, or infarction in some studies
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57. Laparoscopy
to evaluate and resect intermediate-sized cysts
The major concern is for the unrecognized
malignant tumor rupturing with intraperitoneal
spillage.
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58. 3 questions to be answered once a pelvic mass
is discovered during pregnancy
1. What is the mass and what is the likelihood that it is
malignant?: MR correctly identified the origin of
unknown pelvic masses
2. Is there a good possibility that the mass will
regress?
3. If observed, will the mass undergo torsion or
rupture, or will it be an obstruction to vaginal delivery?
:Time, serial US, and labor will provide answers to the
last two questions. ABOUBAKR ELNASHAR

59. Recommendations (Wiliam, 2010)
I. Resection
1. >10 cm {risk of malignancy and torsion}.
2. 6 to 10 cm: US with color Doppler or MR imaging or
both: suggests a neoplasm
3. <6cm: begin to display malignant qualities, or
become symptomatic.
If the corpus luteum is removed before 10W: 17-OH-
progesterone, 250 mg IM/W tell 10W gestation.
II. Observation: serial US
1. Cystic masses that are thought to be benign
2. <6 cm
Elective surgery at 14 to 20 w {most masses that will
regress will have done so by this time}.
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60. Surgical tips (Telende, 2008)
Time of surgery:
Elective surgery should be avoided in the first trimester
{many lesions represent the cystic corpus luteum of
pregnancy and resolve spontaneously}: US should be
repeated in 6 weeks to determine if the mass is
persistent before considering surgical intervention.
The optimum time: 16-18 w
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61. Mode of delivery:
Patients in whom the asymptomatic mass is noted at
or near term may be considered for delivery by CS with
careful intraoperative evaluation of the adnexa.
Vaginal delivery in this situation has been associated
with torsion, rupture, and hemorrhage that can occur
during labor or immediately postpartum.
The size and ultrasound characteristics of the mass
will help to guide the clinician's decision concerning the
best route of delivery
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62. Laparotomy
vertical incision is preferred {after 16 weeks' gestation,
the ovary is an abdominal rather than pelvic structure}.
The incision should be placed higher than usual.
The uterus should be handled gently
frequent irrigation {prevent the tissue from drying}.
When ovarian cystectomy is required, an internal
closure with use of a 50 absorbable is recommended.
Alternatively, one can decide to perform no closure. The
traditional Buxton-type closure should be avoided.
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63. Before the decision is made to perform
oophorectomy:
exclude hyperreactio luteinalis and luteoma of
pregnancy.
Total abdominal hysterectomy and bilateral
salpingectomy are rarely indicated {most malignant
ovarian tumors are unilateral}
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64. Postoperative
The role of progesterone to prevent labor in the
postoperative period is unclear
Progestrone should be considered if the surgery
occurs in the first trimester.
The patient should be monitored for contractions
and fetal heart tones checked
If contractions occur, these can be treated with
hydration, sedation, indomethacin (if before 32 w),
or standard tocolytic therapy.
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65. ABOUBAKR ELNASHAR