Adnexal mass during Caesarean section

Adnexal mass
during
Caesarean section
Prof. Aboubakr
Elnashar
Benha university Hospital, Egypt
1/19/2019 ABOUBAKR ELNASHAR

Gynecological
1. Uterine
1. Hysterectomy
2. Myomectomy
3. IUD insertion
2. Extra uterine:
1. Ovarian cystectomy
2. Oophrectomy
3. Tubal ligation
4. Salpingectomy
Non gynecological
1. Intraperitoneal
appendectomy
2. Extraperitoneal
1. Abdominoplasty
2. Excision of ugly scar
II. From another incision
1. Hernioplasty
2. Cholecystectomy
OPERATINS DURING CS
I. From same incision

1.Planned
1. Hernioplasty
2. Cholecystectomy
3. Abdominoplasty
2.Not planned
1.Ovarian cystectomy
2.Hysterectomy

CONTENTS
1.INCIDENCE
2.TIME OF DIAGNOSIS
3.TYPES
4.MANAGEMENT
 CONCLUSION

1. INCIDENCE
 During pregnancy
1–4% of all pregnancies
1.methods of detection
2.differences in the definition of clinically
significant masses
3.adequate health care.
 Steadily increasing
 widespread use of ultrasound, other imaging
techniques

 During CS
 0.49%
 increased by the increased rate of CS
(Ulker et al, 2010)
 1.64%
(Yu et al, 2018)

2. TIME OF DIAGNOSIS
 During pregnancy:
 Only 29.78%
 although 99.00% received a antenatal
examination.
 more than half of the masses were diagnosed
incidentally during CS.
(Baser et al, 2013)

 Why?
1. Most adnexal masses
 Asymptomatic
 small (≤5 cm)
2. Pregnant patients refused
1. pelvic examination
2. TVS for the fear of abortion
3. Some adnexal masses might
 emerge after pregnancy
 gravid uterus may obscure the correct
visualization and detection.
 it is important to promote the use of USG and
improve the USG technique during preconception and
prenatal visits.

3. TYPES
Ulker et al, 2010

Follicular cyst1/19/2019 ABOUBAKR ELNASHAR

Histological types
and sizes of
adnexal
masses
surgically
removed during
cesarean section
Cristian et al, 2012

Cengiz et al, 2012

Ovarian serous cystadenoma

Baser
et al,
2013

Huge paraovarian cyst

Yu et al, 2018
1300 CS

Theca lutein cysts

4. MANAGEMENT
 During pregnancy
 Risk of obsrvation
 torsion
 rupture
 bleeding,
 obstruction, or
 malignancy.
 Risk of Surgery
 intraoperative and perioperative risks
 fetal loss
 preterm contractions
 an increased risk of embolic events

< 5 cm
 Observation
 cystic benign-appearing
{Early in pregnancy, this is likely a corpus
luteum cyst, which typically resolves by the
early second trimester}.
 Excision
 sonographic characteristics suggest cancer-
 thick septa
 nodules,
 papillary excrescences, or
 solid components
(William,2018)

 Unilocular
 Thin-walled
 Anechoic
Follicular cyst1/19/2019 ABOUBAKR ELNASHAR

Simple ultrasound rules: 2012
5 ultrasonic features to predict a malignant tumour
(M features):
Irregular solid tumour (M1),
Ascites (M2),
At least four papillary structures (M3),
Irregular multilocular solid tumour with a largest
diameter of at least 100 mm (M4)
Very high colour content on colour Doppler
examination (M5).
ABOUBAKR ELNASHAR1/19/2019

5 ultrasonic features to predict a benign tumour (B
features):
Unilocular cyst (B1),
Presence of solid components for which the largest
solid component is <7 mm in largest diameter (B2)
Acoustic shadows (B3)
Smooth multilocular tumour (B4)
No detectable blood flow on Doppler examination
(B5).
ABOUBAKR ELNASHAR1/19/2019

5 - 10 cm
 color Doppler and possibly MRI
 Observation
 simple cystic appearance
(Schmeler, 2005; Zan etta, 2003) .
 Excision
 display malignant qualities
 symptomatic
 cysts grow
10 cm:
Excision
{substantial risk of malignancy, torsion, or labor
obstruction}

 Resection
 When
 at 14 to 20 w
 {most masses that will regress will have done
so by this time}.
 If the corpus luteum is removed before 10W:
17-OH-progesterone, 250 mg IM/W tell 10W
gestation.
 Laparoscopic removal is ideal
(Naqvi, 20 1 5 ; Sisodia, 2015 )
 If cancer is strongly suspected,
 consultation with a gynecologic oncologist.
(ACOG, 2017)

During CS:
If diagnosed during ante natal
 Plan of management before delivery.
 Consent for removal
 Paracentesis
for huge masses to minimize their volume and avoid
complications
 Endometrioma or mature cystic teratoma
 may be resected
 postpartum or
 during CS for obstetrical indications.

 Removal of all masses during CS, especially if the
larger than 5 cm,
 Why?
1. to prevent
 subsequent complications:
 torsion or rupture
 future requirement for surgery
2. removal during CS was not associated with any
complications.
 Why all masses
considerable proportion of neoplastic lesions were
smaller than 5 cm

If incidentally discovered
 Incidence: 1 in 200
 Exteriorizing the uterus during CS:
 less intraoperative complications
 less hemorrhage
 better inspection of pelvic organs: incidental
adnexal mass discovery not such a rare event.

 Medico-legal issues on the informed consenting
process
 additional procedures during CS should not be
carried out without further discussion with the
woman
 This includes procedures which
 may be appropriate but
 not essential at the time,
 such as ovarian cystectomy or
oophorectomy
 Additional non-emergency procedures during a cesarean section should not be
carried out without the consent of the woman.
[RCOG, 2016]. .

Under general anesthesia
 If an ovarian cyst suggestive of malignancy:
• Seek an on-the-table review by an oncology
specialist.
• Take peritoneal washings for cytology.
• Consider biopsies of cyst wall or visible
peritoneal lesions.
 when she is conscious
 Inform the patient of the findings
 seek her permission to send any specimens for
laboratory investigations.
 Plan definitive management in consultation with
a gynecologic oncologist.

Under regional anesthesia
• Inform and seek consent for further management.
• If the cyst appears benign:
 consider performing a cystectomy, but without
spillage of cyst contents.
• If the cyst suggestive of malignancy:
 take peritoneal washings
 consider performing an oophorectomy with or
without additional surgery.
 The procedure should be performed by an
oncology specialist.
 Once histology is available, interval staging
laparotomy can be planned as appropriate.

 Incidental adnexal masses should be surgically
removed,
 avoiding later surgery
 establishing malignancy status of the mass.
 no complication or increase of morbidity and
mortality
 safe surgical act.

 Type of operation
 depending on the
1. manifestation of the masses.
2. exclude malignancies
 with a biopsy (or wedge resection) and then
freeze the section in order to avoid
unnecessary surgical excision.
 frozen section
 offers a great help in making an
intraoperative decision
 unfortunately a 24 hs frozen section
examination not available.
 referral of the patient to an oncological
center after CS will not influence
negatively the patient’s chances.1/19/2019 ABOUBAKR ELNASHAR

 Cystectomy
 is the recommended procedure, if no malignancy
 signs
 Ovarectomy and ovarectomy with salpingectomy:
complex cases.
 ovarian masses should be removed intact when
possible, especially in suspicious cases.

CONCLUSION
 Preconception care and routine prenatal care,
including USG examination, may optimize the
detection and management of an adnexal mass.
 Removal of incidental or known adnexal masses at
cesarean section, especially if they are larger than
5cm.

You can get this lecture and 400
lectures from:
1.My scientific page on Face book: Aboubakr
Elnashar Lectures.
https://www.facebook.com/groups/22774488
4091351/
2.Slide share web site
3. elnashar53@hotmail.com
4.My clinic: Althwara st, Mansura, Egypt

Adnexal mass during Caesarean section

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