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Adnexal masses in pregnancy
- 1. How to manage adnexalmass in pregnancy? Dr.KG Hewawitharana
- 2. • This iscommon • 0.1% - 8.8% incidence • Ovarian malignancy is found in 1 / 1500-32000 pregnancies • Management depend on benign or malignant nature of mass • Most are benign & can mx with conservative measures
- 4. Clinically significant adnexalmasses in pregnancy • 1.Corpus luteum • Support pregnancy by provision of progesterone • Resolves after 8 weeks • Highly vascular & if damaged may bleed spontaneously • Inadvertent surgical resection can cause pregnancy loss
- 5. • 2.Follicular cyst •Physiological cyst is about 2 cm • If fails to rupture or ovulate can enlarge up to 6cm • Typically resolves before 16 weeks
- 6. 3.Haemorrhagic cysts Present withacute pain and if clinically stable, best mx conservatively There is no color flow in solid looking clot in contrast to true solid area
- 7. • 3.Ovarian Hyperstimulation •In conventional IVF, incidence of OHSS is 33% • 3%-8% cases are composed of moderate to severe OHSS • Severe cases may have ovarian size of 12 cm which are likely to rupture or undergo torsion • Surgery is only indicated in such conditions • During handling ovaries may damage & bleed profusely
- 8. • 4. Hyperreactioluteinalis • USS ft are like OHSS • Beta HCG endogenous production causes this in the absence of ovulation induction • Maternal virilization may occur in up to 25% pts.
- 9. • 5.Luteoma ofpregnancy • Benign & rare • Luteinized stroma replaces ovarian parenchyma • Excess androgen production cause maternal virilization in 25% cases • If maternal virilization occurs, 50% risk of female fetal virilization exists
- 10. • 6.Heterotropic pregnancy •Rare • 1-2% risk if ARTs done
- 11. • 7. Maturecystic teratoma or Dermoid • Most common adnexal lesion diagnosed after 16 weeks of pregnancy • <6 cm dermoid cysts are usually asymptomatic • >6cm dermoid cysts are prone for torsion • Torsion risk is about 25%
- 12. • 8.Malignant germcell tumors • 40% 0f invasive ovarian neoplasm includes this • Dysgerminomas are commonest with good prognosis-sensitive to chemo- radiation
- 13. • 9. Borderlineor low malignant potential masses • Cystic lesions with malignant cytological ft. but no stromal invasion • Most are mucinous or serous in origin • Ovarian crescent sign in USS helps to differentiate from malignant masses
- 14. • 10. TOAs/PID •Rare in pregnancy as thick cervical mucus is protective • TOAs can happen in ARTs • Tetracyclines are not used in mx until 15 weeks since dental discoloration may occur. But they are not teratogenic.
- 15. • 11.Appendicular mass •Acute appendicitis occurs in 1/1500 pregnancies • Masses seen in 5% • Appendicectomy is the most common non-obstetric surgery in pregnancy • After T1 , appendix moves upwards to pelvic brim at T2 & reaches lower Right upper quadrant in T3
- 17. Assessment of adnexalmass • USS - sensitivity 85-95% and specificity 70-90% • Factors suggestive of malignancy include • 1.solid components in situ • 2. papillary projection >6mm • 3.high color flow in papillary projections • 4.size increment >20% in subsequent USS • 5.presence of septations • 6.free fluid extend beyond POD
- 19. • Color doppler-assess tumor vascularity and help to differentiate benign from malignant • IOTA suggests • If no flow- benign • If high flow -malignant • If other flow rates – undetermined • But in pregnancy as with increasing vascularity, this is a debatable fact • Pooled sensitivity 85% And specificity 90%
- 20. IOTA tool –sensitivity 95% AND specificity 91%, if any M rule, refer to gynae- oncologist & RMI /ROMA score – not useful in pregnancy
- 21. Tumor Markers • 1.AFP & HCG- both altered in pregnancy and less valuable. • 2. LDH-levels rise with Dysgerminoma and pregnancy does not affect. useful in pregnancy. • 3.CA 125- Level become peak in T1 and then decline with POG. High cut off>112 can be used in 11-14 weeks. This can still be use as a baseline in pregnancy. If levels grossly elevated that highlight for malignancy
- 22. Cont. • 4-HE 4 •glycoprotein increase in ovarian CA. • Also increase in Mesothelioma, lung, breast & endometrial CA. • HE4 do not increase with endometriosis. • has less false positive results compare with CA125 for benign conditions • better in sensitivity & specificity in differentiating benign form malignant • Serum level drops in pregnancy.
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- 24. 1.Conservative management • 75%of adnexal masses in pregnancy are simple & < 5cm, they often functional cysts and resolve spontaneously by 16 weeks. Therefore, no further follow-ups required for such cysts. • Follow up scans should offer for those larger or complex cysts at around 14-16 weeks & interventions should delay until 16 weeks over, thereby allow spontaneous resolution and avoid damage to luteal cysts. • Persistent ovarian or para-ovarian cysts have low risk of CA thus can be mx conservatively • Complex masses which are ultrasonically benign (eg-Dermoid) left untreated unless symptomatic. But educate patients over possibility of cyst accidents.
- 26. 2.USS guided aspiration •useful in acute pain relief and reduces cyst rupture/torsion risk • well tolerated procedure with fewer side effect • recurrence rate is high as 40% • only suitable for simple cysts
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- 28. Surgical Approach • Laparoscopyis safe in pregnancy • RCT shows- less blood loss, good visualization, less uterine irritation • Pneumoperitoneum does not modify uteroplacental flow in studies • No difference in FGR/IUD rates • No adverse fetal outcome in the pressure range of 12-15 mmHg • Possible uterine injury can be prevented with Open Hassen technique or Palmers point entry • Laparoscopy become difficult after 12 week and impossible in T3 • If in T3-do the delivery with LSCS same time • Incision site & Type change with POG
- 29. Adnexal torsion • 1-5/10000pregnancies • High as 16% if OHSS exists • Can occur in anytime of pregnancy but more common in T1/T2 • Can occur even without adnexal mass • even normal ovary may undergo torsion during pregnancy present with acute abdomen • N/V present in about 85% cases. • Recurrent torsion risk in pregnancy is about 2X high.
- 30. • USS features-tender mass with thick edematous capsule, Avascular center with bland • Mx-immediate SX, ideally laparoscopy with detorsion, aspiration & cystectomy or Salphingo-oophorectomy • Aim of sx-detorsion to revascularize & preserve ovary, reduce size of ovary to avoid recurrence • Ischemic, friable, edematous ovaries may mx with simple puncture & drainage with minimal risk for pregnancy. • In case if obvious necrosis with no revascularization after detorsion, proceed with U/L salphingo-oophorectomy.
- 31. Suspected malignant mass •Majority of these are borderline or early stage Dx with good prognosis. • Requires MDT • MRI require with left lateral tilt of pregnant lady( if it takes time ) • Think about-Woman’s age , parity , POG ,future fertility desires & Stage of disease • T1-discuss about risk of miscarriage, termination of pregnancy with advanced disease • Late T2/T3 expedite delivery with CS & continue with gynae oncological mx.
- 32. Further more • Primarysurgery can be salphingo-oophorectomy or surgical staging laparotomy (cytology, omentectomy, peritoneal biopsy + appendicectomy if abnormal) • Re-Staging requires after pregnancy together with imaging/biomarkers especially with invasive epithelial tumors as extra-ovarian disease may not sufficiently addressed during pregnancy surgery.
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