This document discusses the management of adnexal masses during pregnancy. It notes that the incidence of detecting adnexal masses increases with routine ultrasound screening in early pregnancy. The majority of adnexal masses detected during pregnancy are benign cysts that often regress spontaneously without intervention. For larger or complex masses, observation with serial ultrasound is recommended. Surgery is considered if there is a risk of complications like rupture or torsion, or if malignancy cannot be ruled out. The optimal timing for surgery is after 14 weeks to minimize risks to the pregnancy.

1. Management of adenxal
mass during pregnancy
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt
elnashar53@hotmail.com
ABOUBAKR ELNASHAR

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. 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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9. 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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10. 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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11. 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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12. Diagnosis
1. Bimanual examination
2. US
3. MRI
4. Color Doppler
5. CT
6. Tumor markers
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13. 1. Bimanual examination:
detected if it is at least 5 cm
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14. 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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15. ovary
uterus
Unilocular, thin-walled, anechoic
I. Simple ovarian Cyst
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16. Unilocular
Thin-walled
 Anechoic
Follicular cyst ABOUBAKR ELNASHAR

17. Simple cysts
Corpus luteal or follicular cyst
Haemorrhagic cysts
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18. Massively enlarged
ovaries
Thin-walled septation
Ascites may be present
OHSS
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19. Hydrosalpinx
Tubular-shaped
structure
Anechoic content
Incomplete
septum
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20. 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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21. Anechoic with lacelike internal
echoes within cyst
HemorrhagicC.
Corpus Luteum
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22. 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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23. Diffuse ‘ground glass’ pattern due to
presence of old bloodEndometrioma
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24. 1-Dermoid Cyst
The commonest 36%
2-Endometriotic cyst 5%
3-Malignant Cyst 1-3%
III. Complex cyst
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25. Dermoid
Complex mass solid
and cystic ( fat, bone)
Fill in Pattern
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26. 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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27. U/S echogenic mural nodule in cystic
mass.
Papillary serous Cystadenom
Few small papillae
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28. Mucinous
Cystadenocarcinoma
Solid areas Many
papillary. P
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29. IV. Solid Adnexal Masses
•Subserous Fibroid
Luteoma of pregnancy
Ovarian Fibroma
Dysgerminoma
Gonadal stromal tumors
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30. At 16 weeks' gestation with R
adnexal solid mass Leiomyoma
or ovarian mass.
A
B
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31. 3. MRI:
Indications:
Suspicious
Poorly visualized
Inadequately localized
Disadvantages:
More expensive
More time consuming than US
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32. • 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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33. 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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34. Endometrioma
T2 MRI
Very low
signal
intensity
TI MRI High
signal
intensity
TI MRI
Fat -
saturated
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35. MRI: Right ovarian Mucinous cystadenoma 30 w.ABOUBAKR ELNASHAR

36. MRI Mass originating from right lateral
wall of uterus Leiomyoma
A
B
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37. 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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38. 5. CT
Has little place in pregnancy in
modern obstetrics
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39. 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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40. 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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41. Management
•Depends on:
1. Size
2. Sonographic appearance
3. Symptoms
A. Observation
B. Aspiration
C. Surgery
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42. 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.
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43. 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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44. 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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45. 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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46. 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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47. •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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48. 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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49. 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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50. •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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51. •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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52. 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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53. • 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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54. •Adnexal mass discovered at CS:
The most common lesions:
Dermoid cysts
Paratubal cysts
Cystadenomas
Endometriotic cysts
Corpus luteal cysts.
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55. 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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56. Precaution:
1.Avoid intra-abdominal contamination.
2.The contralateral ovary should be examined & if
indicated, biopsied accordingly.
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57. 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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58. 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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59. 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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60. 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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61. 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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62. 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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63. 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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64. •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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65. ABOUBAKR ELNASHAR