Over the last 20 years, the use of ultrasound in pregnancy has dramatically increased the numbers of ovarian cysts diagnosed. The majority of these ovarian cysts in pregnancy either resolve spontaneously or are due to benign conditions. Ovarian cancer is extremely rare in women of childbearing age and thus most of these cysts can be managed conservatively. In terms of malignancy potential, those that are malignant are likely to be borderline. Unless there is a suspicion of malignancy or there is a significant cyst complication, such as torsion, surgery is not indicated. MRI is a safe and useful tool to help evaluate cysts in more detail in situations where ultrasound provides an inconclusive answer. If surgery is planned, this should take place during the second trimester to minimise the risk of miscarriage. Whether surgery is done laparoscopically or using a traditional open approach, it is largely dependent on operator experience and patient preference. Aspiration of ovarian cysts is only indicated where they appear simple on ultrasound and where they are causing pain or are thought to be obstructing the birth canal. If surgery does not take place, then ultrasound follow-up during and after pregnancy may be advised accordingly.

1. MANAGEMENT OF
ADENEXAL MASSES
DURING PREGNANCY
Wafaa B. Basta
Mataria Teaching Hospital
MRCOG
ERC MEMBER
ERC-RCOG CPD Program – Sonesta 18th November 2011

2.  How often is it reported & what are the
commonest types?
 How can these masses be diagnosed,
evaluated &followed up ?
 What are the common complications?
 Is the trend to conserve justified ?
 What factors that may help determine
the need for surgical intervention?
 When to operate?
 What is the extent of surgical
intervention?

3. Numbers & Facts
 Adenexal masses are now reported in up to 4% of all
pregnant women.
 Nearly all ovarian masses detected in pregnancy are
benign.
 Incidence of ovarian cancer in pregnant women varies
from 0.004–0.04%.
 Most of the ovarian cancer diagnosed appear to be
borderline with a low malignant potential and are
complex on ultrasound assessment.
 The majority of complex cysts are either benign
teratomas or endometriomas.
TOG ,2006;8:14-18 /Royal college of Obstetrician & Gynaecologist

4. Causes of pelvic masses during
pregnancy
 Ovarian
 Functional ovarian cysts
(commonest form)
 Retention cysts (corpus luteum
cysts)
 Endometriotic cysts (chocolate
cysts)
 Benign neoplasia
 Commonest is benign cystic
teratomas.
 Serous or mucinous cyst-adenomas.
 Fibromas.
 Brenner tumour
 Malignant neoplasia
All rare and usually low-stage/low-
grade:
 Germ cell tumours
 Epithelial tumours
 Sex cord-stromal tumours
 Metastatic (secondary) tumours
(breast & GIT)
Tubal
 Hydrosalpinx
 Heterotopic pregnancy
 Tubo-ovarian abscess
 Paratubal cyst
Uterine
 Leiomyoma
 sarcoma
Non-gynaecological
 Mesenteric cyst
 Appendicular mass
 Diverticular abscess
 Peritoneal pseudocysts
 Pelvic kidney
 Urachal cyst
 Lymphoma
 Retroperitoneal tumour
Management of suspected ovarian masses in premenopausal women ; green top GLNo.62
RCOG/BSGE joint GL November 2011

5. DIAGNOSTIC TOOLS OF ADENEXAL MASSES
DURING PREGNANCY
 History & examination
 Abdominal &trans-vaginal US
 Colour Doppler study
 MRI&CT
 Tumour markers

6. History & examination
History
 Risk factors & protective factors for ovarian
malignancy.
 Family history of ovarian or breast cancer.
 Symptoms suggestive of endometriosis .
 Symptoms suggesting possible ovarian
malignancy.
 Symptoms suggesting complications.
Physical examination
 Clinical examination has poor sensitivity in the
detection of ovarian masses (15–51%).
 Important in the evaluation of mass tenderness,
mobility .
 The presence or absence of local lymph-
adenopathy.
 Signs of complications.

7. Role of Ultra-sound
 Ultrasound is the primary imaging tool.
 Determine the size, location, appearance and
likelihood of any problems.
 US morphologic criteria can distinguish benign
from malignant masses with a sensitivity of 82 to
91% and specificity of 68 to 81% .
 If combined with Doppler, sensitivity specificity
increase to 86 & 91% respectively.
Evidence based practice centre ,Durham, NC / Journal of clinical oncology Jan 2011
vol18 No.1

8. FUNCTIONAL OVARIAN
CYSTS
e.g. Follicular cyst
Simple ovarian cyst
 Uni-locular
Thin-walled
 Anechoic

9. CORPUS LUTEUM CYST
Is the most common
adnexal mass in the first
trimester.
Rarely persists beyond
16 weeks’ gestation
If persist ,this is a normal
component of pregnancy.
Small cystic structure ,
with smooth borders and
a fluid centre.
 It may sometimes
contain debris, such as
clotted blood.
Can reach 10cm in size.

10. BENIGN CYSTIC TERATOMA
Benign cystic teratomas
(and cystadenomas) are the
most common neoplastic
ovarian lesions associated
with pregnancy.
Complex mass with solid &
cystic areas due to
presence of fat, hair, bone
& sebaceous material
 It often has multiple tissue
lines, evidence of
calcification, and layering of
fat and fluid contents.
Is unlikely to grow during
pregnancy.
Hypo/anechoic cysts containing
one or more hyperechoic nodules
(“dermoid plug”),

11. BENIGN CYSTIC TERATOMA
A) Transvaginal scan: the teratoma appears as a well-
encapsulated oval mass with complex echostructure, due to
the internal presence of hypoechoic material (sebum) mixed
with more echogenic areas (accumulation of hair) with a
posterior cone of shadow (black arrows).

12. Haemorrhagic cysts Endometrioma
An-echoic with echo-genic
material within cyst
Diffuse ‘ground glass’ pattern due
to presence of old blood
(‘chocolate’) within the cyst

13. HYPER-STIMULATED
OVARIES
History of ART
Massively enlarged
ovary
Thin walled
Multilocular cysts
Ascites may be present

14. MALIGNANT OVARIAN TUMOUR
More than 10 cm.
Complex with solid and
cystic areas .
Multi-septate mass.
Papillary projections or
nodules.
Irregular borders.
 Ascites may be present.
Bilateral in up to 25% of
cases.
Each alone has been
shown to have relatively
reasonable specificity for
raising suspicion for
malignancy; however,
combinations of these
factors are often more
sensitive in predicting
malignancy.

15. IOTA Group ultrasound ‘rules’ to classify
masses as benign (B-rules) or malignant (M-
rules) (sensitivity was 95%, specificity 91%,)
B-rules
 Uni-locular cysts
 Presence of solid
components where
the largest solid
component <7 mm
 Presence of acoustic
shadowing
 Smooth multi-locular
tumour with a largest
diameter <100mm
 No blood flow
M-rules
 Irregular solid
tumour
 Ascites
 At least four
papillary structures
 Irregular multi-locular
solid tumour with
largest diameter
≥100 mm
 Very strong blood
flow
Management of suspected ovarian masses in premenopausal women ; green top
GLNo.62
RCOG/BSGE joint GL November 2011

16. TORSION IN OVARIAN CYST
• The presence of multiple
follicles rimming an
enlarged ovary .
•This finding reflects
ovarian congestion and
edema.
•The twisted pedicle may
also give the appearance
described as a whirlpool,
or a snail shell, that is, a
rounded hyper-echoic
structure with multiple
inner concentric hypo-
echoic broad rings
(Vijayaraghavan, 2004).

17. HYDRO-SALPINEX
Tubular-shaped
structure
With anechoic content
Incomplete septum of
tubal wall
Always stays the same
size during pregnancy

18. UTERINE LEIOMYOMA
When solid adenexal
mass is diagnosed by
US, It should be re-
evaluated with more
detailed US or MRI, as it
may be a uterine
leiomyoma mimicking an
adnexal tumour.
Cystic change may
occur if red degeneration
develops.

19. DIAGNOSTIC TOOLS OF ADENEXAL MASSES
DURING PREGNANCY
 Abdominal &trans-vaginal US
 Colour Doppler study
 MRI&CT
 Tumour markers

20. The use of Doppler to distinguish benign from
malignant ovarian masses.
Benign lesions demonstrate little or
no blood flow.
Neo-vascularization and low
resistance and pulsatility indices
(usually less than 1) are suspicious
of malignancy

21. The Doppler limitations
 Due to increased pelvic vascularity in pregnancy,
Doppler imaging is unreliable in this setting.
 Neo-vascularization and low resistance indices is
also seen in many benign conditions such as
endometriomas and other benign complex ovarian
masses.
 In ovarian torsion Doppler shows absent arterial
and/or venous blood flow to the ovary
 A recent study shows that 19% of patients with
torsion had normal preoperative Doppler flow .
Thus, torsion should not be excluded on the basis
of a normal Doppler study alone. (Chiou, S.Y., et al., Adnexal
torsion: new clinical and imaging observations by sonography, CT& MRI. J
Ultrasound Med, 2007. 26(10): p. 1289-301. )

22. DIAGNOSTIC TOOLS OF ADENEXAL MASSES
DURING PREGNANCY
 Abdominal &trans-vaginal US
 Colour Doppler study
 MRI&CT
 Tumour markers

23. MRI in diagnoses of ovarian mass in
pregnancy
 MRI used when additional
information is required.
 MRI is useful in:
1. Assessment of an ovarian
mass that is thought to be
malignant .
2. Confirming the diagnosis of
large degenerating
leiomyomas.
3. Defining both endometriotic
and dermoid cysts.
The use of gadolinium contrast
enhancement in pregnancy is
contraindicated ( cross the
placenta ).

24. MRI in diagnoses of ovarian mass in
pregnancy
 Compared with CT
scanning:
1. No harmful ionising
radiation------safe in
pregnancy.
2. Provides superior
resolution
3. It permits visualisation of
the more lateral and
posterior areas of the true
pelvis locations, which
may be obscured by the
bony foetal structures .

25. DIAGNOSTIC TOOLS OF ADENEXAL MASSES
DURING PREGNANCY
 Abdominal &trans-vaginal US
 Colour Doppler study
 MRI&CT
 Tumour markers

26. The role of tumour markers
In the non-pregnant state:
Tumour marker Elevated in
CA125 75% of epithelial ovarian carcinoma
AFP and beta-hCG germ cell tumours
Serum inhibin granulosa cell tumours and
mucinous carcinomas.
Serum lactate
dehydrogenase (LDH)
dysgerminomas.

27. The role of tumour markers
During pregnancy, :
 Serum CA125 , AFP, beta-
hCG and inhibin levels are
all raised due to decidual
cell production& placental
synthesis .
 The use of these markers
in evaluating suspicious
ovarian cysts is limited.
 Are used mainly to monitor
disease status during
treatment.
 A markedly elevated serum
levels , may be of value.

28. COMPLICATIONS OF ADENEXAL MASSES
DURING PREGNANCY
 Cyst rupture
 Cyst haemorrhage
 Torsion (up to5%)
 Obstructed labour
 Foetal mal-presentation.

29. Incidence of Complications
 Occur in fewer than 10 %.
 The most common: dermoids or cyst-adenomas.
However, some ovarian cancers may present acutely .
 Timing: during the first trimester or in the immediate
puerperium (up to 14 days after delivery)
 Ovarian torsion can occur with normal adnexa, but in 50
to 80 % of cases unilateral ovarian masses are
identified (Nichols, 1985; Warner, 1985).
 The highest rates of torsion are found in adnexal
masses from 6 to 10 cm (Houry, 2001).
 More common on the right side owing to the sigmoid
colon restricting the mobility of the left ovary

30. Presentation of complications
Rupture ovarian cyst
Torsion
 Sudden, unilateral, sharp
pelvic pain, associated with
strenuous exercise.
 May lead to tachycardia and
hypotension.
 If hemorrhage or peritonitis
ensues,----- diffusely tender
abdomen with rebound
tenderness and guarding.
 Serous or mucinous ---
asymptomatic.
 Sebaceous material from
dermoid cyst -------
granulomatous reaction and
chemical peritonitis, painful
 Sharp lower abdominal,
sudden onset ,worsens
intermittently , localized
to the involved side, with
radiation to the flank and
thigh.
 Nausea and vomiting
frequently accompany
the pain

31. Torsion of Adnexal Masses
 Blood flow is initially maintained despite twisting of their
vascular pedicles:
 First, adnexa are supplied from both the uterine and
ovarian vessels.
 Secondly, although low-pressure veins are compressed
by the twisting pedicle, high-pressure arteries initially
resist compression.
 Continued inflow + Arrested return of blood, the
adnexa become congested and edematous, but do not
infarct.
 Because of this, it is reasonable to conservatively
manage cases of early torsion.
 With continued stromal swelling, however, arteries may
become compressed, leading to infarction and necrosis.
 Low-grade fever suggests adnexal necrosis.

32. MANAGEMENT OPTIONS OF ADENEXAL MASSES
DURING PREGNANCY
 Conservative & follow up.
 Fine needle aspiration.
 Surgical : (either Laparoscopy or Laparotomy).
1. Ovarian cystectomy
2. Oophrectomy
3. Staging laparotomy.
 Management in pregnancy depends on:
1. Size of the adnexal mass.
2. Sono-graphic appearance .
3. Associated clinical symptoms.

33. Management Rationale
 The underlying management rationale
is to minimise patient morbidity by
conservative management where
possible.
 Use of laparoscopic techniques where
appropriate, thus avoiding laparotomy
where possible
 Referral to a gynaecological
oncologist where appropriate.Management of suspected ovarian masses in premenopausal women ;
green top GLNo.62
RCOG/BSGE joint GL November 2011

34. Clinical algorithm for the management of ovarian cyst in
pregnancy
TOG ,2006;8:14-18 /Royal college of Obstetrician &
Gynaecologist

35. Cyst Aspiration
 In persistent, simple, uni-locular cysts that are larger
than 5 cm, with liability to complications, or when the
cyst in the posterior cul-de-sac & more liable to rupture.
1. Either trans-vaginally or abdominally under US
guidance.
2. Using a fine needle (greater than 20 gauge).
3. Local anaesthesia .
4. Antibiotic cover .
5. Cytological analysis of aspirated fluid.
6. Rescan to determine cyst recurrence.(risk 33-50%)
7. Well tolerated and without short or long-term
complications.
 Should be done after 14 weeks of gestation in order to
minimise disturbance to the corpus luteum.
Caspi B, et al / Aspirate of simple pelvic cyst during pregnancy
Gynaecol Obstet Invest 2000;49:102-5

36. What is the best time to operate?
 During the first trimester: Surgery is generally
not recommended because of;
1. Pregnancy loss : disruption of the corpus luteum .
2. The high likelihood of a corpus luteum cyst .
3. The low likelihood of an invasive malignancy .
4. The low risk of adnexal complications associated with
observation.
 After 24 weeks : surgery not recommended due
to:
1. Risk of PTL ,IUGR, or both.
2. Restricted pelvic exposure
3. Need for significant uterine manipulation

37. So,
 During the early to mid second trimester(15-
18 weeks) is the best time for elective surgery
as it:
1. Minimise the risk of foetal loss, although this risk
is very small.
2. Affords pelvic exposure .
3. No need for significant uterine manipulation .
4. Has been associated with a lower risk of
pregnancy complications.
 If beyond 24 weeks : beta-methasone .
 If prior to 10 weeks: progesterone
supplementation .

38. Surgical management
 Operative intervention is required in :
1. if malignancy is suspected .
2. if an acute complication develops.
3. if any mass demonstrates a 30–50
per cent increase in size at any time .

39. Laparoscopy or laparotomy?
 The standard approach
is to perform the surgery
via a laparotomy but
laparoscopic surgery
has been used safely.
 If laparoscopic surgery is
performed during the
second trimester, an
‘open’ method (Hasson)
is preferred to avoid
uterine injury from the
primary trocar
introduction.

40. Laparoscopy Laparotomy
• Advantages:
1. Less operative time
2. Less peri-operative
morbidity
3. Reduces manipulation of the
pregnant uterus
4. Shorter hospital stay
5. Less post-operative pain.
6. Is now widely used in
laparoscopic staging in early
stage ovarian cancer.
• Disadvantages:
• Skill dependant.
• Advantages :
1. Good exposure to the
pelvis
2. Access to the upper
abdomen if surgical
staging be indicated.
• Disadvantages:
1. Increased postoperative
recovery time
2. Increased incisional pain
and discomfort
3. Risk of postoperative
thrombo-embolism

41. Guidelines for Use of Laparoscopy for Surgical
Problems during Pregnancy
 Laparoscopy is a safe and effective treatment in gravid
patients with symptomatic ovarian cystic masses. (Low;
Strong).
 Laparoscopy is recommended for both diagnosis and
treatment of adnexal torsion unless clinical severity
warrants laparotomy (Low; Strong).
 Tocolytics should not be used prophylactically in
pregnant women undergoing surgery but should be
considered peri-operatively when signs of preterm labor
are present (High, Strong).
By the Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES), published on: 01/2011

42. Extent of surgery
 Decided by the intra-operative findings :
Cystectomy
For benign appearing masses, if there is enough normal
ovarian cortex and a clear border of the mass from the
ovary.
Oophorectomy
reserved for more complex appearing masses.
Staging laparotomy
 for confirmed higher-grade malignancies.
 Complete survey of the abdomen and pelvis.
 Pelvic washings for cytology.
 Biopsies from suspicious areas & contra lateral ovary.
 Avoid cyst rupture as this would result in an upstaging
of the patient .

43. Management of complications
(Cyst rupture and hemorrhage )
 Cyst rupture and hemorrhage may be treated
conservatively with observation if the patient is
stable, with follow-up scanning to confirm
resolution.
 Surgery is indicated in:
1. Hemodynamic instability.
2. Possibility of torsion.
3. No relief of symptoms within 48 hours.
4. Increasing hemo-peritoneum .
5. Falling hemoglobin concentration.

44. Management of complications
(Ovarian Torsion)
 Previously, adnexectomy was usually done to avoid
possible thrombus release upon de-torsion and
subsequent embolism.
 Evidence does not support this. McGovern and co-
workers (1999) reviewed nearly 1,000 cases of torsion
and found pulmonary embolism in only 0.2 percent, all
after adenexectomy.

45. Management of complications
(Ovarian Torsion)
 Within minutes following untwisting, ----ovarian cyanosis
and volume typically diminish. If not ----prompt adnexal
removal.
 A persistently black-bluish ovary, however, is not
pathognomonic for necrosis.(Cohen and
associates1999)
 Cystectomy in an ischemic, edematous ovary, however,
may technically be difficult.
 Unilateral or bilateral oophoropexy has been described
to minimize the risk of repeat adnexal torsion
(Djavadian, 2004; Germain, 1996).

46. Should pregnancy be terminated in
ovarian cancer?
 The most important consideration when deciding
whether to continue the pregnancy is the need for
adjuvant chemotherapy.
 A short delay (4–6 weeks) may be appropriate to allow
the pregnancy to progress to maturity.
 Pregnancy does not appear to alter the prognosis for
the patient with an ovarian malignancy, and ovarian
cancer has not been reported to metastasise to the
fetus.

47. Can we afford elective CS for
persistence adenexal mass?
 An elective caesarean section is sometimes
performed specifically to manage a persistent
adnexal mass.
 Factors that warrant consideration are:
1. The elective uterine incision.
2. The higher risks associated with caesarean
delivery in general.
3. The potential for better exposure or laparoscopy at
a later date.

48. Discovery at CS
 The adnexae should be inspected after closing the
uterine incision in all women who are delivered by
caesarean section
 Incidence : about 0.5% .
 After cyst removal, the contents should be inspected
thoroughly before closing the mother’s abdomen. If
there are any signs of malignancy, the ovary should be
removed completely or, if available, rapid frozen
section assessment performed. The contra-lateral
ovary should be examined thoroughly and, if indicated,
biopsied accordingly.

49. Conclusion
 Over the last 20 years, the use of ultrasound in pregnancy
has dramatically increased the numbers of ovarian cysts
diagnosed.
 The majority of these ovarian cysts in pregnancy either
resolve spontaneously or are due to benign conditions.
 Ovarian cancer is extremely rare in women of childbearing
age and thus most of these cysts can be managed
conservatively.
 In terms of malignancy potential, those that are malignant
are likely to be borderline.
 Unless there is a suspicion of malignancy or there is a
significant cyst complication, such as torsion, surgery is not
indicated.
 MRI is a safe and useful tool to help evaluate cysts in more
detail in situations where ultrasound provides an

50. Conclusion (cont.)
 If surgery is planned, this should take place during the
second trimester to minimise the risk of miscarriage.
 Whether surgery is done laparoscopically or using a
traditional open approach, it is largely dependent on
operator experience and patient preference.
 Aspiration of ovarian cysts is only indicated where they
appear simple on ultrasound and where they are causing
pain or are thought to be obstructing the birth canal.
 If surgery does not take place, then ultrasound follow-up
during and after pregnancy may be advised accordingly.

51. THANKYOU
Any
Questions
???????????
?