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Adnexal Masses in Pregnancy

Contributor: Eric Dellinger, MD
Last Update: 4/10/2018

Suggested algorithm:


 

The incidence of first trimester adnexal masses detected by ultrasound may be as high as 25%, with 85% resolving spontaneously. The majority of these are function cysts such as corpus luteal cysts which do not require intervention. Most (90%) in fact will resolve before the second trimester. Only 5% of these early tumors will prove to be malignant with a stated incidence of ovarian cancer in pregnancy of 1 in 18,000-47,000 deliveries.

Classification Of Persistent Adnexal Masses Found In Pregnancy:

graphic

Malignancy Risk Factors:
Risk factors that have been linked to an increased risk of malignancy in adnexal tumors in nonpregnant patients include age >55, complex cyst morphology, ascites, bilaterality, diameter >10 cm, and CA-125 levels >35. However, CA-125 levels are commonly elevated in pregnancy and not reliably predictive.

Complications:
There are no randomized controlled trials comparing surgical management with observation. Surgery in the second trimester has long been felt to be safe, and laparoscopy has been used successfully and offers some improvement in recovery time and postoperative pain.7
Observed complications with conservative management include ovarian torsion (1-22%), severe pain (26%), cyst rupture (0-9%), and labor obstruction (2-17%). Ovarian torsion tends to occur around 10-17 weeks (60%) with few events beyond 20 weeks (6%).8,9   In a 2013 observational study of  803 women with ovarian masses identified before 24 weeks of pregnancy, only 5 (0.6%) women required emergency surgery: 3 for torsion and 2 for rupture of the mass.10 If symptoms suspicious for torsion, rupture, or infection develop, surgical exploration may be indicated regardless of the gestational age.

Evaluation:
Most adnexal masses in pregnancy are identified during routine ultrasound.  Ultrasound is 97% sensitive for detection of malignancy with a specificity of 77%.  The corresponding positive predictive value is 29% and the negative predictive value is 99.6%.  Color and pulsed wave Doppler can improve the diagnostic accuracy of malignancy.11 Magnetic Resonance Imaging (MRI) can add information in selected cases.12  Tumor markers are unreliable in pregnancy and are NOT recommended.

Therapy:
First trimester management is almost always conservative. Exceptions would include a high suspicion of malignancy or an acute abdomen. If the corpus luteum is removed prior to 8 weeks, progesterone supplementation is required.
Third trimester cases are typically managed conservatively due to approaching fetal maturity as well as the risk of surgery resulting in iatrogenic prematurity. Exceptions are similar to those mentioned for the first trimester.
If surgery is indicated, the preferred timing is in the early second trimester.  Organogenesis has ended, spontaneous abortions are rare, and the risk of inciting preterm labor is low.
Masses encountered unexpectedly at cesarean section which are suspicious for malignancy should be removed, not aspirated. Cystectomy rather than salpingoophorectomy is indicated for suspected benign disease.
Consultation with Gyn Oncology, Anesthesiology, and Neonatology should be obtained when appropriate.

Perioperative Considerations:
Document fetal heart tones before and after a surgical procedure.  Viable fetuses may be continuously monitored. Place the mother in a left lateral tilt position if 20 or more weeks of gestation.  A preoperative dose of a broad spectrum antibiotic is recommended by some. The use of lower extremity compression devices is recommended.  Consideration of antenatal steroids is appropriate if the gestational age is greater than 23 weeks.  The role of perioperative tocolytics is unclear in the midtrimester, but may be  used as needed in the third trimester.

Suspected Malignancy:
For any suspicious adnexal mass, consult with Gyn Oncology prior to surgery. Employ the use of a midline incision. Obtain frozen section biopsy of any suspicious lesions. If the disease appears to be stage I, the recommended procedure is often unilateral salpingoophorectomy, pelvic washings, omentectomy, peritoneal biopsies (especially suspicious areas), and pelvic and paraaortic lymph node dissection. For higher stages, cytoreductive surgery may be indicated. Intraoperative communication with the family is critical in these situations. If a cancer is encountered unexpectedly, the surgeon should not perform any procedures outside of the scope of his or her training or practice. Intra-operative consultation with or post-operative referral to a gynecologic oncologist would be preferable in this situation.

References

  1. Berghella, V. (2017). Obstetric Evidence Based Guidelines, Third Edition. Boca Raton: CRC Press. pp 343-7.
  2. Yazbek J, Salim R, Woelfer B, et al. The value of ultrasound visualization of the ovaries during the routine 11-14 weeks nuchal translucency scan. Eur J Obstet Gynecol Reprod Biol. 2007;132:157-8.
  3. Horowitz NS. Clin Obstet Gynecol. 2011 Dec;54(4):519-27.
  4. Dgani R, Shoham Z, Atar E, Zosmer A, Lancet M. Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the years 1960 and 1984. Gynecol Oncol. 1989;33:326–31.
  5. McDonald JM, Doran S, DeSimone CP, et al. Obstet Gynecol. 2010 Apr;115(4):687-94.
  6. Niloff JM, Knapp RC, Schaetzi E, et al. CA125 antigen levels in obstetric and gynecology patients. Obstet Gynecol. 1984;64:703-7.
  7. Balthazar U, Steiner AZ, Boggess JF, Gehrig PA. J Minim Invasive Gynecol. 2011 Nov-Dec;18(6):720-5.
  8. Schmeler KM, Mayo-Smith WW, Peipert JF, et al. Adnexal masses in pregnancy: Surgery compared with observation. Obstet Gynecol. 2005;105:1098–1103.
  9. Struyk AP, Treffers PE. Ovarian tumors in pregnancy. Acta Obstet Gynecol Scand. 1984;63:421–424.
  10. Brady PC, Simpson LL, Lewin SN, et al. Safety of conservative management of ovarian masses during pregnancy. J Reprod Med 2013;58:377–382.
  11. Wheeler TC, Fleischer AC. Complex adnexal mass in pregnancy: Predictive value of color Doppler ultrasonography. J Ultrasound Med. 1997;16:425–428.
  12. ACOG Practice Bulletin No. 174, Obstetrics & Gynecology, 2016, 128, 5, e210.

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