Management of Adenxal Mass during Pregnancy Prof. Aboubakr Elnashar Benha University Hospital elnashar53@hotmail.com

Adnexa refers to the appendages of an organ An adnexal mass is a lump in tissue near the uterus, usually in the ovary or fallopian tube

Contents Incidence Causes Characters Diagnosis Management Conclusion

Incidence Increase Detection Rate Routine U/S in early pregnancy: 4% At CS: 0.5%

Causes I. Ovarian Simple cyst Haemorrhagic cyst OHSS Endometrioma Luteoma Brenner tumour Epithelial tumours: serous and mucinous; endometrioid and clear-cell carcinomas

8. Germ cell tumours: mature and immature teratomas, dysgerminomas, endodermal sinus tumours, embryonal carcinomas 9. Sex cord-stromal tumours: fibrothecomas; granulosa cell, sclerosing stromal and Sertoli-Leydig cell tumours 10. Metastatic tumours: Krukenberg,Lymphoma

IV. Non-gynaecological 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

Characters 1. Nearly all are benign Ovarian cancer: 0.004–0.04%. Most are borderline with a low malignant potential

2. High possibility of regression -Ovarian cysts: Most ovarian cyst 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

3. Complications of ovarian cysts in pregnancy Rupture Haemorrhage Torsion (up to 5%) Obstructed labour Fetal malpresentation

Diagnosis Bimanual examination US MRI Color Doppler CT Tumor markers

Bimanual examination: detected if it is at least 5 cm

US: Abd & TV Diagnostic in most cases (> 90%) Types: Simple cyst Low level echo cyst Complex cyst Solid Complex (Solid–cystic) lesions are more likely to be malignant. Purely solid or purely cystic lesions are more likely to be benign.

II. Low-level echo cysts Endometrioma 95%          Hemorrhagic cyst 50% Teratoma           18% Malignant Neoplasm 12% Patel et al (Radiology. 1999;210:739-745.)

IV. Solid Adnexal Masses Subserous Fibroid Luteoma of pregnancy Ovarian Fibroma Dysgerminoma Gonadal stromal tumors

3. MRI: Indications: Suspicious Poorly visualized Inadequately localized Disadvantages: More expensive More time consuming than US

Advantages: 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

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.

5. CT Has little place in pregnancy in modern obstetrics

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.

a. Serum AFP, BhCG& inhibin levels: b. Serum CA125 levels: 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.

Management Depends on: Size Sonographic appearance Symptoms Observation Aspiration Surgery

Observation Simple cysts <5 cm: Complex cysts: 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.

Adnexal masses that undergo torsion: Usually dermoids or cystadenomas. Usually during 1st trimester or in the immediate puerperium (up to 14 days after delivery) More commonly 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

Why The New Conservative Concept? Torsion is rare till postnatal Most malignancy are Border line or LMP MRI cane differentiate most malignancy. Surgery: PTL in10% at 2nd trimester

B. Aspiration: Indications Timing 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}.

Method 1. Transvaginally or abdominally 2. US guidance 3. Fine needle (>20 gauge). 4. Local anaesthesia for the skin 5. Antibiotic 6. Fluid aspirated should be sent for cytology 7. Rescan to determine recurrence

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.

C. Surgery Indication depend on: Timing: Degree of suspicion of malignancy 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}.

Approach: Tocolytics: Laparotomy 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.

Adnexal mass discovered at CS: The most common lesions: Dermoid cysts Paratubal cysts Cystadenomas Endometriotic cysts Corpus luteal cysts.

Management: Simple cysts <5 cm: left alone Simple cysts>5 cm or complex cysts: cystectomy. After cyst removal contents should be inspected: any signs of malignancy (solid excrescences): Oovarectomy or, if available, rapid frozen section.

Precaution: 1.Avoid intra-abdominal contamination. 2.The contralateral ovary should be examined & if indicated, biopsied accordingly.

Clinical Algorithm For The Management Of Ovarian Cysts In Pregnancy Complex or simple cyst > 5 cm. Simple cyst < 5 cm. No further action Rescan in 4 weeks MRI in suspicious US Resolution Sever pain/ torsion/pressure symptoms No increase in size Rapid increase in size or High ? Malignancy Rescan 6 weeks postnatal Surgery Aspiration if simple cyst

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.

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.