1. Management of Adenxal Mass during Pregnancy
Prof. Aboubakr Elnashar
Benha University Hospital

2. 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

3. Contents
Incidence
Causes
Characters
Diagnosis
Management
Conclusion

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

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

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 and Sertoli-Leydig cell tumours
10. Metastatic tumours: Krukenberg,Lymphoma

7. 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

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

9. 2. High possibility of regression
-Ovarian cysts: Most ovarian cyst are undetectable at 14 w (mostly C.Luteum)
Simple (<5 cm), hemorrhagic, OHSS: %
-Ovarian mass:< 6cm: 95%
>6cm: 60%
Persistent: 75% are complex

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

11. Diagnosis
Bimanual examination US
MRI
Color Doppler CT
Tumor markers

12. Bimanual examination:
detected if it is at least 5 cm

13. 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.

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

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

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

31. 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

36. 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.

37. 5. CT
Has little place in pregnancy in modern obstetrics

38. 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.

39. 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.

40. Management Depends on: Size Sonographic appearance Symptoms
Observation
Aspiration
Surgery

41. 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.

42. 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

43. 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

44. 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}.

45. 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

46. 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.

47. 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}.

48. 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.

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

50. 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.

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

52. 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

53. 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.

54. 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.