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Review Management of adnexal

masses in pregnancy
Authors Chris P Spencer / Phil J Robarts
Asymptomatic adnexal masses are frequently diagnosed in
pregnancy, either at the early booking scan or at the time of
caesarean section. They are mostly ovarian in origin. In this
article we discuss the role of magnetic resonance imaging,
computed tomography, Doppler studies and the use of tumour
markers in diagnosis. The majority of 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. If
there is a suspicion of malignancy or there is a significant cyst
complication, such as torsion, and surgery is planned, this should
take place during the second trimester to minimise the risk of
miscarriage.
Keywords adnexal masses / magnetic resonance imaging / ovarian cancer / ovarian
cysts / pregnancy / ultrasonography
Please cite this article as: Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. The Obstetrician & Gynaecologist 2006;8:1419.
Author details
Chris P Spencer MD FRCOG
Consultant in Obstetrics and Gynaecology
St Johns Hospital, Wood Street, Chelmsford,
CM2 9BG, UK
E-mail: cpspencer@doctors.org.uk
(corresponding author)
Phil J Robarts FRCOG
Consultant in Obstetrics and Gynaecology
St Johns Hospital, Chelmsford, UK
Review 2006;8:1419 10.1576/toag.8.1.014.27203 www.rcog.org.uk/togonline The Obstetrician & Gynaecologist
14 2006 Royal College of Obstetricians and Gynaecologists
Introduction
Routine sonographic assessment of women in
early pregnancy for the purposes of dating,
viability and determination of the number of
fetuses, as well as the measurement of nuchal fold
thickness, has led to an increase in the diagnosis of
adnexal masses. Before the routine use of obstetric
ultrasound, adnexal masses were only discovered
on abdominal or pelvic examination. These masses
are now reported in up to 4% of all pregnant
women.
1
In addition, the incidence of ovarian
pathology detected at caesarean section has been
reported as being 0.5%.
2
The majority of adnexal
masses are ovarian in origin, but can also be due to
paratubal cysts, chronic fallopian tube disease
(hydrosalpinges) and fibroids that appear to be
extrauterine. Fibroids that are pedunculated or
located in the broad ligament are sometimes seen
as separate from the uterus and thus reported as
adnexal masses. The causes of adnexal masses are
listed in Box 1.
Nearly all ovarian masses detected in pregnancy
are benign, but the overall reported incidence of
ovarian cancer in pregnant women varies from
0.0040.04%.
311
The most commonly reported
malignancy in pregnancy and the puerperium
appears to be breast cancer.
11
Most of the ovarian
masses diagnosed appear to be borderline with a
low malignant potential
3,8
and are complex on
ultrasound assessment. Malignant tumours vary in
size but 75% of them are larger than 5 cm in
diameter and most of these have solid, as well as
cystic, elements on ultrasound evaluation.
4
Diagnosis of adnexal masses
The use of ultrasound in early pregnancy, both
abdominal and transvaginal, is the most
commonly employed imaging modality. If the
woman is assessed by bimanual examination, an
adnexal mass can be detected if it is at least 5 cm
in diameter. Tables 1 and 2 summarise the
ultrasound appearances of the various adnexal
conditions encountered. Ultrasound images of
various adnexal masses are shown in Figures 14.
Other radiological techniques include magnetic
resonance imaging (MRI) and computed
tomography (CT). Although the overall incidence
of adnexal masses in pregnancy is approximately
4%,
12
the incidence of complex or simple
persistent cysts measuring more than 6 cm is only
0.07%.
13
Three-quarters of these persistent cysts
are complex in nature and the majority of
complex cysts are either benign teratomas or
endometriomas. Other pathologies include
paratubal cysts and cystadenomas.
According to several studies, the rate of ovarian
cancer in adnexal masses varies considerably.
Some researchers have found no confirmed cancer
cases at all,
1214
while others have quoted rates of
0.8%,
15
3.6%,
16
6%,
3,17
and even as much as
13%.
4
Table 3 summarises these studies over the
last two decades. It should be noted that in all
these series, the majority of tumours identified
have been shown to be early stage borderline
tumours. The range of histologies of the invasive
tumours are summarised in Box 2.
The role of MRI and CT
scanning
MRI can safely be used in pregnancy but is more
expensive and more time consuming than
ultrasonography. Nevertheless, MRI is particularly
good at defining both endometriotic and dermoid
cysts (benign teratomas)
18,19
and provides
superior resolution when compared with CT
scanning methods.
20
Other advantages of MRI
scanning include the ability to create images in
several planes and the lack of ionising radiation
requirement compared with CT scanning.
Consequently, the use of CT scanning in
Type of mass Ultrasound appearance Resolution rate (%)
Table 1
Ultrasound appearance of common ovarian
cysts in pregnancy and resolution rates
Simple ovarian cysts
(follicular, corpus
luteal)
Unilocular, thin-walled,
anechoic
90100 if ,5 cm in
diameter
Haemorrhagic cysts Anechoic with
echogenic material
within cyst
90100
Hyperstimulated
ovaries
Massively enlarged,
thin-walled,
multilocular cysts
.90
Ascites may be present
Ovarian
Simple cyst
Haemorrhagic cyst
Hyperstimulation in women who have undergone
fertility treatment
Luteoma
Endometrioma
Brenner tumour
Epithelial tumours: serous and mucinous;
endometrioid and clear-cell carcinomas
Germ cell tumours: mature and immature teratomas,
dysgerminomas, endodermal sinus tumours,
embryonal carcinomas
Sex cord-stromal tumours: fibrothecomas; granulosa
cell, sclerosing stromal and Sertoli-Leydig cell tumours
Metastatic (secondary) tumours; for example,
Krukenberg
Lymphoma
Tubal
Hydrosalpinx
Heterotopic pregnancy
Paratubal cyst
Leiomyoma
Non-gynaecological
Mesenteric cyst
Appendix mass
Diverticular disease
Pelvic kidney
Urachal cyst
Box 1
Causes of adnexal masses
in women with an
intrauterine pregnancy
The Obstetrician & Gynaecologist 2006;8:1419 Review
2006 Royal College of Obstetricians and Gynaecologists 15
pregnancy has little place in modern obstetric
practice. As with other non-pregnant patients,
there are contraindications to the use of MRI in
pregnancy and these include the presence of
ferromagnetic aneurysm clips and severe maternal
claustrophobia. Although the movement of the
fetus can produce erroneous images, this can be
reduced with the use of fast imaging techniques.
Using MRI, endometriotic cysts typically appear to
have a homogenous high-signal intensity on T1-
weighted images and a low-signal intensity on T2-
weighted images. The high fat and sebum content
of dermoid cysts can be detected easily using MRI
scanning; these cysts typically demonstrate high-
signal intensities on T1-weighted images and
reduced signal intensities on fat-suppressed
images. In addition, MRI can be useful in
confirming the diagnosis of large degenerating
leiomyomas, which can resemble ovarian tumours.
These typically show high-signal intensity on T1-
weighted imaging and have characteristic
appearances on T2-weighted imaging.
MRI can be particularly helpful in the assessment
of an ovarian mass that is thought to be malignant
partly because of its ability to identify vegetations
in a cystic tumour and necrosis in a solid
tumour.
21
Enhanced accuracy of MRI can be
obtained with the use of gadolinium contrast
enhancement,
22
but the use of this agent in
pregnancy is contraindicated due to its ability to
cross the placenta and unknown half-life within
the fetal circulation.
The role of tumour markers
In the non-pregnant state, CA125 is the most
reliable serum marker for epithelial ovarian
carcinoma as it is raised in over 75% of cases.
23
In
addition, measurement of serum CA125 levels is
useful in determining a womans response to
postoperative chemotherapy and in detecting early
relapse in women who have already received a
diagnosis of ovarian cancer. Serum alpha-
fetoprotein (AFP) and beta-hCG (human chorionic
gonadotrophin) levels are also very useful in the
preoperative evaluation and management of
ovarian germ cell tumours in non-pregnant
women. In addition, elevated serum inhibin levels
can be detected in women with granulosa cell
tumours of the ovary and mucinous carcinomas.
During pregnancy, however, serum AFP, beta-
hCG and inhibin levels are all raised due to
placental synthesis and thus the use of these
markers in evaluating suspicious ovarian cysts is
limited. Serum CA125 levels also become elevated
during pregnancy
24
due to decidual cell
production,
25
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-
Table 2
Ultrasound appearances of adnexal
pathology
Pathology Ultrasound appearance
Teratoma Complex mass with solid and cystic areas due to
presence of fat, bone, sebaceous material and hair
Endometrioma Diffuse ground glass pattern due to presence of old
blood (chocolate) within the cyst
Malignant/
borderline ovarian
tumour
Complex, multi-septate mass with solid and cystic
areas
Papillary projections or mural nodules
Ascites may be present
Appearance may be bilateral in up to 25% of cases
Hydrosalpinx Tubular-shaped structure with anechoic content and
incomplete septum of tubal wall
Always stays the same size during pregnancy
Leiomyoma Hypoechoic, round, solid masses
Cystic change may occur if red degeneration develops
Figure 1
Simple ovarian cyst
Figure 2
Benign ovarian teratoma
Figure 3
Endometriotic cyst
Figure 4
Complex ovarian cyst
Review 2006;8:1419 The Obstetrician & Gynaecologist
16 2006 Royal College of Obstetricians and Gynaecologists
pregnant state.
26
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. Certain malignant germ
cell tumours, such as ovarian dysgerminomas, have
been found to be associated with raised serum
lactate dehydrogenase (LDH) levels.
27
However,
due to the rarity of this neoplasm, data regarding
this association are sparse.
The role of Doppler studies
The use of colour flow Doppler imaging to
distinguish benign from malignant ovarian masses
in the non-pregnant state has been studied.
28,29
Malignant masses are usually vascular while
benign lesions demonstrate little or no blood flow.
In tumours that have malignant potential, the
resistance and pulsatility indices are usually less
than 1, but this pattern is also seen in many benign
conditions such as endometriomas, corpus luteal
cysts and other benign complex ovarian masses. In
addition, due to increased pelvic vascularity in
pregnancy, the degree of overlap of these indices
in both benign and malignant lesions makes
Doppler imaging unreliable in this setting.
30
Management in pregnancy
Management in pregnancy depends on the size of
the adnexal mass, its sonographic appearance and
any associated clinical symptoms, although the
majority of women are likely to be asymptomatic.
Simple cysts that are less than 5 cm in diameter do
not need further evaluation and rescanning is only
required if there is a clinical indication, such as
pelvic pain. The majority of simple cysts resolve
spontaneously during the course of pregnancy
7,31
and women should be reassured as such. Cysts
that have a complex nature, i.e. solid and cystic
elements, need further evaluation irrespective of
size. Further ultrasound assessment should take
place at 4-week intervals to determine whether the
cyst is becoming larger. In the majority of cases,
both simple cysts larger than 6 cm and all complex
cysts resolve during the course of the pregnancy.
7
Adnexal masses that undergo torsion are usually
dermoids or cystadenomas. If this complication
occurs, it does so during the first trimester or in
the immediate puerperium (up to 14 days after
delivery) and more commonly on the right side.
Ovarian dermoids that measure less than 6 cm are
unlikely to grow significantly in pregnancy and
can be managed conservatively as the risk of
complications, such as torsion, is thought to be
low.
32
The woman should be rescanned in the
postnatal period to determine further
management of any ovarian dermoid that has not
resolved spontaneously.
Persistent, simple, unilocular cysts without any
solid elements that are larger than 10 cm can be
aspirated either transvaginally or abdominally
under ultrasound guidance using a fine needle
(greater than 20 gauge).
33
This procedure is only
indicated if the cyst is causing pain or thought to
be increasing the risks of fetal malpresentation or
obstructed labour due to its location in the
pelvis.
13,33
Although not commonly employed,
this technique seems to be a reasonable alternative
to surgery in suitable women and appears to be
Author Year
Number of
women with
adnexal mass
(surgical)
Incidence per
live births Commonest lesion found
Number of women
with
malignant
tumours* (%)
Table 3
Summary of published studies of adnexal
masses in pregnancy
Hasan
42
1983 10 (10) 1 in 900 Benign cystic teratoma 1 (10)
Ballard
40
1984 93 (93) 1 in 594 Benign cystic teratoma 2 (2.2)
Struyk
41
1984 90 (69) 1 in 640 Benign cystic teratoma 3 (4)
Hopkins
43
1986 23 (23) 1 in 556 Benign cystic teratoma
Nelson
1
1986 38 (5) 1 in 88 Corpus luteal cyst
Hogston
5
1986 137 (21) 1 in 191 Simple cyst 1 (0.73)
Ashkenazy
6
1987 38 (38) 1 in 2328 Benign cystic teratoma 2 (5.3)
Thornton
31
1987 131 (81) 1 in 346 Benign cystic teratoma 7 (8.6)
Tchabo
10
1987 12 (12) 1 in 2334 Benign cystic teratoma 1 (8.3)
Hess
17
1988 54 (54) 1 in 1300 Benign cystic teratoma/cystadenoma 2 (5.9)
Koonings
2
1988 91 (91) 1 in 197 Benign cystic teratoma
Sunoo
44
1990 228 (228) 1 in 163 Hydatid cyst of Morgagni
El-Yahia
45
1991 67 (67) 1 in 653 Benign cystic teratoma 3 (4.5)
Platek
13
1995 31 (19) 1 in 1399 Functional cyst (simple/haemorrhagic)
Ueda
38
1996 106 (106) 1 in 79 Benign cystic teratoma 5 (4.7)
Bromley
15
1997 125 (96) Not recorded Benign cystic teratoma 1 (0.8)
Hill
12
1998 328 (18) 1 in 444 Benign cystic teratoma
Whitecar
3
1999 130 (130) 1 in 1312 Benign cystic teratoma 8 (6.1)
Bernhard
7
1999 432 (25) 1 in 43 Benign cystic teratoma 1 (0.23)
Zanetta
16
2003 82 (23) 1 in 84 Benign cystic teratoma 3 (3.6)
Sherard
4
2003 56 (56) 1 in 602 Benign cystic teratoma 8 (14.2)
Condous
14
2004 161 (7) 1 in 19 Serous cystadenoma 1 (0.62)
Lee
39
2004 89 (89) Not recorded Benign cystic teratoma 2 (2.2)
Schmeler
46
2005 63 (59) 1 in 2000 Benign cystic teratoma 5/59{ (8.5)
*Including borderline tumours
Immature teratoma
Serous/mucinous cystadenocarcinoma
Dysgerminoma
Granulosa cell tumour
Sertoli-Leydig cell tumour (androblastoma,
arrhenoblastoma)
Burkitts lymphoma
Box 2
Histology type of invasive
ovarian cancer in adnexal
masses
The Obstetrician & Gynaecologist 2006;8:1419 Review
2006 Royal College of Obstetricians and Gynaecologists 17
well tolerated and without short or long-term
complications. Local anaesthesia is normally used
for the skin and antibiotic cover given. All fluid
aspirated should be sent for cytological analysis
and the woman subsequently rescanned to
determine whether cyst recurrence has taken place.
The risk of this is thought to be in the region of
3350%
33
and the mother should therefore be
counselled that further aspirations can be required
during the rest of the pregnancy. Fine needle
aspirations should be done after 14 weeks of
gestation in order to minimise disturbance to the
corpus luteum.
The indications for surgery will depend on the
degree of suspicion of malignancy in the mass or
the development of cyst complications (Box 3). If
there is doubt regarding the diagnosis, MRI can
prove useful as a tool to help distinguish dermoids
and endometriomas from malignant neoplasms. If
elective surgery is embarked upon, this should be
done after 14 weeks gestation to minimise the risk
of fetal loss due to miscarriage, although this risk
is very small.
34,35
This recommendation is based
on the principle that the developing pregnancy is
dependent on the corpus luteum during the first
trimester and much less so after 12 weeks. The
standard approach is to perform the surgery via a
laparotomy but laparoscopic surgery has been
used, although it is skill-dependent and more time
consuming than open surgery.
36
If laparoscopic
surgery is performed during the second trimester,
an open method (Hasson) is preferred to avoid
uterine injury from the primary trocar
introduction.
37
The routine use of tocolytic drugs
is not thought to be necessary, but if uterine
irritability occurs, then standard tocolytic
regimens can be employed.
Adnexal pathology detected for the first time at
caesarean section has been reported in the region
of 0.5%,
2
but this figure is likely to be lower in
areas where routine antenatal ultrasound is
employed for dating and fetal anatomy assessment
purposes. If adnexal pathology is discovered at
caesarean section, the options include:
conservative management, ovarian cystectomy or
oophorectomy. Simple cysts that are smaller than
5 cm in diameter can be left alone but larger cysts
or those appearing complex should be treated by
cystectomy.
Care should be exercised in removing cysts in
order to avoid intra-abdominal contamination.
The most common lesions found are dermoid
cysts, paratubal cysts, cystadenomas,
endometriotic cysts and corpus luteal cysts.
2
After
cyst removal, the contents should be inspected
thoroughly before closing the mothers abdomen.
If there are any signs of malignancy, such as the
presence of solid excrescences, the ovary should be
removed completely or, if available, rapid frozen
section assessment performed. The contralateral
ovary should be examined thoroughly and, if
indicated, biopsied accordingly.
Conclusions
Over the last 20 years, the use of ultrasound in
pregnancy has dramatically increased and many
centres now offer early dating scans as well as 20-
week fetal anomaly scans. Consequently, the
numbers of ovarian cysts diagnosed has increased,
leading to a greater probability of operative
intervention. The majority of these ovarian cysts
in pregnancy either resolve spontaneously or are
Figure 5
Clinical algorithm for the management of ovarian
cysts in pregnancy.
Box 3
Complications of ovarian
cysts in pregnancy
Cyst rupture
Cyst haemorrhage
Torsion (up to 5%)
Obstructed labour
Fetal malpresentation
Review 2006;8:1419 The Obstetrician & Gynaecologist
18 2006 Royal College of Obstetricians and Gynaecologists
due to benign conditions, such as dermoids or
endometriomas. 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 is largely dependent on operator
experience and patient preference. In some
situations, there may be grounds for performing
an elective caesarean section at term in addition to
dealing with a large, complex ovarian tumour that
has persisted during the pregnancy but which has
not required earlier operative intervention.
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. Figure 5 provides a
clinical algorithm for the management of ovarian
cysts in pregnancy.
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