Imaging of Adnexal Masses in Pregnancy

Gloria Chiang, BA, Deborah Levine, MD

Objective. To illustrate the imaging appearances of a variety of adnexal masses in pregnancy.
Methods. Cases of adnexal masses in pregnancy were chosen to illustrate the appearance on ultra-
sonography and magnetic resonance imaging. Results. Adnexal masses in pregnancy have a wide
spectrum of imaging characteristics and clinical manifestations. Sonography is important in diag-
nosing, monitoring, and determining the malignant potential of these masses. Common adnexal
lesions seen in pregnancy include simple cysts, hemorrhagic cysts, leiomyomas, and hyperstimulat-
ed ovaries in patients who have undergone assisted fertility. Uncommon adnexal lesions specific to
pregnancy include hyperreactio luteinalis, theca lutein cysts with moles, and luteomas. Adnexal
masses associated with pain include ovarian torsion and heterotopic pregnancy. Adnexal lesions
that are found incidentally include teratomas, endometriomas, hydrosalpinx, cystadenomas, and
cystadenocarcinomas. When the diagnosis of the adnexal mass cannot be made on the basis of
sonographic appearance alone, magnetic resonance imaging may help. Conclusions. Familiarity
with the clinicopathologic and sonographic features of common and uncommon adnexal masses
in pregnancy is important for diagnosis and treatment. Key words: magnetic resonance imaging;
neoplasm; ovary; pregnancy; sonography.
Received December 28, 2003, from Harvard
Medical School (G.C.) and Departments of
Radiology and Obstetrics and Gynecology, Beth
Israel Deaconess Medical Center (D.L.), Boston,
Massachusetts USA. Revision requested January 21,
2004. Revised manuscript accepted for publication
February 10, 2004.
Address correspondence and reprint requests to
Deborah Levine, MD, Department of Radiology,
Beth Israel Deaconess Medical Center, 330
Brookline Ave, Boston, MA 02215.
E-mail: dlevine@caregroup.harvard.edu.
Abbreviations
hCG, human chorionic gonadotropin; MR, magnetic
resonance; T1, longitudinal relaxation time; T2, trans-
verse relaxation time
dnexal masses in pregnancy have a wide spec-
trum of imaging characteristics and clinical
manifestations. Between 1% and 2% of preg-
nant women will have an adnexal mass that is
sonographically detected and is persistent, and 1% to
3% of these will be malignant.
1,2
Sonography is impor-
tant in diagnosing, monitoring, and determining the
malignant potential of these masses.
Common adnexal lesions associated with pregnancy
include simple cysts, hemorrhagic cysts, leiomyomas, and
hyperstimulated ovaries in patients who have undergone
assisted fertility. Uncommon adnexal lesions specific to
pregnancy include hyperreactio luteinalis, theca lutein
cysts with moles, and luteomas. Adnexal masses associat-
ed with pain include ovarian torsion and heterotopic
pregnancy. Some adnexal entities are found incidentally,
such as teratomas, endometriomas, hydrosalpinx, cys-
tadenomas, and cystadenocarcinomas. Although the
diagnosis of most adnexal pathologic conditions can be
made on the basis of sonographic appearance alone,
magnetic resonance (MR) imaging may help when the
2004 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2004; 23:805819 0278-4297/04/$3.50
A
Image Presentation
sonographic appearance is not specific.
Familiarity with the clinicopathologic and sono-
graphic features of common and uncommon
adnexal masses in pregnancy is important for
diagnosis and treatment. In this image presenta-
tion, we illustrate common and uncommon
types of adnexal masses in pregnancy.
Cysts and More Cysts
Simple Cysts
Most adnexal masses detected on sonography
during pregnancy are simple cysts or hemor-
rhagic corpus luteum cysts. Simple cysts are
unilocular and anechoic and have a smooth, thin
wall (Figures 1 and 2). Corpus luteum cysts
enlarge during the first trimester, regress by the
12th week of gestation, and disappear later on in
the pregnancy.
3
Size is the best indicator of
whether the mass requires surgical intervention:
90% to 100% of masses smaller than 5 cm in
diameter will resolve spontaneously.
4
Because
larger cysts have an increased risk of torsion, rup-
ture, and labor obstruction, close monitoring
and sometimes surgery are necessary.
4,5
Hemorrhagic Cysts
Hemorrhagic corpus luteum cysts can have a
variety of sonographic appearances due to the
changing appearance of the blood clot.
Hemorrhagic cysts appear as predominantly
anechoic masses that contain hypoechoic
material within them (Figures 3 and 4). They
exhibit increased sound through-transmission
because of their fluid nature. Most resolve by the
second trimester.
6
Acutely hemorrhagic cysts can
appear as echogenic masses with internal echoes
more hyperechoic than surrounding normal
ovarian parenchyma (Figure 5).
Hyperstimulated Ovaries
Hyperstimulated ovaries are typically diagnosed
in patients who have undergone ovulation induc-
tion. The ovaries are enlarged with multiple cysts
(Figures 68). More than 90% of patients who
have hyperstimulation will have spontaneous
resolution of these benign cysts. Ovarian hyper-
stimulation syndrome appears as markedly
enlarged ovaries containing multiple, large,
peripherally located, thin-walled cysts that some-
times exude fluid from hemorrhage or ascites.
7
The large ovaries are at risk of torsion (Figure 9)
and hemorrhage, but usually they regress sponta-
neously later in pregnancy or after delivery.
7
Masses Unique to Pregnancy
Hyperreactio Luteinalis
A similar appearance of hyperstimulated ovaries
can be seen in patients who have not undergone
ovulation induction. It is thought to result from
hypersensitivity of the ovary to circulating
human chorionic gonadotropin (hCG), which
may or may not be high (Figures 10 and 11).
5,8
806 J Ultrasound Med 23:805819, 2004
Imaging of Adnexal Masses in Pregnancy
Figure 1. Corpus luteum cyst in a 29 year-old woman, 8 weeks
pregnant, with an 8-cm thin-walled anechoic cyst (calipers). The
cyst resolved after first-trimester therapeutic abortion.
Figure 2. Corpus luteum cyst in a 24 year-old woman at 19
weeks gestation being scanned for fetal anomalies, with inci-
dental note of a 4.5-cm left adnexal cyst. On MR imaging, this
has the characteristics of a benign cyst, being thin walled, with
fluid signal intensity on a T2-weighted image, and having no
nodular elements. This cyst was present slightly later in gestation
than the typical corpus luteum cyst. However, it had resolved at
the time of postpartum imaging.
Because this is commonly mistaken for an ovari-
an neoplasm, MR imaging can be used to better
visualize the predicted sites for peritoneal
implants that are associated with ovarian malig-
nancy and to decrease the likelihood of this pos-
sibility.
5
The lesions usually spontaneously
involute after delivery.
5
This condition can be seen in a normal preg-
nancy but has also been associated with polycys-
tic ovary disease and triplet pregnancies (due to
high levels of hCG).
5,810
Clinical manifestations
J Ultrasound Med 23:805819, 2004 807
Chiang and Levine
Figure 5. Acutely hemorrhagic cyst. Transvaginal scan from a
35-year-old woman shows a 5.5-cm echogenic mass with
internal echoes more hyperechoic than surrounding ovarian
parenchyma and with echogenicity greater than that seen in
the typical hemorrhagic cyst, consistent with an acutely hem-
orrhagic cyst.
Figure 4. Hemorrhagic cyst, 38-year-old woman with a 5-cm
multiloculated cyst with thick septations in the right ovary
(calipers), consistent with the classic cobweb appearance of a
hemorrhagic cyst.
Figure 3. Ruptured hemorrhagic cyst in a 34 year-old woman, 7
weeks pregnant, with sudden onset of lower abdominal pain,
nausea, and loss of consciousness. Hematocrit was 36% and
subsequently dropped to 28% after intravenous fluid resuscita-
tion. A, Transabdominal scan shows an intrauterine gestational
sac (g), with subchorionic hemorrhage (arrow) and a moderate
amount of free fluid (ff) in the pelvis compatible with hemor-
rhage. B, Sagittal view of the right upper quadrant shows fluid
(arrowheads) with debris (D), consistent with a large amount of
blood around the liver. C, Transvaginal scan shows a 6-cm het-
erogeneous right adnexal mass (M). This appearance was consis-
tent with either a ruptured hemorrhagic cyst or heterotopic preg-
nancy. A ruptured hemorrhagic cyst was found on laparoscopy.
A
B
C
include maternal abdominal pain, excessive
abdominal distention, abnormal liver function
test results, respiratory difficulties, and hir-
sutism.
5
Patients with this condition may also
be asymptomatic. These lesions may be found
incidentally during routine obstetric imaging or
cesarean delivery.
Theca Lutein Cysts With Moles
Molar pregnancy complicates about 0.1% of
pregnancies.
11
Theca lutein cysts are reported
with complete hydatidiform moles 14% to 30%
of the time.
12
They appear as anechoic, multi-
loculated, ovarian cysts (Figure 12). The pres-
ence of a uterus filled with echogenic tissue
with small cysts is the key to the diagnosis.
These cysts are typically not seen in the first
trimester of molar pregnancies because of rela-
tively low -hCG values at that time.
13
Partial
molar pregnancy is not likely to have theca
lutein cysts.
808 J Ultrasound Med 23:805819, 2004
Imaging of Adnexal Masses in Pregnancy
Figure 6. Hyperstimulated ovaries in a 32-year-old woman, 19 weeks pregnant, with twins conceived by in vitro fertilization. A and B, Transvaginal
views show enlarged ovaries measuring up to 11 cm, with the largest cyst being 8 cm. The cysts resolved during pregnancy and were no longer pre-
sent at the time of cesarean delivery.
A B
Figure 7. Hyperstimulated ovaries in a 36-year-old woman, 18 weeks pregnant, with twins conceived by in vitro fertilization. A and B, Transabdominal
scans show 9-cm ovaries with multiple cysts, the largest of which was 11 cm. Ovaries were normal at the time of cesarean delivery at 32 weeks.
A B
Luteomas
Luteomas are rare solid ovarian lesions that
occur in pregnancy. Fewer than 200 cases of
luteoma have been reported in the literature.
14
Luteomas cause maternal virilization in 25% to
30% of cases and carry a 50% risk of virilizing a
female fetus.
15,16
Luteomas are usually asymp-
tomatic and are found incidentally at cesarean
delivery.
15,16
They are thought to result from ele-
vated plasma androgens after stromal cell prolif-
eration during pregnancy and to involute post-
partum with falling androgen levels.
14,15
On sonography, they appear as heterogeneous
solid masses, predominantly hypoechoic com-
pared with normal ovarian tissue, with thick
walls and irregular internal contours in an
enlarged ovary (Figure 13).
14,15
They are often
highly vascular and mimic ovarian neoplasms.
14
The appearance of virilizing symptoms in the
pregnant patient leads to this diagnosis. When a
luteoma is suspected, laparotomy can be avoid-
ed during pregnancy because the lesions regress
after delivery.
Masses Associated With Pain
Leiomyomas
Leiomyomas are the most common solid masses
in pregnancy.
3
They are seen on sonography in
1.4% of pregnancies.
17
Most are within the body of
the uterus, but pedunculated and broad-ligament
myomas can simulate an ovarian neoplasm.
They appear on sonography as hypoechoic,
round, persistent masses (Figure 14). Leiomyo-
mas may enlarge during pregnancy and may
cause focal pain. When the leiomyoma outgrows
its blood supply, it may undergo red degenera-
tion, which results in the development of cystic
spaces, an echogenic rim, or a coarse heteroge-
neous pattern consisting of hyperechoic clusters
with focal areas of distal shadowing.
3,18
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Chiang and Levine
Figure 9. Hyperstimulated ovary with torsion in a 31-year-old woman at
11 weeks gestation with hyperstimulated ovaries and severe right lower
quadrant pain. A, Transabdominal scan shows an enlarged ovary, mea-
suring up to 11 cm. B, Transvaginal scan shows an arterial waveform pre-
sent in the solid portion of the ovary. Venous flow was present. Because
of extreme pain, the patient was taken to surgery, during which the ovary
was found to be twisted 3 times about its pedicle.
A
B
Figure 8. Hyperstimulated ovaries in a 36-year-old woman, 12
weeks pregnant, with in vitro fertilization gestation. Transvaginal
scan shows 6-cm ovaries with multiple cysts, some of which con-
tain debris, consistent with hemorrhagic corpus luteum cysts. LO
indicates left ovary; and RO, right ovary.
Sonography is the mainstay of leiomyoma diag-
nosis. However, MR imaging can be helpful in
confirming the diagnosis of a large degenerating
leiomyoma, which can simulate an ovarian neo-
plasm on sonography (Figure 15). On longitudi-
nal relaxation time (T1)-weighted images,
degenerated leiomyomas appear heterogeneous
with central low intensity. When red degenera-
tion has occurred, the T1-weighted images can
show high signal intensity. On transverse relax-
ation time (T2)-weighted images, they can
appear heterogeneously bright centrally, with
punctate areas of hyperintensity and a thin band
of myometrium around them.
19,20
When blood
products are present, the T2-weighted appear-
ance can be variable. Magnetic resonance imag-
ing can clearly delineate the uterine origin of
leiomyomas, which can help differentiate them
from solid ovarian tumors, thereby avoiding
surgery during pregnancy.
21
Heterotopic Pregnancy
Heterotopic pregnancy occurs in 1 per 7000
pregnancies and is increasing because of the ris-
ing prevalence of ectopic pregnancies and
increased use of ovulation-inducing agents.
22
The reference standard is being able to identify
cardiac motion in intrauterine and extrauterine
pregnancies, but this only occurs in about 14% of
cases.
23
Heterotopic pregnancy should be con-
sidered in patients who have undergone ovula-
tion induction or in vitro fertilization but can also
occur spontaneously (Figure 16).
Ovarian Torsion
About 1% of large and complex masses have
torsion (Figures 1719).
2,25
Torsion of an ovarian
mass most frequently occurs in the mid to late
first trimester, when the gravid uterus is enlarg-
ing most rapidly.
26
Lack of flow on 2-dimensional
Doppler sonography of the ovarian vessels on
the ipsilateral side of the clinical condition is the
classic finding of ovarian torsion.
27
Care must
be taken in making the diagnosis of torsion
because blood flow may be present even in the
presence of torsion. This is due to the dual
blood supply of the ovary, with the ovarian
artery perfusing the ovary laterally and a branch
of the uterine artery perfusing the ovary medial-
ly. The presence of venous flow is predictive of
ovarian viability.
28
When an adnexal mass is
seen and the patient has severe pain, torsion
should be considered.
810 J Ultrasound Med 23:805819, 2004
Imaging of Adnexal Masses in Pregnancy
Figure 10. Hyperreactio luteinalis in a 34-year-old woman with
diamniotic dichorionic twins at 19 weeks. A, Transabdominal
scan shows the twins. B and C, Transvaginal scans show bilater-
al enlarged ovaries measuring up to 14 cm with multiple cysts.
Six weeks after vaginal delivery of twins, the ovaries had
decreased dramatically in size, but cysts were still present. The
woman was not taking hyperstimulating agents.
A
B
C
J Ultrasound Med 23:805819, 2004 811
Chiang and Levine
Figure 11. Hyperreactio luteinalis in a 38-year-old woman at 18
weeks gestation with large adnexal cysts noted on routine
obstetric sonography. The patient had not taken any hyperstim-
ulating agents. A, Right upper quadrant scan shows a portion
of the adnexal cyst (C). This was anechoic, measured 12 10
5 cm, and had thin septations versus adjacent cysts. B and C,
Axial and coronal T2-weighted MR images show the enlarged
cysts (C) in bilateral ovaries crossing the midline. No other
abnormality was visualized. The cysts resolved after delivery.
A
B
C
Figure 12. Complete hydatidiform mole with theca lutein cysts
in a 19-year-old woman, 11 weeks pregnant, with vaginal
bleeding and an hCG level of 400,000 U/L. A, Transabdominal
scan shows an enlarged uterus (calipers) with a thickened
endometrium and multiple small cysts. B and C, Transvaginal
scans show bilateral enlarged ovaries (calipers), the left up to
6 cm and the right up to 9 cm, with multiple cysts. The findings
are consistent with a complete hydatidiform molar pregnancy
with bilateral theca lutein cysts.
A
B
C
Massive ovarian edema occurs when there is
intermittent torsion of an ovary, which interferes
with venous and lymphatic drainage and causes
ovarian enlargement. It is usually unilateral and
involves the right ovary in two thirds of cases. On
sonography, it appears as a solid mass with a cys-
tic component and heterogeneous internal echo
texture (Figure 19). Magnetic resonance imaging
exhibits homogeneous low signal intensity on
T1-weighted imaging and high signal intensity
on T2-weighted imaging that becomes brighter
on more heavily T2-weighted images.
29,30
812 J Ultrasound Med 23:805819, 2004
Imaging of Adnexal Masses in Pregnancy
Figure 13. Luteoma in a 33-year-old woman, 28 weeks pregnant, with hirsutism and a 6-cm solid right adnexal mass. Serum androgen levels were ele-
vated. The mass decreased in size to 2 cm after delivery (not shown). Hirsutism resolved 6 months after delivery. A, Transvaginal scan shows a 5-cm solid
mass arising from normal-appearing ovarian tissue (arrowheads). B, Color Doppler image shows flow within the solid mass. Reproduced with permis-
sion from the Journal of Ultrasound in Medicine.
14
A B
Figure 14. Leiomyoma in a 33-year-old woman, 32 weeks preg-
nant, with a 7-cm complex right adnexal mass (calipers) with a
broad base in the myometrium, consistent with exophytic
leiomyoma. At first glance, it may look like a hemorrhagic cyst,
but hemorrhagic corpus luteum cysts do not persist into the
third trimester.
Figure 15. Degenerated leiomyoma in a 39-year-old woman,
16 weeks pregnant, with a 14-cm complex mass superior to the
uterus and separate from the ovaries on sonography. T2-weight-
ed MR image shows a broad base with the myometrium, low
signal intensity peripherally, and extensive high T2 signal areas
centrally, consistent with an exophytic degenerated leiomyoma.
This was of low signal intensity on T1-weighted imaging (not
shown), consistent with cystic degeneration.
Incidental Findings
Teratomas
Teratomas show a complex echo pattern due to
the presence of fat, solid components and calci-
fied material (Figure 20).
3,31
Acoustic shadowing
due to the dense calcification is also seen.
25
Most ovarian teratomas have a typical sono-
graphic appearance and can be correctly diag-
nosed by sonography. In the rare cases in which
the diagnosis is unclear, MR imaging is often
helpful in highlighting the fat within the mass.
21
Magnetic resonance imaging can also help
determine the size of the mass if surgical
removal is contemplated during pregnancy.
Teratomas may be pedunculated and are prone
to undergoing torsion and rupture, leading to
peritonitis.
3
Hydrosalpinx
Hydrosalpinx appears as anechoic tubular
fluid collections (Figure 21). They typically do
not change in size or appearance throughout
pregnancy.
31
J Ultrasound Med 23:805819, 2004 813
Chiang and Levine
Figure 16. Heterotopic pregnancy in a 32-year-old woman at 7 weeks gestation with abdominal pain. A, Transabdominal scan shows a live intrauter-
ine pregnancy with surrounding fluid with debris, consistent with blood. B, Transvaginal scan shows a 6-cm complex heterogeneous left adnexal mass
(arrowheads) that was separate from the ovary and a moderate amount of free fluid with debris. Histology showed ectopic pregnancy.
A B
Figure 17. Corpus luteum cyst with torsion in a 29-year-old woman, 9 weeks pregnant, with acute right lower quadrant pain. A, Transabdominal
scan shows a 12-cm ovary (calipers) containing 2 cysts with debris. B, No flow was seen in the walls of the cysts or adjacent ovarian tissue. At surgery,
torsion of 360 was noted. Histologic examination revealed corpus luteum cysts.
A B
Endometriomas
Because endometriosis is a cause of infertility,
it is uncommon to find an unsuspected
endometrioma at routine obstetric imaging.
Endometriomas have a classic appearance of a
chocolate cyst with diffuse low-level internal
echoes (Figure 22).
Cystadenomas and Cystadenocarcinomas
When an ovarian cyst is complex (and not hem-
orrhagic), the likelihood of neoplasm is
increased. Cystadenomas may be simple cysts
or have thin septations (Figures 2325). Serous
cystadenomas tend to be anechoic, whereas
mucinous tumors have low-level internal
echoes. Irregular septations and mural nodules
increase the likelihood of malignancy. When
malignancy is suspected in utero, a minilaparo-
tomy is typically performed in the second
trimester (to avoid spontaneous miscarriage in
the first trimester and the risk of precipitating
preterm delivery in the third trimester; Figure
26). If diagnosis is not made until late in gesta-
tion, surgical removal of the ovary can be per-
formed at the time of cesarean delivery.
814 J Ultrasound Med 23:805819, 2004
Imaging of Adnexal Masses in Pregnancy
Figure 18. Teratoma with torsion in a 28-year-old woman, 30
weeks pregnant, with acute right-sided pain. Sonography shows
a 9-cm cyst (calipers) with heterogeneous internal echoes and a
hyperechoic nodule, consistent with a teratoma. No Doppler
flow was seen around the cyst. At surgery, 2 complete twists of
the right adnexa were found. Histologic examination revealed a
teratoma. It is common to not visualize flow around a teratoma.
However, the amount of pain the patient has is the key to the
diagnosis.
Figure 19. Massive ovarian edema in a 33-year-old woman at 14 weeks
gestation with quadruplets spontaneously reduced to twins.
Sonography (not shown) showed an enlarging left adnexal mass. A,
Transverse T2-weighted MR image shows a 14-cm solid-appearing left
ovary (LO) with a high-signal-intensity stroma and peripheral cysts, some
of which are hemorrhagic. B, Transverse T2-weighted MR image shows
an enlarged hyperstimulated right ovary (RO) in the cul-de-sac.
Histologic examination showed massive ovarian edema of the left ovary.
Reproduced with permission from Abdominal Imaging.
24
A
B
Conclusions
Adnexal masses exhibit a wide range of imaging
characteristics. Knowledge of the clinical
appearance and sonographic findings allows for
correct diagnosis in most. Complex cystic mass-
es include corpus luteum cysts, theca lutein
cysts, cystadenomas, and teratomas. Solid mass-
es are commonly uterine leiomyomas. Magnetic
resonance imaging can be useful when the diag-
nosis is not clear on sonography.
J Ultrasound Med 23:805819, 2004 815
Chiang and Levine
Figure 20. Teratoma in a 38-year-old woman, 12 weeks preg-
nant, with incidental notation of a 4-cm echogenic left adnexal
mass (calipers) on a transverse view of gravid uterus. The cyst
was removed at the time of cesarean delivery, and histologic
examination revealed a teratoma.
Figure 21. Hydrosalpinx in a 19-year-old woman, 15 weeks
pregnant, with an oblong fluid collection (A, arrows) posterior to
the gravid uterus. B, Postpartum image showing a hydrosalpinx
(H) and a normal ovary (O).
A
B
Figure 22. Endometrioma in a 29-year-old woman with a 7 3
4-cm bilobed left adnexal mass with diffuse low-level internal
echoes seen at 11 weeks (A) and again at 28 weeks (B) with no
change. The cyst was removed after delivery, and histologic
examination showed an endometrioma.
A
B
816 J Ultrasound Med 23:805819, 2004
Imaging of Adnexal Masses in Pregnancy
Figure 23. Mucinous cystadenoma in a 41-year-old woman,
7 weeks pregnant, with a 16-mm cyst containing a 6-cm
mural nodule. The cyst was removed laparoscopically after a
miscarriage, and histologic examination revealed a mucinous
cystadenoma.
Figure 24. Mucinous cystadenoma in a 40-year-old woman, 17
weeks pregnant. A and B, Sonograms show an 8-cm predomi-
nately anechoic cyst with septations and no nodularity (B,
calipers). An MR examination was performed for further charac-
terization. C, Axial T2-weighted MR image shows the cyst (C)
with thin septations and no nodularity. Because both modalities
suggested a benign neoplasm, the cyst was followed during
pregnancy and was not removed until cesarean delivery.
Histologic examination showed a mucinous cystadenoma.
A C
B
J Ultrasound Med 23:805819, 2004 817
Chiang and Levine
Figure 25. Serous cystadenoma in a 34-year-old woman with a cyst. A, Transabdominal scan at 19 weeks shows a 10-cm left adnexal cyst (calipers),
anechoic, with a thin wall. B, At 31 weeks, the cyst (calipers) increased in size to 13 cm. After delivery (not shown), the cyst was 15 cm. It was removed
and found to be a benign serous cystadenoma.
A B
Figure 26. Borderline mucinous tumor in a 33-year-old woman with a complex cyst. A and B, Transvaginal scans at 8 weeks shows a 3.7 2.6
3.1-cm complex right ovarian cyst (calipers) with relatively avascular septations and avascular echogenic nodules. Follow-up sonography at 11 weeks
(not shown) showed no change. C and D, Coronal (C) and Axial (D) T2-weighted MR images reveal the complex cyst (C) with several septations, nodu-
lar components, and no fat (confirmed on T1-weighted images; not shown). Histologic examination revealed a borderline ovarian tumor.
A B
C D
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