Adnexal masses in pregnancy: a series of 12 patients

Objective

The aim of this study was to evaluate the clinico-pathological features, rate of complications and pregnancy outcomes of pregnancy-associated adnexal masses.

Methods

A total of twelve patients were admitted to our clinic with diagnosis of adnexal mass in pregnacy during this period. Eleven of the twelve patients have been operated. Four of eleven patients (33,3 %) needed an emergency surgical intervention due to clinical signs and symptoms of acute abdomen. Three of these cases (25%) were diagnosed as adnexal torsion. Seven of the patients (58,3 %) were operated under elective conditions. The most common histopathological diagnosis was dermoid cyst (27.3%) and mucinous cystadenoma in 27.3% of cases. None of the cases were malignant. None of the patients had an adverse pregnancy outcome due to emergency laparotomy.

Results

A retrospective study was designed to review the medical records of cases of adnexal masses in pregnancy that admitted to our tertiary center clinic between November 2006 and August 2009.

Conclusion

Conservative management can be preferred in pregnancy associated adnexal masses which don’t cause acute abdomen and do not have the signs of malignity with clinical evaluation and imaging methods.

Keywords

Pregnancy, adnexial masses, management

Introduction

Adnexal masses in pregnancy are not rare or unusual findings. They are observed more frequently after the routine use of obstetric ultrasonographic examination for evaluation of pregnancy. The incidence of adnexal masses in pregnancy is estimated to be between 1% and 2%(1). Most of them are corpora lutea which are physiological conditions in pregnancy and tend to resolve spontaneously at the begining of the second trimester. Most clear cysts having less than 5 cm diameter are usually functional and can be managed expectantly as they also resolve by 16 weeks of pregnancy
(2). An adnexal mass persisting beyond 16 weeks of pregnancy needs to be considered for risks of torsion, tumor rupture and obstetric risks such as abortion, preterm labor and delivery, obstruction of labor, rupture of membranes(3). Additionally, such a condition carries the risk of malignant disease. The incidence of ovarian malignancy is reported to be as high as 2 to 6% among all adnexal masses diagnosed during pregnancy(4). The tumor antigen CA-125 has a limited value due to its elevated and fluctuating level in normal pregnancy and the other markers such as β-hCG and alpha-fetoprotein are routinely used for fetal surveillance rather than tumor detection during pregnancy
(5). There is still a controversy regarding the optimal management option, whether it should be in the form of expectant management or surgical intervention, for an adnexal mass diagnosed during pregnancy due to possible fetal risks and surgical morbidity on one hand, and the risk of need for emergency surgery and delay in the diagnosis of malignancy when expectant management is chosen, on the other hand(3). We conducted a retrospective review of the patients with adnexal masses some of whom operated during pregnancy and evaluated the pathological features, rate of complications and outcome of the pregnancies.

Methods

A retrospective study was designed to review the medical records of cases of adnexal masses in pregnancy that admitted to our tertiary center clinic between November 2006 and August 2009 . There were totally 3306 deliveries during the period of the study. Age, gravidity, parity were noted. Gestational weeks at the time of diagnosis, gestational age at the time of delivery and at the time of surgery (if surgery is performed) were collected according to date of the first day of last menstrual period and if those were missing, depending on the ultrasonographic fetal biometry at the first trimester. Three dimensional diameters of the masses in milimeters were measured sonographically and the mean sizes were calculated by division of sum of these three diameters into three. Cases were divided into two according to the indication of the surgery, whether they are emergent or elective. The ultrasonographic findings of masses such as septations and papillary projections were noted. Complaints of the patients for hospital admission (if they existed), serum CA-125, β-hCG and alpha-fetoprotein levels were collected. The surgical aspects, type of delivery (C-section and vaginal delivery), postoperative complications such as PPROM and preterm labor and the treatment modalities for postoperative complications were established. Birth weight and gender of babies, apgar scores at the first and the fifth minutes, perinatal and neonatal complications were defined. Finally, pathological diagnosis of surgical specimen and frozen section specimen (if they were needed to be sent to the pathology department intraoperatively) were noted from the pathological examination reports. Values were expressed as mean±SD (standard deviation) unless stated otherwise.

Results

A total of twelve patients were admitted to our tertiary center clinic with diagnosis of adnexal mass in pregnacy between November 2006 and August 2009. The mean maternal age was 24,1±3,8 years (range 19-31 years). The mean gravidity was 1,9±0,99 (range 1-4) and mean parity was 0,67±0,78 (range 0-2). The median gestational weeks at the time of diagnosis of the adnexal mass and at the time of the surgery was 8 weeks and 3 days (range 5 weeks 5 days to 38 weeks 2 days) and 20 weeks (range 7 weeks to 38 weeks 6 days) respectively. The mean time of delivery was 37 weeks (range 32 weeks to 38 weeks 6 days). The mean birth weight was 3165±644 grams (range 2260 to 4110 grams). The mean first minute Apgar score was 7,5±1,4 (range 5 to 9) and the fifth minute was 8,7±1,0 (range 7 to 10) (Table1). The mean size of the masses were 87,83±48,18 milimeters (range 41 mm to 210 mm). Serum CA-125 levels were assessed in nine of twelve patients and the mean level was 41,78±37,0 IU/ml (referance range 0 – 35 IU/ml) (range 11 to 130 IU/ml). As a sum, eleven of the twelve patients have been operated. Four of eleven patients (33,3 %) needed an emergency surgical intervention due to clinical signs and symptoms of acute abdomen. Seven of the patients (58,3 %) were operated under elective conditions. In emergent cases, one was diagnosed at 31. week with the presenting symptom of abdominal pain. There was a 132 mm hypoechoic cystic mass in the left adnexa sonograhically. She had two previous cesarean sections. This patient admitted to the emergency department with severe abdominal pain and uterine contractions at 35. week. Cesarean and left oophorectomy was performed concurrently. Frozen section and final pathology report revealed a mucinous cyst adenoma. Three of these cases were diagnosed with the clinical symptoms and signs of adnexal torsion, two of which were the torsion of an ovarian mass (one was simple cyst and the second was hemorrhagic cyst) and one was isolated tubal torsion. Two of these patients underwent surgery at the first tirmester and the one (isolated tubal torsion) in the third trimester. Two of the emergent cases were operated just after the diagnosis of the adnexal lesion because the clinical presentation was adnexal torsion. One of them was 30 week and 1 day, there was a 73 mm multiloculated hypoechoic cystic mass with incomplete septations in the right adnexal region diagnosed with sonograhy. At laparotomy right ovary was appeared normal while the right fallopian tube was twisted two times around itself. The intraoperative findings at the emergent laparotomy were consistent with the isolated right tubal torsion. The fallopian tube was not seemed necrotic, so detorsion was done. 2 weeks later at 32. gestational week this patient admitted to the emergency department with regular uterine contractoins, 3 cm dilatation and 50% effacement. With the indication of breech presentation, cessarean section was performed and 2700 gr baby was born. The other case was diagnosed and operated at the nine week two days. The presenting symptom of this patient was abdominal pain. A 58 mm bilobulated hypoechoic cystic mass was diagnosed by sonography. CA-125 value of this patient was not studied due to urgent conditions of the operation. Intraoperative diagnosis was ovarian torsion. The final pathology report of this patient revealed necrotic hemorrhagic corpus luteum. This patient was lost to follow up after the operation. The other emergent case was diagnosed at 6 week and 5 day. There was a multiseptated anoekoik kistik lesion in the right adnexal region. At 10 week and 4 day this patient was admitted to the emergency department with the clinical signs and symptoms of acute abdomen. A laparotomy was made with the diagnosis of adnexal torsion. Intraoperatively right ovary was twisted around the infundibulopelvic ligament. The ovary was appeared edematous and hemorrhagic but not necrotic. So detorsion of the ovary and cystectomy was done. This patient had undergone elective cesarean at 38 week and 6 day and 2630 gr baby was born. There were 7 cases operated under elective conditions. Six of these seven patients were diagnosed at the first trimester by routine obstetric ultrasound examination. One of them was diagnosed at the third trimester. Three patients were operated in the first trimester, in one of the patients, surgery was delayed to second trimester. The remaining three patients including the patient diagnosed at the third trimester were operated during the cesarean section. In one of the patients, bilateral multiple simple ovarian cysts among which the biggest having the mean size 72 mm were diagnosed at the eleventh week. The appearance of ovaries was just like in the ovarian hyperstimulation syndrome, but there was no ascites and the conception was spontanous. These cysts have resolved during the course of pregnancy spontaneously, no surgery was intended for this patient. During the cesarean section, no adnexal mass was found. Two of the patients were lost to follow-up after the operation for adnexal mass. Eight of the remaining ten patients were delivered by cesarean section (80%) and two patients (20%) were delivered vaginally. Two of the patiensts operated under emergent conditions had preterm labor. One is the patient with isolated tubal torsion operated at 30 week and one day. At 32. week she had preterm labor. Due to breech presentation she had undergone cesarean section. The other one is the emergent patient with mucinous cyst adenoma who is operated at 35. week and had a cesarean at the same time. In three cases (27,3% of all cases), pathological diagnosis was mucinous cystadenoma. In the other three (27,3 % of all cases), the diagnosis was dermoid cyst (mature cystic teratoma). There was three adnexal torsion cases, one was torsion of right fallopian tube, two were torsion of benign simple cyst and hemorrhagic corpus luteum. In two cases, the pathologic diagnosis was paraovarian cyst (Table 2).

Discussion

In our series, 3 of 12 patients (25 %) required an urgent laparotomy with indication of adnexal torsion. One of them was isolated tubal torsion. The other two adnexal torsion cases had the diagnosis of corpus luteum and benign-functional cyst after the pathological examination. The rate of torsion reveals a great variability among the series, from 1 % to 22 %(6). Adnexal torsion usually presents in the first trimester, as the uterus is moving out of the pelvis, although some cases have been described in the second and, rarely, in the third trimester. The most common pathological diagnoses were dermoid cyst (mature cystic teratoma) and mucinous cystadenoma. The other pathologically reported cases were paraovarian cyst, benign-functional ovarian cyst and hemorrhagic corpus luteum. In literature dermoid cysts are the most common types of adnexal masses in pregnancy and tend to result in torsion more commonly. They comprise approximately 37% of all adnexal masses diagnosed during pregnancy. Cystadenomas are seen as 24 %, persistent corpus luteum cysts as 20 %, paraovarian cysts as 5 %, endometriomas as 5 %, leiomyomas as 5 %. Malignant tumors are found in upto 5,9% of the cases(7). In our series, we found no evidence of malignant disease. Also, no sonographic criteria for risk of ovarian malignities such as solid mass, nodular appearance, thick septations were observed in any of the cases. The incidence of malignancy for adnexal masses in pregnancy was estimated to be as high as 6.8%8. In our case series, we did not encounter any malignant cases. The management of adnexal masses during pregnancy is still a controversial issue. Surgery and observation of the mass are the two management options, but there is not a standard established protocol for those patients. Surgery is the preferred way of treatment when malignancy is suspected or there is the risk of torsion, cyst rupture or labor obstruction. Sometimes, observation of the lesion may be the optimum way of management to avoid maternal morbidity and adverse fatal-neonatal outcomes. In our series, we performed surgery for 11 of the 12 patients. Four of them were performed under emergency circumstances. Three of them presented with adnexal torsion and one of them presented with signs of the acute abdomen and had a mass of 132 mm diameter. There were no significant difference between emergent and elective surgery groups according to maternal and fetal-neonatal outcomes. Results of similar series are consistent with ours when the perinatal outcomes of emergent and elective surgery were compared. Also, no postoperative complications and maternal morbidity is observed in our series.

Conclusion

Majority of adnexal masses that observed in the first trimester are corpus luteum cysts and they are expected to resolve spontaneously at the begining of the second trimester. Adnexal masses persisting beyond the second trimester need to attract attention especially due to their risks of torsion and rupture and potential obstetrical risks they carry. Also, there is a risk of missing the underlying malignancies. Although, no maternal or fetal-neonatal adverse outcome is reported in this series, surgical point of view must be limited in patients having the risks previously mentioned. Conservative management can be preferred in pregnancy associated adnexal masses which don’t cause acute abdomen and do not have the signs of malignity with clinical evaluation and imaging methods. Further studies and larger series are needed to have more clear guidelines on management of adnexal masses in pregnancy which is still a challange and issue of controversy.

References

1) Leiserowitz GS, Xing G, Cress R, Brahmbhatt B, Dalrymple JL, Smith LH. .Adnexal masses in pregnancy: how often are they malignant? .Gynecol Oncol. May 2006;101(2):315-321..
2) Turkcuoglu I, Meydanli MM, Engin-Ustun Y, Ustun Y, Kafkasli A. .Evaluation of histopathological features and pregnancy outcomes of pregnancy associated adnexal masses. .J Obstet Gynaecol. Feb 2009;29(2):107-109..
3) Kumari I, Kaur S, Mohan H, Huria A. .Adnexal masses in pregnancy: a 5-year review. .Aust N Z J Obstet Gynaecol. Feb 2006;46(1):52-54..
4) Leiserowitz GS. .Managing ovarian masses during pregnancy. .Obstet Gynecol Surv. Jul 2006;61(7):463-470..
5) Hasiakos D, Papakonstantinou K, Kontoravdis A, Gogas L, Aravantinos L, Vitoratos N. .Adnexal torsion during pregnancy: report of four cases and review of the literature..J Obstet Gynaecol Res. Aug 2008;34(4 Pt 2):683-687..
6) Yen CF, Lin SL, Murk W, et al. .Risk analysis of torsion and malignancy for adnexal masses during pregnancy. .Fertil Steril. May 2009;91(5):1895-1902..
7) Hess LW, Peaceman A, O’Brien WF,Winkel CA, Cruikshank DP, Morrison JC.Adnexal mass occurring with intrauterine pregnancy: report of fifty-four patients requiring laparotomy for definitive management.American Journal of Obstetrics and Gynecology 1988;158:1029–1034.

	File/Dsecription
	Table 1. Information on maternal and neonatal.
	Table 2. Clinical characteristics of patients.
	Table 3. Pathological features of adnexal masses (n=11).