Adnexal Masses in Pregnancy - Cmebyplaza.com

Adnexal Masses in Pregnancy 

James M. Shwayder, M.D., J.D. 

Associate Professor 

University of Louisville SOM 

Director: Division i i of Gynecology 

Director: Fellowship in Minimally Invasive Surgery 

Louisville, Kentucky


James M. Shwayder, MD, JD 

Disclosures: 

• Cook OB-Gyn: 

• Philips Ultrasound: 

• Ethicon EndoSurgery: 

Honorarium, Royalties 

Honorarium 

Honorarium, Fellowship Support

Objectives 

• Discuss the use of ultrasound in 

adnexal evaluation during pregnancy 

• Diagnosis 

• Patient counseling 

• Procedure planning 

• Case examples


• Age 

• Morphology 

• Doppler 

• Tumor markers

Age Related Risk of Malignancy of 

an Ovarian Tumor (959 Patients) 

Malignant 

Benign 

Age, Yrs N % N % RM (%) RR 

< 20 14 5 446 24.1 29 

2.9 

21 - 30 12 4 132 19 8.3 1.0 

31 - 40 21 8 138 20 13.2 1.6 

41 - 50 42 16 180 15 43.3 2.3 

51 - 60 81 30 106 15 43.3 5.2 

61 - 70 68 25 56 8 54.8 66 

6.6 

> 71 33 12 32 5 50.8 6.1 

Rate of malignancy (RM) 

Relative Risk of malignancy (PR) 

Minaretzis et al. Gynecol Obstet Invest 1994; 38, 140-144144

Morphology 

Differentiating Benign from Malignant Ovarian 

Lesions 

Author n PPV 

NPV 

Sens 

Spec 

Koboyashi (1976) 406 31 93 71 73 

Meire et al (1978) 51 83 91 83 91 

Pussell et al (1980) 25 83 91 83 84 

Hermann et al (1987) 241 75 95 82 93 

Finkler et al (1988) 102 88 81 62 95 

Benacerraf et al (1990) 100 72 91 80 87 

Granburg et al (1990) 180 74 95 82 92 

Sassone et al (1991) 143 37 100 100 83

Color Flow Doppler 

• Significant ifi overlap in blood flow 

patterns between pregnancy 

and malignancy 

• False positive rate ~ 50% 

Wheeler and Fleischer. J Ultrasound Med 1997;16:425-28. 

28.

Tumor Markers 

• CA125 Epithelial ovarian cancer (80%) 

• CA 19-9 

• AFP 

Exception: mucinous tumors 

Mucinous tumors 

Germ cell tumors 

Endodermal sinus tumor 

• β-hCG 

Germ cell tumors 

Choriocarcinoma 

• LDH 

Dysgerminoma

26 y.o. G2P1001 

• Ultrasound for early dating 

• Poor dates

26 y.o. G2P1001 at 9w4d

RI = 0.81 

PI = 2.27

26 y.o. G2P1001 at 9w4d 

US for early dates 

• Single, viable IUP 

• CRL =2.8 cm c/w 9w4d 

• Right ovary: Corpus luteum 1.9 x1.5 cm 

• Left ovary: 13.23 x 12.19 x 9.91 cm cyst, 

unilocular with internal echoes, a thin 

septation and wall nodularity.

26 y.o. G2P1001 at 9w4d 

• Probable diagnosis 

• Serous or mucinous cystadenoma 

• Should we operate 

• Let’s talk

RISKS TO THE 

MOTHER 

RISKS TO THE 

PREGNANCY


Why operate 

• Possible malignancy 

• Prevent complications 

• Torsion 

• Rupture 

• Obstruction of labor


Risks of Surgery 

• Spontaneous miscarriage 

i 

• Rupture of membranes 

• Preterm labor 

• Preterm birth


• 1-4 % of pregnant women are diagnosed with 

an adnexal mass 1,2 

• 82% 3 to 94% 4 rate of spontaneous resolution 

1 Hill et al. Am J Obstet Gynecol 1998; 179: 703-707. 707. 

2 

Nelson et al. J Clin Ultrasound 1986; 14: 509-512. 

512. 

3 Thornton and Wells. Obstet Gynecol 1987;69:717-21. 

4 Grimes et al. Am J Obstet Gynecol 1954;68:594-605. 605.


• 82% 1 to 94% 2 rate of spontaneous resolution 

• Particularly simple, unilocular cysts 

• Most of the others are a corpus luteum and 

resolve by 16 weeks 

• Expectant management is appropriate for 

adnexal masses < 6 cm in the first trimester 1,2 

1 Thornton and Wells. Obstet Gynecol 1987;69:717-21. 

2 Grimes et al. Am J Obstet Gynecol 1954;68:594-605. 605.


• 1–8% of persistent masses are malignant 

• Traditionally, most masses were treated by 

laparotomy at 16-20 weeks of gestation 

Whitecar et al. Am J Obstet Gynecol 1999;181:19-24.


Surgery vs. Observation 

• Retrospective review of 127,177 

deliveries i between 1999 – 2003 

• Adnexal mass > 5 cm in 63 (0.05%) 

• Pathology available in 59 (94%) 

• Lost to follow-up: 4 

• Antepartum surgery: 17 (29%) 

• Postpartum surgery: 42 (71%) 

Schmeler et al. Obstet Gynecol 2005; 105: 1098-1103. 1103.


Antepartum Surgery (n = 17) 

• Suspicion of malignancy 13 (76.5%) 

• Mixed cystic and solid components 

• Septations 

• Papillary projections 

• Wall nodularity 

• Emergency surgery for torsion 4 (23.5%) 

• 68%of59masses 

6.8 • Surgery at 9, 13, 25, 34 weeks of gestation 

• PPROM at 23 w chorioamnionitis 

Schmeler et al. Obstet Gynecol 2005; 105: 1098-1103. 1103.


Pathologic diagnosis i (n=59) 

Pathologic Diagnosis # % 

Dermoid 25 42.3 

Functional cyst 9 15.3 

Cystadenoma 9 15.3 

Adenofibroma 3 50 5.0 

Fibroid 4 6.8 

Malignancy 4 68 6.8 

Endometrioma 3 5.1 

Borderline tumor (LMP) 1 17 1.7 

Resolution of mass 1 1.7


Pathologic diagnosis i (7 studies) 

Pathologic Diagnosis % 

Dermoid 25 

Functional cyst, paraovarian 17 

Serous cystadenoma 14 

Mucinous cystadenoma 11 

Endometrioma 8 

Malignancy 28 2.8 

Borderline tumor (LMP) 3 

Leiomyoma 2 

Hoover and Jenkins.Am 

JObstet 

Gynecol 2011;205(2):97-102.


Study 

AP 

Surgery 

Malignancy 

% Cancer LMP 

Complications 

SAB 

Torsion 

Bernard 1988-1993 79 0 3.1 NA 3.1 

Platek 1988-1994 59 0 0 3.2 0 

Bromley 1988-1995 19 0.8 0 0 0.8 

Whitecar 1989-1994 66 3.1 3.1 1.5 5.4 

Sherard 1990-2002 55 5.0 8.3 4.7 1.8 

Schmeler 1990-2003 27 6.8 1.7 0 6.8 

Yen 1990-2004 44 2.3 3.4 14.8


Risk of Malignancy 

Size Matters


Risk Malignancy 

• Retrospective review of 1990-2002 

• 60 patients (0.15% of pregnancies) 

• EGA at diagnosis 

12 weeks 

• EGA at surgery 

20 weeks 

• Malignancy (CA + LMP) 13.3% 

• % CA 3 37% 5.0% 

• % LMP 5 63% 8.3% 

Sherard et al. Am J Obstet Gynecol 2003;189:358-63.



Category 

Size 

Malignant 

11.5 cm 

Benign 

7.6 cm 




Size 

> 10 cm 

Growth > 0.35 cm/week 

Odds of Malignancy 

11.2 

8.77% vs 0.85% 

10.2 

8.33% vs 0.88% 

Yen et al. Fertil Steril 2009;91:1895-1902. 1902.


Risk Analysis of Torsion and Malignancy 

• Retrospective review of 1990-2004 

• 213 patients 

t 

• 174 were followed during pregnancy 

with ithakno known nt tumor 

• Torsion 24 13.8% 

• Ovarian cancer 4 23% 

2.3% 

• Malignancy (CA+LMP) 6 3.4% 



Risk of Torsion - Size 

Size 

All 

Patients 

Known 

tumors 

Overall 14.8% 13.8% 

5-10 cm 69.7% 

6-8 cm 51.5% 22.4%* 

*compared to 9.6% for tumors of other sizes 

Yen et al. Fertil Steril 2009;91:1895-1902. 

1902.


Risk of Torsion 

• No difference 

• Age 

• Parity 

• Right = Left 

• Size in known and unknown 

tumors that undergo torsion 



Risk of Torsion - EGA 

Gestational Age 

Percentage of 

torsions 

10-17 weeks 60.0% 

15-16 weeks 36.7% 

> 20 weeks 5.9% 



Surgical Complications 

Laparotomy at 16-20 weeks (n=60) 

Category 

Percentage 

Preterm Birth Rate 9% 

Miscarriage Rate 4.7% 




Laparotomy at 6-41 weeks (n=34) 

Category 

(Surgery in 2 nd Trimester) 

Percentage 

Preterm Birth Rate 58% 5.8% 

Miscarriage Rate 2.9% 

Balci et al. J Obstet Gynaecol Res. 2008;34:524-28. 28.



Laparoscopy py 

2 ND Trimester 

Author 

Miscarriage 

PPROM 

Preterm Labor 

Yeun and Chang 1 

n=6 

Tazuke et al. 2 

n=9 

Stepp et al. 

3 

n=11 

0% 0% 0% 

0% 11.1% 0% 

0% 0% 0% 

1 Yuen and Chang. Acta Obstet Gynecol Scand 1997;76:173-76. 

76. 

2 Tazuke et al. J Am Assoc Gynecol Laparosc 1997;4(5):605-608. 608. 

3 Stepp et al. J Am Assoc Gynecol Laparosc 2003;10(1):55-59. 59.

26 y.o. G2P1001 at 13 weeks 

• Probable bl diagnosis 

i 

• Serous or mucinous cystadenoma 

• Should we operate 

• Yes 

• Laparoscopy v. Laparotomy 

• Surgeon dependant d 123 

1,2,3 

1. Moore and Smith. J Reprod Med. 1999; 44: 97-100. 

2. Parker et al. Am J Obstet Gynecol. 1996: 174; 1499-15011501 

3. Roman et al. J Min Invasive Gynecol. 2005; 21: 377-78. 78.

26 y.o. G2P1001 at 13 weeks 

• L/S left salpingoophorectomy 

• Serous cystadenoma of LMP 

• No complications 

• Delivered at term

21 y.o. G1P0 

• LMP = unknown 

• Exam: Palpable cul-de 

de-sac 

mass 

• No FHT’s by Doppler

FHR = 160 bpm

OUTCOME 

• Resolved spontaneously 

• Probable luteal cysts

22 y.o. G1P0 

• Enters c/o abdominal pain 

• EGA ~ 5 weeks

22 y.o. G1P0 

• Laparoscopy 

• Torsion – right ovary 

• Dermoid

24 y.o. G2P1001 

• Presents for ultrasound 

• Unknown dates

RIGHT OVARY

PI = 0.93 

RI = 0.57

24 y.o. G2P1001 

• Laparoscopy 

• Post-partum 

• Bilateral ovarian cystectomies 

• Dermoids

26 y.o. G1P0 

13w4d

26 yo y.o. G1P0 

13w4d 

• LSO 

• Right ovarian cystectomy 

• Bilateral endometriomas, the 

right was decidualized

40 y.o. G2P1001 

13w2d 

• Ultrasound for complex mass on 

first trimester study

13w2d

13w2d

13w2d

13w2d

13w2d

40 y.o. G2P1001 

13w2d 

• Laparoscopic p 

LSO 

• Dermoid

28 y.o. G3P2002 

• Routine ultrasound for dating 

• 14w5d

RI = 0.73

Color Flow Doppler 

• Significant ifi overlap in blood flow 

patterns between pregnancy 

and malignancy 

• False positive rate ~ 50% 

Wheeler and Fleischer. J Ultrasound Med 1997;16:425-28. 28.

28 y.o. G3P2002 

History 

• Prior laparotomy 

• Stage III-B Serous tumor LMP 

• Elected on observation

28 y.o. G3P2002 

• Vaginal delivery at term 

• Final staging g post-partumpartum 

• Serous tumor of LMP 

• No evidence of metastasis

37 y.o. G4P3003 

• Referred ee ed for adnexal a 

mass 

identified on ultrasound at 

planned amniocentesis 

• US EGA = 15w3d

37 y.o. G4P3003 

15w3d

37 y.o. G4P3003 

23w2d

23w2d

23w2d

23w2d

23w2d

23w2d

37 y.o. G4P3003 

26w2d

26w2d

26w2d

26w2d

26w2d

37 y.o. G4P3003 

34w2d

34w2d

34w2d

34w2d

37 y.o. G4P3003 

• Cesarean delivery at 39 wks 

• Left salpingo-oophorectomy 

oophorectomy 

• Frozen: Cannot rule-out borderline 

tumor 

• Permanent: Serosal endometriosis 

and a serous tumor of LMP


Summary 

• 82%-94% of masses detected t d in 

the 1 st trimester resolve 

spontaneously 

• Observation is appropriate with 

masses < 6 cm in size


Summary-Malignancy 

Of those that persist 

• Risk of malignancy 1-7% 

• CA + LMP 1-13% 13% 

• Risk greatest 

• Size > 10 cm 

• Growth > 1 cm in 3 weeks


Summary-Torsion 

• Risk of torsion 1-15% 15% 

• 5-10 cm 69% 

• Timing go of toso 

torsion 

• 10-1717 weeks 60% 

• 15-1616 weeks 39% 

• > 20 weeks 6%


Summary 

Surgical risks (at laparotomy) 

• Preterm Birth Rate 9% 

• Miscarriage Rate 4.7% 

• These risks are reduced with 

laparoscopy


Indications for Surgery 

• Strong suspicion for malignancy 

• Increased risk of 

torsion/rupture/obstruction in labor 

• Symptomatic 

ti

Thank You

Adnexal Masses in Pregnancy - Cmebyplaza.com

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