Professional Documents
Culture Documents
Ov Mass in Pregnancy PDF
Ov Mass in Pregnancy PDF
CME REVIEWARTICLE
19
CHIEF EDITORS NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA category 1 creditsTM can be earned in 2006. Instructions for how CME credits can be earned appear on the
last page of the Table of Contents.
463
464
Malignant Tumors
Functional cysts
Follicular cysts
Corpus luteum cysts
Theca-lutein cysts
Hemorrhagic cysts
Paraovarian cysts
Benign cystic teratomas
Serous cystadenoma
Mucinous cystadenoma
Endometriomas
Cancer
14
10
5
3
14
8
34
1
89
Low Malignant
Potential Tumor
83
34
117
465
TABLE 3
Risk of ovarian malignancy based on sonographic criteria
Risk of Ovarian Cancer
Low
Intermediate
High
Sonographic Criteria
Cystic, unilocular
Size 5 cm
Cystic, multilocular
Complex
Thin septations
Solid mass
Nodules
Thick septations
Size 5 cm
466
their limited series of pelvic masses during pregnancy that MRI correctly identified the etiology in 17
of 17 (100%) pelvic masses, whereas US was accurate in 12 of 17 (71%). Although MRI can provide
valuable diagnostic information beyond the ability of
US, the number of situations in which this is clinically important is limited. Both modalities are very
dependent on the experience of the physician who
interprets the scan. MRI probably adds minimally to
the evaluation of most ovarian masses compared with
US but may be valuable when the US diagnosis is
uncertain and when a radiologist experienced in interpreting MRI of adnexal masses and pregnancy is
available.
Serum tumor markers are primarily used for surveillance of known, treated ovarian malignancies but are of
variable benefit in the initial assessment of ovarian
masses. CA-125 is elevated in 80% of epithelial ovarian
malignancies with mucinous adenocarcinomas being a
notable exception. CA-125 has limited diagnostic accuracy in premenopausal women, because multiple benign
gynecologic conditions are associated with elevated values such as menses, uterine fibroids, and especially
pregnancy (20). When elevated, the CA-125 can provide a baseline value before treatment of ovarian cancer
but will not help differentiate between benign and malignant masses during pregnancy. Various other tumor
markers are used to monitor germ cell tumors (AFP
endodermal sinus tumor, -hCGchoriocarcinoma,
lactic dehydrogenasedysgerminoma) (21). Although
germ cell tumors are among the most common ovarian
malignancies seen in pregnancy, both -hCG and AFP
have very limited use as tumor markers during pregnancy. Tumor markers should be obtained before any
surgical intervention when there is a suspicion of
ovarian malignancy to provide a baseline should a
malignancy be diagnosed. Any elevation in the
tumor markers should be considered in conjunction with the results of the imaging tests to avoid
unnecessary intervention when possible.
MANAGEMENT OPTIONS
Conservative
The main consideration in choosing intervention
versus expectant management centers on the risks to
the mother and fetus. The specter of malignancy is
quickly raised whenever an ovarian mass is detected.
However, a rational decision should be based on an
accurate assessment of the malignancy risk. As noted
previously, ovarian masses in pregnancy have a cancer risk that ranges between 0.9% and 3%. More
The likelihood of malignancy with a complex ovarian mass is relatively low (29.4% in Lerners study
[14]), but increases if there are other associated findings such as ascites or omental thickening. Historically, many authors have emphasized the risks of
torsion, cyst rupture, and obstruction of labor, but
these usually occurred in large, symptomatic masses.
Struyk et al (8) reported their experience with ovarian tumors in pregnancy and noted torsion in 12%,
rupture in 9%, and obstruction of labor in 17%. In
Whitecars series (7), 16 of 130 women underwent
urgent laparotomy for acute abdominal pain, 14 before delivery. Eleven of the 16 either had documented or presumptive torsion (11 of 130 [8.5%]).
Bromley and Benacerraf in their series of 131 ovarian masses in 125 pregnant women reported a far
lower rate of antepartum problems (15). Only one
patient had an ovarian torsion and one patient was
explored for an ovarian cyst that was not found at
laparotomy. Bernhard reported a 1% risk of torsion
in their series of 102 ovarian masses (2) and that
one occurred in a patient with a palpable mass.
Overall, it appears that later studies report lower
risks of torsion and rupture than earlier studies.
This probably reflects a higher proportion of
asymptomatic, US-detected ovarian masses that
are less prone to complicate the pregnancy.
The choice of laparotomy versus laparoscopy is
dependent on the risks of malignancy, the urgency
of the procedure, and the skills of the surgeon. As
surgeons gain training and experience, there has
been acceleration in the frequency of laparoscopic
operations during pregnancy. Laparoscopic surgery has been commonly reported for treatment of
appendicitis and cholecystitis during pregnancy
with generally excellent results and minimal risk
of fetal loss and preterm delivery (23,24). Laparoscopy for adnexal masses has become increasingly standard management for benign ovarian
masses in nonpregnant women (25), and it has
been used in selected cases of ovarian cancer (26).
Consequently, it has also been adopted in management of some pregnant patients with adnexal tumors (24,2731). The presumptive benefits of
laparoscopy in pregnancy include a minimally invasive approach with decreased recuperative time
and risk of fetal loss/preterm delivery compared
with laparotomy (23). The most recent case series
demonstrate that experienced laparoscopic surgeons are able to manage a spectrum of adnexal
pathologies, including ovarian cysts, adnexal torsion, heterotopic pregnancy, and bleeding ovarian
cysts (2931).
467
Patients who potentially benefit the most by laparoscopic surgery of the adnexal mass should fit the following criteria: first or second trimester of pregnancy
and an ovarian mass that is not suspicious for malignancy. Sound clinical judgment is critical for patient
selection and is clearly tempered by the surgeons skill
and experience. Caution is strongly advised when considering laparoscopic management of possible ovarian
cancer. Port site recurrences are noted in 2.3% of patients treated laparoscopically for their malignancy in a
recent review (32), although these were most common
in patients with primary peritoneal cancer and recurrent
cancer. Ovarian masses, especially suspicious ones,
must be removed intact when possible. Although it
remains controversial (25), spillage or rupture of a
malignant ovarian cyst was associated with decreased
survival in a recent study (33). The risk of adverse fetal
outcomes is not eliminated with a minimally invasive
approach. Soriano reported that the rates of spontaneous
abortion were 12.8% (5 of 39) in the first trimester and
8% (2 of 25) in the second trimester, although all
these miscarriages occurred in women with ovarian torsion (30).
Patients with very large ovarian masses fall into 2
groups: those with large but simple unilocular cysts
and those with complex cysts. In both groups, consideration can be given to expectant management
with surgical intervention reserved for symptoms resulting from possible torsion or rupture or if the mass
risks obstructing vaginal delivery. Alternatively,
multiple case series report that aspiration of simple
unilocular cysts can avoid the need for major surgery
and provide symptomatic relief (16,34,35). However,
aspiration of a complex ovarian cyst runs the potential risk of malignant fluid spillage. Surgical intervention for large complex ovarian masses should be
by laparotomy because these masses will not fit into
endoscopic bags.
Whether by laparoscopy or laparotomy, consideration can be given to ovarian cystectomy if the US
criteria for a benign mass are met. Otherwise, oophorectomy is appropriate. If there is a risk of disrupting
a corpus luteum cyst up to 12 weeks gestation, then
progesterone support is indicated.
Surgical management of ovarian cancer is discussed separately subsequently.
MATERNAL AND FETAL OUTCOMES
The adverse consequences to mother and fetus are
primarily a result of complications from the ovarian
mass and/or the interventions for the mass. If an
ovarian malignancy is present, then there are also
468
risks of the cancer and the consequences of its treatment as well. In reviewing the literature, it is often
difficult to determine if the adverse effects were the
result of the adnexal mass, the treatment of the mass,
or unrelated (eg, spontaneous abortion of fetus with
multiple anomalies in a patient with an ovarian
mass). Nevertheless, surgical intervention for benign
adnexal masses in pregnancy is associated with a
higher risk of preterm deliveries and low neonatal
birth weights compared with those patients who did
not have surgery (11).
Pain is the most common symptom in pregnant
patients with adnexal masses (26% in the Struyk
study [8]). This ranges from mild (which can be
managed expectantly) to severe (requiring emergent
laparotomy). The etiology of the pain is usually torsion, although ovarian rupture also occurs. Whitecar
reported in his series that nearly half of the patients
with acute abdominal pain required emergency laparotomy for ovarian masses and uterine leiomyomas
(7). The rate of torsion is quite variable in many
series, from 1% to 22% (5,15). Rupture appears to
be less common, ranging from 0% to 9% (7,8,15).
Obstruction of labor is also reported to occur in 2%
to 17% of patients (8,10). Other less frequent problems include bleeding and infection. Struyk noted the
relationship between tumor size and the risk of complications as 35% for tumors between 5 and 6 cm in
diameter and up to 85% for larger tumors (8). However, no other authors reported such a high maternal
complication rate. Observational US studies by Bernhard and Zanetta report far lower complication rates
resulting from problems of torsion and obstruction of
labor (2,16).
Adverse fetal outcomes are most commonly the
result of an abdominal catastrophe from ovarian torsion or rupture associated with abdominal surgery. In
many cases, the relationship of poor fetal outcomes
to the adnexal mass is not apparent. Elective surgical
intervention is preferably timed for the second trimester in which the risk of subsequent fetal loss is
minimized (3). Whitecar found that adverse pregnancy outcomes, including preterm deliveries and
fetal loss, were significantly less frequent if laparotomy occurred before 23 weeks gestational age (odds
ratio 0.15, P .005) (7). The effectiveness of
tocolytics for suppression of preterm delivery is unclear. In Whitecars series, tocolytics were administered in 13 patients who had surgeries in the second
and third trimesters. Six of 13 had preterm deliveries, although only 2 occurred within 2 weeks
of laparotomy.
469
REFERENCES
1. Goff BA, Paley PJ, Koh W-J, et al. Cancer in the pregnant
patient. In: Hoskins WJ, Perez CA, Young RC, eds. Principles
and Practice of Gynecologic Oncology, 3rd ed. Philadelphia:
Lippincott Williams & Wilkins, 2000:501528.
2. Bernhard LM, Klebba PK, Gray DL, et al. Predictors of persistence of adnexal masses in pregnancy. Obstet Gynecol 1999;
93:585589.
3. Marino T, Craigo SD. Managing adnexal masses in pregnancy. Contemp Obstet Gynecol 2000;45:130143.
4. Montz FJ, Schlaerth JB, Morrow CP. The natural history of
theca lutein cysts. Obstet Gynecol 1988;72:247251.
5. Hermans RH, Fischer DC, van der Putten HW, et al. Adnexal
masses in pregnancy. Onkologie 2003;26:167172.
6. Usui R, Minakami H, Kosuge S, et al. A retrospective survey of
clinical, pathologic, and prognostic features of adnexal
470
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.