Expert Reviews
org
Adnexal masses during pregnancy: diagnosis,
treatment, and prognosis
Ann M. Cathcart, MD, PhD; Farr R. Nezhat, MD; Jenna Emerson, MD; Tanja Pejovic, MD, PhD; Ceana H. Nezhat, MD;
Camran R. Nezhat, MD
Introduction
The frequency of adnexal masses in
pregnancy is 2 to 20 in 1000, approxi-
mately 2 to 20 times the rate in the age-
matched general population.1e4 The
increased frequency of adnexal masses
in pregnancy is largely attributable to
the widespread use of antenatal
ultrasound, as most masses are asymp-
tomatic and not identified by physical
examination.5,6
Although most adnexal masses in
pregnancy spontaneously resolve, inter-
vention may be indicated for symptom-
atic patients or those at high risk of
malignancy or torsion.4,5 This article
reviewed the differential diagnosis,
From the Department of Obstetrics and
Gynecology, Oregon Health & Science
University, Portland, OR (Drs Cathcart,
Emerson, and Pejovic); Weill Cornell Medical
College, Cornell University, New York, NY (Dr F
Nezhat); New York University Long Island
School of Medicine, Mineola, NY (Dr F Nezhat);
Division of Gynecologic Oncology, Oregon
Health & Science University, Portland, OR (Drs
Emerson and Pejovic); Atlanta Center for
Minimally Invasive Surgery and Reproductive
Medicine, Atlanta, GA (Dr CH Nezhat); and
Center for Special Minimally Invasive and
Robotic Surgery, Palo Alto, CA (Dr CR Nezhat);
University of California San Francisco, San
Francisco, CA (Dr CR Nezhat); and Stanford
University Medical Center, Palo Alto, CA (Dr CR
Nezhat).
Received Sept. 27, 2022; revised Nov. 15,
2022; accepted Nov. 15, 2022.
A.M.C. is a member of the Product Advisory
Board for Delfina Care Inc, San Jose, CA. F.R.N.,
J.E., T.P., C.H.N., and C.R.N report no conflict
of interest.
This study received no funding.
Corresponding author: Farr R. Nezhat, MD.
farr@farrnezhatmd.com
0002-9378/$36.00
ª 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2022.11.1291
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ajog.
Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000,
approximately 2 to 20 times more frequently than in the age-matched general popu-
lation. The most common types of adnexal masses in pregnancy requiring surgical
management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%),
serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of
adnexal masses in pregnancy are malignant. Although most adnexal masses in preg-
nancy can be safely observed and approximately 70% spontaneously resolve, a minority
of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion
of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy
because of accuracy, safety, and availability. Several ultrasound mass scoring systems,
including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and
International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa
scoring systems have been validated specifically in pregnant populations. Decisions
regarding expectant vs surgical management of adnexal masses in pregnancy must
balance the risks of torsion or malignancy with the likelihood of spontaneous resolution
and the risks of surgery. Laparoscopic surgery is preferred over open surgery when
possible because of consistently demonstrated shorter hospital length of stay and less
postoperative pain and some data demonstrating shorter operative time, lower blood
loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices
for laparoscopic surgery during pregnancy include left lateral decubitus positioning after
the first trimester of pregnancy, port placement with respect to uterine size and pathology
location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal
capnography, pre- and postoperative fetal heart rate and contraction monitoring, and
appropriate mechanical and chemical thromboprophylaxes. Although planning surgery
for the second trimester of pregnancy generally affords time for mass resolution while
optimizing visualization with regards to uterine size and pathology location, necessary
surgery should not be delayed because of gestational age. When performed at a facility
with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in
pregnancy generally results in excellent outcomes for pregnant patients and fetuses.
Key words: adnexal mass, Assessment of Different NEoplasias in the adneXa,
biomarker, cyst, cystadenoma, dermoid, endometrioma, hyperreactio luteinalis, Inter-
national Ovarian Tumor Analysis, laparoscopic, laparoscopy, Lerner, luteoma, malig-
nancy, ovarian cancer, ovarian cyst, ovarian mass, pregnant, robotic surgery, Sassone,
torsion, ultrasound
workup, and management of adnexal searching for combinations of the
masses in pregnancy, including special aforementioned key words with “ma-
considerations regarding surgery in the lignancy,” “ultrasound,” “MRI,” “tumor
pregnant patient. markers,” “CA-125,” “laparoscopy,”
A literature review was conducted by “laparoscopic,” “robotic,” “pneumo-
searching PubMed for articles using key peritoneum,” or “anesthesia.” Original
words “adnexal mass,” “adnexal research articles addressing the epide-
masses,” “ovarian mass,” “ovarian miology, diagnosis, evaluation, and
masses,” “pregnancy,” and “pregnant.” management of adnexal masses in
Additional articles were identified by pregnancy were reviewed.
JUNE 2023 American Journal of Obstetrics & Gynecology 601
Expert Reviews ajog.org

Differential diagnosis Luteomas are benign proliferations of

FIGURE 1
Approximately three-quarters of inci- luteinized cells that form solid and often
dentally identified adnexal masses in bilateral tumors that arise in later preg-
Laparoscopic image of twisted
pregnancy are simple cysts <5 cm.4,6,7 nancy, spontaneously regress after preg-
dermoid cyst at 9 weeks
Among masses at least 2.5 to 5.0 cm or nancy, and can be associated with
gestation
with complex features, 68% to 72% hirsutism or virilization in 25% of pa-
spontaneously resolve by 6 weeks after tients. When maternal virilization oc-
delivery.4,5 Of those that require surgical curs, 60% to 70% of female infants are
management or are removed at the time also born with features of viriliza-
of cesarean delivery, dermoid cysts are tion.18,21 Other rare causes of adnexal
most common (32%), followed by se- mass in pregnancy include heterotopic
rous and mucinous cystadenomas pregnancies, estimated to affect 1 in
(19%), endometriomas (15%), and 30,000 spontaneous pregnancies, and
functional cysts (12%) (Table 1 and tubo-ovarian abscesses, which have been
Figures 1e3).8e17 Bilateral adnexal reported in case literature (Figure 5).22-25
masses have been reported in up to 4% Approximately 2% of adnexal masses
of cases; of the published reports, all in pregnancy are malignant.8e17 A
Image reproduced with permission from Nezhat
bilateral masses were benign.10,13,14 population-based study of nearly 5
et al.119
Adnexal masses unique to pregnancy million patients using California hospi-
Cathcart. Diagnosis and management of adnexal masses
include hyperreactio luteinalis (a term tal records identified 87 cases of ovarian during pregnancy. Am J Obstet Gynecol 2023.
referring to the growth of several theca malignancy in pregnancy, 51% of which
lutein cysts) and luteomas.18-20 Hyper- were epithelial tumors, 39% were germ
reactio luteinalis presents as bilateral cell tumors, and 9% were pseudomyx-
ovarian enlargement, usually in the third oma peritonei.2 Epithelial tumors were
trimester of pregnancy, likely because of most commonly serous carcinomas, and endodermal sinus tumors.2,26,27 Sex
ovarian hyperstimulation by human followed by mucinous, endometrioid, cord-stromal tumors are rare in preg-
chorionic gonadotropin (Figure 4).19 and clear cell carcinomas.2,26 Germ cell nancy.26,28 Most ovarian cancers (64%
Hyperreactio luteinalis typically sponta- tumors are most commonly dysgermi- e81%) diagnosed during pregnancy are
neously regresses after delivery. nomas, followed by malignant teratomas stage I, with most of these cases being
stage IA and the minority of these being
stage IC.2,26,27 Ovarian malignancy
diagnosed during pregnancy is more
TABLE 1 likely to be of earlier stage and lower
Histologic subtypes of adnexal masses in pregnancy requiring surgical grade and is associated with more
management
Type of adnexal mass Incidence (range)
Dermoid 32.0% (18.0%e50.0%) FIGURE 2
Ultrasound of ovarian serous
Endometrioma 15.0% (0.0%e24.0%)
cystadenoma at 8 weeks
Functional cyst 12.0% (3.0%e41.0%) gestation
Serous cystadenoma 11.0% (4.0%e19.0%)
Mucinous cystadenoma 8.0% (3.0%e15.0%)
Hyperreactio luteinalis 9.0% (0.0%e14.0%)
Paraovarian or paratubal cyst 6.0% (0.0%e19.0%)
Fibroma 2.0% (0.0%e5.0%)
Malignancy 2.0% (0.0%e6.0%)
Borderline 1.0% (0.0%e8.0%)
Brenner tumor 0.3% (0.0%e3.0%)
Leiomyoma 0.2% (0.0%e3.0%)
The incidence of each histologic subtype of adnexal mass surgically removed during pregnancy was computed from the Image reproduced with permission from Nezhat
retrospective series of Whitecar et al8 (n¼118), Usui et al9 (n¼69), Sherard et al10 (n¼60), Balci et al11 (n¼36), Türkçüoglu
et al12 (n¼35), Ulker et al13 (n¼119), Baser et al14 (n¼146), Goh et al15 (n¼69), Yu et al16 (n¼1303), and Zhang et al17 et al.119
(n¼228). Cathcart. Diagnosis and management of adnexal masses
Cathcart. Diagnosis and management of adnexal masses during pregnancy. Am J Obstet Gynecol 2023. during pregnancy. Am J Obstet Gynecol 2023.

602 American Journal of Obstetrics & Gynecology JUNE 2023

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ajog.org
FIGURE 3
Photograph of left ovarian
mucinous cystadenoma removed
during cesarean delivery
Image reproduced with permission from Nezhat
et al.119
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
favorable outcomes than that diagnosed
outside of pregnancy.2
Evaluation
Initial identification of the adnexal mass in
pregnancy is frequently performed by ul-
trasound, which should be accompanied
by history and physical examination,
including bimanual and rectovaginal
evaluation.29 Among symptomatic pa-
tients, the most common complaint is
pain.29
FIGURE 4
Ultrasound of enlarged
hyperstimulated ovary with
multiple peripherally located
cysts
Image reproduced with permission from Nezhat
et al.119
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
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Expert Reviews
Ultrasound is highly accurate, low
FIGURE 5
cost, readily available, and safe in preg-
nancy. Ultrasonographic features of
Laparoscopic image of a tubo-
adnexal masses in pregnancy are similar
ovarian abscess in pregnancy
to those observed outside preg-
nancy.30,31 Teratomas feature complex
echo patterns with hyperechoic areas
and distal shadowing because of the
presence of fat, solid, and calcified
components (Figure 6).32,33 Endome-
triomas are complex unilocular or mul-
tilocular cysts featuring diffuse low-level
internal echoes (Figure 7).34 Simple cysts
are anechoic and unilocular with a Image reproduced with permission from Nezhat
smooth thin wall, whereas hemorrhagic et al.119
Cathcart. Diagnosis and management of adnexal masses
cysts may contain hypoechoic internal during pregnancy. Am J Obstet Gynecol 2023.
debris (Figures 8e10).30 Cystadenomas
may be simple cysts or have thin septa-
tions; serous cystadenomas are typically total of 559 adnexal masses, 46 (8%) of
anechoic, whereas mucinous cys- which were malignant.39
tadenomas may have low-level internal Several ultrasound scoring systems
echoes because of mucin content originally developed for malignancy
(Figure 11).35 Hyperreactio luteinalis is prediction in nonpregnant patients have
characterized by enlarged ovaries with been assessed in pregnant populations,
many peripheral thin-walled cysts. including the Sassone, Lerner, Interna-
Luteomas can mimic neoplasms on ul- tional Ovarian Tumor Analysis (IOTA)
trasound and appear as heterogenous, Simple Rules, and IOTA Assessment of
irregular solid masses.36 Leiomyomas Different NEoplasias in the adneXa
appear hypoechoic and round and may (ADNEX) scoring systems (Table 2).40-45
develop cystic spaces as they degen- The Sassone and Lerner models each
erate.30 Ultrasonographic features sug- assign points based on 4 ultrasound
gesting malignancy include thick or variables, with a cutoff of summed
irregular septations, mural nodules, points used to discriminate malignant
solid or papillary components, and a masses.42,43 The IOTA Simple Rules
diameter >5 cm (Figures 12 and define malignant and benign ultrasound
13).30,37,38 features, with masses exhibiting at least 1
A 1997 study by Bromley and Bena-
benign or malignant feature classified as
cerraf32 found that 95% of dermoid tu-
mors, 80% of endometriomas, and 71%
of simple cysts were correctly charac- FIGURE 6
terized by ultrasonography in a series of Ultrasound showing a dermoid
125 pregnant patients at a single center. cyst with complex echo pattern
Only 10.7% of lesions had ultrasound
characteristics suggestive of malignancy,
and of these cases, 1 patient did have
ovarian cancer. No case of malignancy
was incorrectly diagnosed as benign.31 A
2021 meta-analysis of studies assessing
ultrasound accuracy in diagnosing ma-
lignant masses in pregnancy reported a
pooled sensitivity of 64% (95% confi-
dence interval [CI], 30%e88%), speci-
ficity of 88% (95% CI, 64%e97%),
positive likelihood ratio of 5.6 (95% CI,
Cathcart. Diagnosis and management of adnexal masses
1.2e25.4), and negative likelihood ratio during pregnancy. Am J Obstet Gynecol 2023.
of 0.4 (95% CI, 0.15e1.00) among a
JUNE 2023 American Journal of Obstetrics & Gynecology 603
Expert Reviews
FIGURE 7
Ultrasound showing an
endometrioma with diffuse low-
level echoes
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
such and masses exhibiting either no
feature or both benign and malignant
features classified as inconclusive.44 The
IOTA ANDEX involves the input of 3
clinical features and 6 ultrasound fea-
tures into a Web-based calculator.45,46 A
recent single-institution study of 153
patients, including 12 patients with ma-
lignancy, found the IOTA Simple Rules
to have a sensitivity of 92% and a spec-
ificity of 69% for predicting malignancy
in pregnant patients.47 Another multi-
center study of 236 patients comparing
the Sassone, Lerner, and IOTA ADNEX
models found the Sassone model to
perform the best with a sensitivity of
69% and a specificity of 85%.48 The
IOTA ANDEX model incorporates
FIGURE 8
Ultrasound showing a
hemorrhagic cyst with
hypoechoic debris
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
604 American Journal of Obstetrics & Gynecology JUNE 2023
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FIGURE 9
Ultrasound showing a cystic
mass with focal intracystic
echogenicity
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
patient age, serum CA-125, and presence
of ascites into its risk calculation; these
features may not have the same weight of
clinical relevance in a pregnant popula-
tion, which could explain its relative
underperformance in gravid patients.
Although ultrasound often provides
sufficient information about the risk of
malignancy in pregnancy, magnetic
resonance imaging (MRI) can be a
useful secondary imaging modality
FIGURE 10
MRI showing large left ovarian
cystic mass with benign
appearance
MRI, magnetic resonance imaging.
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
ajog.org
FIGURE 11
Ultrasound showing a mucinous
cystadenoma with low-level
internal echoes
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
for characterizing large masses;
gastrointestinal-related processes, such as
appendicitis and Crohn disease; tubo-
ovarian abscesses; hemorrhagic fibroid
degeneration; and ovarian torsion. When
cancer is confirmed or strongly suspected,
MRI is also useful in assessing the extent of
disease during pregnancy.49,50 T2-
weighted imaging and diffusion-weighted
imaging are valuable techniques for the
characterization of fluid, inflammation,
abscesses, and tumors in the pelvis without
the need for gadolinium-based contrast,
which is avoided because of concerns for
fetal safety.49,51 Although computed to-
mography (CT) can be used in pregnancy,
its use results in fetal ionizing radiation
exposure (2.5 to 50.0 mGy for CT
pelvimetry) and a theoretical risk of fetal
thyroid suppression.51 As ultrasound and
MRI generally provide adequate
FIGURE 12
Ultrasound showing an ovarian
adult granulosa cell tumor
Cathcart. Diagnosis and management of adnexal masses
during pregnancy. Am J Obstet Gynecol 2023.
ajog.org Expert Reviews

metastatic breast cancer, but its use has also

FIGURE 13
been reported in patients with ovarian and
Ultrasound showing an endometrioid ovarian adenocarcinoma with cervical cancer.53 In a retrospective analysis
papillary projections of 63 patients with cancer who underwent
PET during pregnancy, PET modified the
clinical stage in 60% of patients and sub-
sequently affected first-line treatment.54
Suggestions to optimize safety include us-
ing a lower dose of 18F-FDG in pregnant
patients than in nonpregnant patients,
performing PETalone rather than PET-CT
when possible, and employing vigorous
hydration and urinary catheterization to
facilitate rapid elimination of the
radiopharmaceutical.52

Biomarkers
Tumor markers are less reliable in preg-
nant patients than in nonpregnant pa-
tients, with studies of normal ranges in
Cathcart. Diagnosis and management of adnexal masses during pregnancy. Am J Obstet Gynecol 2023.
pregnancy reporting differing and
sometimes contradictory results.55
Nevertheless, if malignancy is strongly
information without these added risks, CT radiation exposure of 1 to 12 mGy.52,53 suspected or identified, tumor marker
is considered a third-line imaging modality Literature regarding PET use in preg- trends may be valuable. In general, the
in pregnancy. Of note, 18F-FDG positron nancy suggests overall safety but is limited tumor marker CA-125 can be elevated in
emission tomography (PET) use in preg- to case reports and small series; published normal pregnancy, whereas CEA,
nancy has been rarely reported in the experience with PET in pregnancy is pre- inhibin B, antimüllerian hormone, and
literature and carries an estimated fetal dominantly in the setting of lymphoma or lactate dehydrogenase (LDH) remain
within normal limits.55-58 CA-125 ele-
vations are expected beginning in the
TABLE 2
first trimester of pregnancy with re-
Ultrasound adnexal mass scoring systems validated in pregnancy
ported mean values ranging from 19 to
System Features Sensitivity Specificity 85 U/mL and a maximum reported value
Sassone Inner wall structure, wall thickness, septa, and 69% 85% of 550 U/mL.55 CA-125 levels are usually
echogenicity at or below the normal range cutoff value
Lerner Wall structure, shadowing, septa, and echogenicity 77% 69% in the second and third trimesters of
pregnancy but can remain persistently
IOTA Benign features: 92% 69%
Simple Unilocular cyst, presence of solid components <7 mm, elevated in some healthy patients, with a
Rules presence of acoustic shadows, smooth multilocular maximum reported value of 73 U/mL in
tumor with the largest diameter <10 cm, and no the second trimester of pregnancy and
Doppler blood flow 2420 U/mL in the third trimester of
Malignant features:
pregnancy.55 Pregnancy-associated con-
Irregular solid tumor, presence of ascites, at least 4
papillary structures, irregular multilocular solid tumor ditions can cause derangements in tu-
with the largest diameter 10 cm, and high Doppler mor markers; for example, LDH can be
blood flow elevated in preeclampsia.55,59 Alpha-
IOTA Clinical features: 62% 85% fetoprotein is often elevated in preg-
ADNEX Age, serum CA-125, oncology center (yes or no) nancies complicated by neural tube
Ultrasonographic features: defects; however, extremely elevated
Maximum lesion diameter, maximum diameter of the values (>10,000 ng/mL) should raise
largest solid part, more than 10 cyst locules, number of
papillary projections, acoustic shadows, and ascites concern for the presence of a germ cell
tumor.60
Ultrasound scoring systems which have been validated in pregnancy for prediction of malignancy in adnexal masses.42-45
Reported sensitivity and specificity are for the prediction of malignancy in pregnant populations specifically.47,48
ADNEX, Assessment of Different NEoplasias in the adneXa; IOTA, International Ovarian Tumor Analysis. Management
Cathcart. Diagnosis and management of adnexal masses during pregnancy. Am J Obstet Gynecol 2023. Risks associated with adnexal masses in
pregnancy principally include labor

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Expert Reviews
FIGURE 14
Management of the adnexal mass during pregnancy
Adapted with permission from Nezhat et al.119
Cathcart. Diagnosis and management of adnexal masses during pregnancy. Am J Obstet Gynecol 2023.
obstruction, torsion, and malignancy.
Approximately 70% of incidentally
identified adnexal masses in pregnancy
spontaneously resolve, with a strong in-
verse correlation between resolution rate
and both size and complexity.4e6,15
Obstruction of labor has been reported
in 3% of cases with cysts >3 cm, and
hospital admission for pain has been
reported in 2% to 10% of patients.5,6,15
Reported rates of torsion in large case
series range from 3% to 12%, with cysts
undergoing torsion having a mean size
of 10 cm.5,12,15,61-63 A high index of
suspicion for torsion must be main-
tained for the pregnant patient with an
adnexal mass and acute lower abdominal
pain, as 38% to 60% of pregnant patients
with torsion have normal Doppler flow
on ultrasound.64-66 Patients with torsion
in pregnancy are at risk of recurrence;
the rates of torsion recurrence in the
same pregnancy have been reported at
4% to 15%, with higher rates among
patients who undergo surgical detorsion
alone vs cyst drainage.67,68 Some studies
have found an increased risk of miscar-
riage and preterm delivery after torsion,
whereas other studies have found no
adverse maternal or perinatal
outcome.69-71 As in nonpregnant
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patients, torsion is an emergency and
requires immediate surgical manage-
ment when identified.
In the nonemergent setting, the deci-
sion for expectant management vs sur-
gical intervention must balance the risks
of torsion or malignancy with the like-
lihood of spontaneous resolution and
the risks of intervention. Consensus
opinion suggests intervening on masses
present after the first trimester of preg-
nancy that are >10 cm or have other
sonographic features concerning malig-
nancy.72 If ovarian malignancy is diag-
nosed at the time of laparoscopic
surgery, extensive surgery should be
avoided. Good practice includes removal
of the involved ovary and fallopian tube
and possibly omentum, allowing for
completion surgery after delivery.73
Practical guidelines reflecting several
decision points in the management of
adnexal masses in pregnancy are pre-
sented in Figure 14.
For proven ovarian malignancy in
pregnancy, special consideration must
be taken as to the use of chemotherapy.
In general, chemotherapy is avoided in
the first trimester of pregnancy because
of the risk of teratogenicity and sponta-
neous abortion, although the fetal
ajog.org
benefits of delaying treatment must be
balanced against maternal risk. In the
second and third trimesters of preg-
nancy, some studies have found an as-
sociation between chemotherapy
exposure and small-for-gestational-age
neonates, whereas others have shown
no increased incidence of adverse fetal
outcomes.26,74,75,76 Overall, the number
of pregnant patients receiving chemo-
therapy in published cohort studies and
case series is small, and the long-term
effects of antenatal chemotherapy
exposure are unknown. For nonpreg-
nant patients with ovarian cancer, any
chemotherapy delay has been associated
with worse overall survival even after
controlling for comorbidities associated
with therapy delay.77-79 Chemotherapy
planning for the pregnant patient must
involve shared decision-making with
acknowledgment of the limitations of
available data. Recommendations for
chemotherapy in pregnancy include
dosing based on actual weight and at the
same dose per weight or body area as in
nonpregnant patients and allowing a 3-
week window between the last cycle of
chemotherapy and delivery for maternal
and fetal bone marrow recovery.80
Breastfeeding during chemotherapy is
not advised.81,82
Surgical considerations
Pregnant patients undergoing pelvic
surgery are at an increased risk of fetal
loss, stillbirth, preterm birth, and having
a low birthweight infant compared with
the general population. The magnitude
of these relative risks in different studies
varies from negligible to two-fold.83-86
Elective surgery is safer than emergent
surgery; a meta-analysis of 67,111 preg-
nant patients undergoing abdomi-
nopelvic surgery found a higher rate of
fetal loss with emergent surgery than
with elective adnexal surgery (5% vs 1%)
and a higher rate of preterm birth (12%
vs 4%).87 Maternal mortality is rare, with
an overall pooled proportion of 0.04% in
that study.87 In general, it is difficult to
separate the risks of surgery from the
risks of the underlying condition when
assessing adverse pregnancy outcomes.85
The first case of laparoscopic manage-
ment of an ovarian mass during pregnancy
ajog.org
was published more than 30 years ago.88
Since that time, several studies comparing
outcomes after laparoscopy and laparot-
omy in pregnancy have established the
relative safety of laparoscopy.89-96 Lapa-
roscopy has been consistently shown to be
associated with shorter hospital length of
stay and less postoperative pain and can be
associated with less manipulation of pelvic
organs and better surgical exposure. Re-
sults regarding operative time, blood loss,
fetal loss, preterm birth, and birthweight
are mixed, with some studies showing no
difference between laparoscopy and lapa-
rotomy and others showing improved
outcomes with laparoscopy.89-96
Chen et al89 reported a randomized
trial of 69 pregnant patients with adnexal
masses requiring surgery who were
randomly assigned to either laparoscopy
or laparotomy. Patients had a mean cyst
diameter of 8 cm and a mean gestational
age at surgery of 16 weeks. The laparos-
copy group had a shorter length of stay
(3 vs 6 days), less postoperative fever
(3% vs 14%), a lower postoperative pain
score, and less adhesive disease at the
time of cesarean delivery. The propor-
tion of patients undergoing cesarean
delivery, gestational age at delivery,
Apgar scores, and birthweight was
equivalent between groups.89
Shigemi et al90 reported a retrospec-
tive cohort study, including 740 pro-
pensity score-matched pairs of patients
undergoing laparoscopy or laparotomy
in pregnancy, and similarly found a
decreased length of stay for patients
undergoing laparoscopy and decreased
rate of blood transfusion and shorter
operative times. In addition, Shigemi
et al90 found a significantly decreased
risk of a composite of adverse fetal out-
comes, including fetal loss, premature
delivery, and stillbirth with laparoscopy,
compared with laparotomy (0.4% vs
1.8%, P¼0.01).
Of 2 recent large meta-analyses, one
found shorter hospital stay with no
difference in blood loss, operative time,
fetal loss, or preterm birth with lapa-
roscopy,91 whereas the other had similar
findings except for reduced blood loss
and 51% lower odds of preterm labor
with laparoscopy.92 Smaller studies have
reported similar results, with any
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differences in blood loss and operative
time generally of small magnitude.93-96
Experience with robotic surgery for
adnexal masses in pregnancy is limited
but appears safe. Of note, 1 retrospective
cohort study of 19 pregnant patients
undergoing robotic resection of adnexal
masses compared with 50 consecutive
laparoscopic controls found a decreased
length of stay and blood loss with robotic
surgery and no difference in intra-
operative or postoperative complica-
tions or pregnancy outcomes.97 A
second case series of 6 pregnant patients
undergoing robotic-assisted ovarian
cystectomy reported 1 case of preterm
premature rupture of membranes at 30
weeks of gestation after a robotic pro-
cedure at 21 weeks of gestation and no
other intraoperative or pregnancy
complication.98
Regarding surgery timing, elective
cases should be postponed until after
delivery, whereas emergent cases should
never be delayed. Historically, 16 to 20
weeks of gestation has been recom-
mended as the optimal timing for non-
emergent laparoscopic cases because of
the theoretical decreased risk of miscar-
riage or preterm labor and improved
visualization.37,99 Laparoscopy is not al-
ways feasible at later gestational ages
owing to the impact of uterine size on
intra-abdominal visualization and
impeded access to pelvic structures.
Nevertheless, recent studies have shown
no significant association between the
trimester of operation and adverse out-
comes, including surgical complications,
fetal loss, and preterm birth, and several
case series have reported the safety of
laparoscopy in both the first and third
trimesters of pregnancy.100-106 Videos
depicting laparoscopic ovarian cys-
tectomy at 16 weeks gestation and
management of unintentional fetoscopy
during laparoscopy are provided in
Figures 15 and 16, respectively.
The physiology of maternal and fetal
responses to pneumoperitoneum during
laparoscopic is incompletely understood.
Early observations drawn from gravid
sheep models have subsequently been
found to differ substantially from obser-
vations in humans. Pregnancy predisposes
to hypoxia during apneic episodes because
JUNE 2023 American Journal of Obstetrics & Gynecology
Expert Reviews
of the combination of increased oxygen
consumption, increased CO2 production,
and decreased functional residual capacity.
During surgery, this predisposition is
exacerbated by increased thoracic pressure
with pneumoperitoneum and Trendelen-
burg positioning.107,108 Theoretically,
cardiac changes associated with pneumo-
peritoneum could result in decreased
uterine blood flow, and elevated maternal
PaCO2 could limit transplacental fetal CO2
excretion and worsen fetal respiratory
acidosis. Gravid sheep models have
demonstrated maternal hypercapnia,
decreased uterine blood flow, increased
fetal PaCO2, decreased fetal pH, and
decreased fetal oxygenation with pneu-
moperitoneum.109-111 However, a more
recent study in humans found no signifi-
cant change in maternal PaCO2 or pH
during laparoscopic surgery.112 A second
study in human patients found no differ-
ence in uterine artery resistance index or
umbilical artery pulsatility index at various
points during surgery.113 A small but stat-
ically significant decrease in fetal heart rate,
although still within normal limits, was
observed during desufflation despite
normal uterine blood blow, but was not felt
to be related to fetal perfusion.113
Effects of general anesthesia on the
developing fetus, and in particular neu-
rocognitive effects, are incompletely
known. Animal models suggest agents
acting via the GABA and NMDA path-
ways may have neurotoxic fetal effects,
whereas dexmedetomidine attenuates
this effect.114 However, no data have
corroborated these findings in humans.
To date, available data regarding the
long-term safety of antenatal exposure to
general anesthesia are limited to case
reports. In 1 case series of 11 children
with antenatal exposure to laparoscopic
surgery, no developmental or physical
abnormality was noted at a follow-up of
1 to 8 years.115 The American College
of Obstetricians and Gynecologists
currently advises that there is no human
evidence for an adverse effect of anes-
thetics or sedatives on the developing
fetal brain and no evidence of terato-
genic effects of anesthetics at any gesta-
tional age.116
The best practices for laparoscopic
surgery in pregnant patients are
607
Expert Reviews ajog.org

TABLE 3
Recommendations for laparoscopy during pregnancy
Recommending
Consideration Recommendation organization
Preoperative planning Non-urgent surgery should be postponed until after pregnancy. ACOG, BSGE
Pregnancy should not be a reason to delay urgent surgery. ACOG, BSGE
Laparoscopy can be safely performed during any trimester of SAGES
pregnancy.
There should be early involvement of an obstetrical BSGE
anesthesiologist with preoperative review of features related to
the pregnancy and patient comorbidities.
Surgery should be performed at an institution with obstetrical, ACOG, BSGE
neonatal, and pediatric services.
If expertise to undertake laparoscopic surgery in pregnancy is BSGE
lacking, laparotomy is acceptable.
Anesthesia Modern anesthetic agents have not been shown to be teratogenic ACOG, BSGE
when used in standard doses.
There is no evidence that in utero human exposure to anesthesia ACOG
affects the developing fetal brain.
Patient positioning After the first trimester of pregnancy, left lateral decubitus or SAGES
partial left lateral decubitus position is recommended.
Port placement Initial access can be safely achieved via open (Hasson), Veress SAGES
needle, or optical trocar technique but must account for fundal
height.
Uterine size should be determined by palpation or ultrasound. BSGE
The benefits of the Hasson entry may include reduced risk of BSGE
uterine trauma or spillage of ovarian cysts.
Primary port location (umbilical, supra-umbilical, or Palmers’ BSGE
point) should be chosen according to uterine size, location of
pathology and operator experience
Ipsilateral secondary port placement may prevent the need for BSGE
instrumentation across the gravis uterus.
Insufflation pressure CO2 insufflation of 10e15 mm Hg is appropriate but should be SAGES
adjusted to the patient’s physiology.
Initial insufflation pressure of 20e25 mm Hg is appropriate for BSGE
port placement but operating pressure should be 12 mm Hg.
Creation of pneumoperitoneum and maternal repositioning should BSGE
be gradual.
Intraoperative CO2 monitoring Intraoperative CO2 monitoring by capnography should be used. SAGES
Capnography should be used and maternal hypo- and hypercapnia BSGE
should be avoided.
Laparoscope choice Both 5- and 10-mm diameter laparoscopes are appropriate. Use BSGE
of a 30-degree laparoscope may be helpful.
Energy modalities Ultrasound, bipolar, and monopolar energy sources are safe to use BSGE
during laparoscopy in pregnancy.
Cathcart. Diagnosis and management of adnexal masses during pregnancy. Am J Obstet Gynecol 2023. (continued)

608 American Journal of Obstetrics & Gynecology JUNE 2023

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TABLE 3
Recommendations for laparoscopy during pregnancy (continued)
Recommending
Consideration Recommendation organization
Fetal heart rate monitoring Fetal heart rate monitoring may assist in maternal positioning and ACOG
cardiorespiratory management and may influence a decision to
deliver the fetus.
Simultaneous fetal heart rate tracing and contraction monitoring ACOG
should be performed before and after surgery for viable fetuses.
Preoperative and postoperative fetal heart rate detection by ACOG
Doppler is sufficient for previable fetuses.
Intraoperative fetal heart rate monitoring may be appropriate ACOG
when the fetus is viable, monitoring is possible, and emergent
cesarean delivery would be considered.
Preoperative and postoperative fetal heart rate monitoring are BSGE, SAGES
recommending past the age of viability, but intraoperative fetal
heart rate monitoring is not recommended.
Tocolytics Routine prophylactic use of tocolytics is not recommended. BSGE, SAGES
Antenatal corticosteroids Corticosteroid administration should be considered for patients ACOG, BSGE
with fetuses at viable premature gestational ages.
Anti-D immunoglobulin Prophylactic anti-D immunoglobulin administration is not BSGE
required.
Antibiotics Routine antibiotics are not required unless infection is suspected. BSGE
Venous thromboembolism prophylaxis Patients should be screened for venous thromboembolism risk ACOG
and have the appropriate perioperative prophylaxis.
Pharmacologic prophylaxis with low-molecular-weight heparin BSGE
should be considered.
Intra- and postoperative sequential compression devices and SAGES
early postoperative ambulation are recommended.
Evidence-based recommendations for laparoscopy in pregnancy were obtained from the ACOG,116 the BSGE,117 and the SAGES.118
ACOG, American College of Obstetricians and Gynecologists; BSGE, British Society for Gynaecological Endoscopy; SAGES, Society of American Gastrointestinal and Endoscopic Surgeons.
Cathcart. Diagnosis and management of adnexal masses during pregnancy. Am J Obstet Gynecol 2023.

summarized in Table 3.116-118 These Conclusion basis of expert clinical opinion,

include left lateral decubitus positioning
after the first trimester of pregnancy,
port placement with respect to uterine
size and pathology location, insufflation
pressure of less than 12 to 15 mm Hg,
intraoperative maternal capnography,
and pre- and postoperative fetal heart
rate and contraction monitoring. Ante-
natal corticosteroids for fetal benefit may
be considered based on the clinical sce-
nario, whereas routine use of tocolytics,
anti-D immune globulin, and antibiotics
are not recommended. As pregnancy is a
hypercoagulable state, patients should be
screened for venous thromboembolism
risk, and appropriate mechanical and
chemical thromboprophylaxes should be
administered.
The diagnosis of adnexal masses in
pregnancy has become more common as
routine first-trimester ultrasound has
become widespread. Most adnexal
masses identified in pregnancy are sim-
ple cysts less than 5 cm, can be safely
observed, and ultimately spontaneously
resolve.
Ultrasound remains the most impor-
tant tool in the workup of adnexal
masses because of its safety, availability,
and predictive ability for differentiating
benign and malignant masses. Although
several formalized ultrasound-based
scoring systems have been validated
specifically in pregnant populations, the
ultimate decision for when to intervene
on a mass in pregnancy is made on the
balancing the risks and benefits of
intervention for a particular patient, and
allowing for shared decision-making.
The last decade of experience has so-
lidified laparoscopy as preferable to lap-
arotomy because of decreased patient
pain and length of hospital stay. Small
benefits in terms of reduced operative
time, blood loss, and adverse fetal out-
comes have also been demonstrated,
although inconsistently. Importantly,
laparotomy is still considered safe in
pregnancy when appropriate expertise
for laparoscopic surgery is unavailable or
anatomic features, such as uterine and
mass size, preclude laparoscopy.
Long-term studies on childhood and
later-life outcomes after antenatal

JUNE 2023 American Journal of Obstetrics & Gynecology 609

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Expert Reviews
exposure to surgery are lacking, and 8. Whitecar MP, Turner S, Higby MK. Adnexal
although small studies support the safety of masses in pregnancy: a review of 130 cases
undergoing surgical management. Am J Obstet
surgery, data limitations must be Gynecol 1999;181:19–24.
acknowledged in preoperative patient 9. Usui R, Minakami H, Kosuge S, Iwasaki R,
counseling. Nevertheless, the real risks of Ohwada M, Sato I. A retrospective survey of
delaying diagnosis and treatment of ma- clinical, pathologic, and prognostic features of
lignancy or creating a need for emergent adnexal masses operated on during pregnancy.
J Obstet Gynaecol Res 2000;26:89–93.
surgery are well-established for the preg- 10. Sherard GB 3rd, Hodson CA, Williams HJ,
nant patient and fetus, and necessary sur- Semer DA, Hadi HA, Tait DL. Adnexal masses
gery should not be delayed due to and pregnancy: a 12-year experience. Am J
pregnancy or gestational age. Careful pre- Obstet Gynecol 2003;189:358–62. discussion
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11. Balci O, Gezginc K, Karatayli R, Acar A,
experienced surgeon at a facility with Celik C, Colakoglu MC. Management and out-
anesthetic, obstetric, and neonatal support comes of adnexal masses during pregnancy: a
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ACKNOWLEDGMENTS logical features and pregnancy outcomes of
The authors thank Dr Andrea Tinelli for providing pregnancy associated adnexal masses.
the ultrasound image in Figure 2; Dr Thomas J Obstet Gynaecol 2009;29:107–9.
Trevett for the ultrasound image in Figure 9; Dr 13. Ulker V, Gedikbasi A, Numanoglu C,
Bryann Bromley for the ultrasound image in Saygi S, Aslan H, Gulkilik A. Incidental adnexal
Figure 13; Drs Kimberly Kho, Nicholas Nezhat, masses at cesarean section and review of the
and Bob Fay for contributions to the video in literature. J Obstet Gynaecol Res 2010;36:
Figure 16; and Dr David Abel for helpful com- 502–5.
ments regarding PET use in pregnancy. 14. Baser E, Erkilinc S, Esin S, et al. Adnexal
masses encountered during cesarean delivery.
Int J Gynaecol Obstet 2013;123:124–6.
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