review adnexal masses pregnancy rcog.pdf

Review Management of adnexalmasses in pregnancyAuthors Chris P Spencer / Phil J Robarts

Asymptomatic adnexal masses are frequently diagnosed in

pregnancy, either at the early booking scan or at the time of

caesarean section. They are mostly ovarian in origin. In this

article we discuss the role of magnetic resonance imaging,

computed tomography, Doppler studies and the use of tumour

markers in diagnosis. The majority of ovarian cysts in pregnancy

either resolve spontaneously or are due to benign conditions.

Ovarian cancer is extremely rare in women of childbearing age

and thus most of these cysts can be managed conservatively. If

there is a suspicion of malignancy or there is a significant cyst

complication, such as torsion, and surgery is planned, this should

take place during the second trimester to minimise the risk of

miscarriage.

Keywords adnexal masses / magnetic resonance imaging / ovarian cancer / ovarian

cysts / pregnancy / ultrasonography

Please cite this article as: Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. The Obstetrician & Gynaecologist 2006;8:14–19.

Author detailsChris P Spencer MD FRCOG

Consultant in Obstetrics and Gynaecology

St John’s Hospital, Wood Street, Chelmsford,

CM2 9BG, UK

E-mail: [email protected]

(corresponding author)

Phil J Robarts FRCOG

Consultant in Obstetrics and Gynaecology

St John’s Hospital, Chelmsford, UK

Review 2006;8:14–19 10.1576/toag.8.1.014.27203 www.rcog.org.uk/togonline The Obstetrician & Gynaecologist

14 ’ 2006 Royal College of Obstetricians and Gynaecologists

IntroductionRoutine sonographic assessment of women in

early pregnancy for the purposes of dating,

viability and determination of the number of

fetuses, as well as the measurement of nuchal fold

thickness, has led to an increase in the diagnosis of

adnexal masses. Before the routine use of obstetric

ultrasound, adnexal masses were only discovered

on abdominal or pelvic examination. These masses

are now reported in up to 4% of all pregnant

women.1 In addition, the incidence of ovarian

pathology detected at caesarean section has been

reported as being 0.5%.2 The majority of adnexal

masses are ovarian in origin, but can also be due to

paratubal cysts, chronic fallopian tube disease

(hydrosalpinges) and fibroids that appear to be

extrauterine. Fibroids that are pedunculated or

located in the broad ligament are sometimes seen

as separate from the uterus and thus reported as

adnexal masses. The causes of adnexal masses are

listed in Box 1.

Nearly all ovarian masses detected in pregnancy

are benign, but the overall reported incidence of

ovarian cancer in pregnant women varies from

0.004–0.04%.3–11 The most commonly reported

malignancy in pregnancy and the puerperium

appears to be breast cancer.11 Most of the ovarian

masses diagnosed appear to be borderline with a

low malignant potential3,8 and are complex on

ultrasound assessment. Malignant tumours vary in

size but 75% of them are larger than 5 cm in

diameter and most of these have solid, as well as

cystic, elements on ultrasound evaluation.4

Diagnosis of adnexal massesThe use of ultrasound in early pregnancy, both

abdominal and transvaginal, is the most

commonly employed imaging modality. If the

woman is assessed by bimanual examination, an

adnexal mass can be detected if it is at least 5 cm

in diameter. Tables 1 and 2 summarise the

ultrasound appearances of the various adnexal

conditions encountered. Ultrasound images of

various adnexal masses are shown in Figures 1–4.

Other radiological techniques include magnetic

resonance imaging (MRI) and computed

tomography (CT). Although the overall incidence

of adnexal masses in pregnancy is approximately

4%,12 the incidence of complex or simple

persistent cysts measuring more than 6 cm is only

0.07%.13 Three-quarters of these persistent cysts

are complex in nature and the majority of

complex cysts are either benign teratomas or

endometriomas. Other pathologies include

paratubal cysts and cystadenomas.

According to several studies, the rate of ovarian

cancer in adnexal masses varies considerably.

Some researchers have found no confirmed cancer

cases at all,12–14 while others have quoted rates of

0.8%,15 3.6%,16 6%,3,17 and even as much as

13%.4 Table 3 summarises these studies over the

last two decades. It should be noted that in all

these series, the majority of tumours identified

have been shown to be early stage borderline

tumours. The range of histologies of the invasive

tumours are summarised in Box 2.

The role of MRI and CTscanningMRI can safely be used in pregnancy but is more

expensive and more time consuming than

ultrasonography. Nevertheless, MRI is particularly

good at defining both endometriotic and dermoid

cysts (benign teratomas)18,19 and provides

superior resolution when compared with CT

scanning methods.20 Other advantages of MRI

scanning include the ability to create images in

several planes and the lack of ionising radiation

requirement compared with CT scanning.

Consequently, the use of CT scanning in

Type of mass Ultrasound appearance Resolution rate (%) Table 1

Ultrasound appearance of common ovarian

cysts in pregnancy and resolution ratesSimple ovarian cysts

(follicular, corpus

luteal)

Unilocular, thin-walled,

anechoic

90–100 if ,5 cm in

diameter

Haemorrhagic cysts Anechoic with

echogenic material

within cyst

90–100

Hyperstimulated

ovaries

Massively enlarged,

thin-walled,

multilocular cysts

.90

Ascites may be present

OvarianSimple cystHaemorrhagic cystHyperstimulation in women who have undergone

fertility treatmentLuteomaEndometriomaBrenner tumourEpithelial tumours: serous and mucinous;

endometrioid and clear-cell carcinomasGerm cell tumours: mature and immature teratomas,

dysgerminomas, endodermal sinus tumours,embryonal carcinomas

Sex cord-stromal tumours: fibrothecomas; granulosacell, sclerosing stromal and Sertoli-Leydig cell tumoursMetastatic (secondary) tumours; for example,

KrukenbergLymphoma

TubalHydrosalpinxHeterotopic pregnancyParatubal cyst

Leiomyoma

Non-gynaecologicalMesenteric cystAppendix massDiverticular diseasePelvic kidneyUrachal cyst

Box 1Causes of adnexal massesin women with anintrauterine pregnancy

The Obstetrician & Gynaecologist 2006;8:14–19 Review

’ 2006 Royal College of Obstetricians and Gynaecologists 15

pregnancy has little place in modern obstetric

practice. As with other non-pregnant patients,

there are contraindications to the use of MRI in

pregnancy and these include the presence of

ferromagnetic aneurysm clips and severe maternal

claustrophobia. Although the movement of the

fetus can produce erroneous images, this can be

reduced with the use of fast imaging techniques.

Using MRI, endometriotic cysts typically appear to

have a homogenous high-signal intensity on T1-

weighted images and a low-signal intensity on T2-

weighted images. The high fat and sebum content

of dermoid cysts can be detected easily using MRI

scanning; these cysts typically demonstrate high-

signal intensities on T1-weighted images and

reduced signal intensities on fat-suppressed

images. In addition, MRI can be useful in

confirming the diagnosis of large degenerating

leiomyomas, which can resemble ovarian tumours.

These typically show high-signal intensity on T1-

weighted imaging and have characteristic

appearances on T2-weighted imaging.

MRI can be particularly helpful in the assessment

of an ovarian mass that is thought to be malignant

partly because of its ability to identify vegetations

in a cystic tumour and necrosis in a solid

tumour.21 Enhanced accuracy of MRI can be

obtained with the use of gadolinium contrast

enhancement,22 but the use of this agent in

pregnancy is contraindicated due to its ability to

cross the placenta and unknown half-life within

the fetal circulation.

The role of tumour markersIn the non-pregnant state, CA125 is the most

reliable serum marker for epithelial ovarian

carcinoma as it is raised in over 75% of cases.23 In

addition, measurement of serum CA125 levels is

useful in determining a woman’s response to

postoperative chemotherapy and in detecting early

relapse in women who have already received a

diagnosis of ovarian cancer. Serum alpha-

fetoprotein (AFP) and beta-hCG (human chorionic

gonadotrophin) levels are also very useful in the

preoperative evaluation and management of

ovarian germ cell tumours in non-pregnant

women. In addition, elevated serum inhibin levels

can be detected in women with granulosa cell

tumours of the ovary and mucinous carcinomas.

During pregnancy, however, serum AFP, beta-

hCG and inhibin levels are all raised due to

placental synthesis and thus the use of these

markers in evaluating suspicious ovarian cysts is

limited. Serum CA125 levels also become elevated

during pregnancy24 due to decidual cell

production,25 with levels rising as pregnancy

progresses. Some researchers have suggested using

a cut-off level of 112 U/ml as the upper limit of

normal, compared with 35 U/ml in the non-

Table 2

Ultrasound appearances of adnexal

pathology

Pathology Ultrasound appearance

Teratoma Complex mass with solid and cystic areas due to

presence of fat, bone, sebaceous material and hair

Endometrioma Diffuse ‘ground glass’ pattern due to presence of old

blood (‘chocolate’) within the cyst

Malignant/

borderline ovarian

tumour

Complex, multi-septate mass with solid and cystic

areas

Papillary projections or mural nodules

Ascites may be present

Appearance may be bilateral in up to 25% of cases

Hydrosalpinx Tubular-shaped structure with anechoic content and

incomplete septum of tubal wall

Always stays the same size during pregnancy

Leiomyoma Hypoechoic, round, solid masses

Cystic change may occur if red degeneration develops

Figure 1

Simple ovarian cyst

Figure 2

Benign ovarian teratoma

Figure 3

Endometriotic cyst

Figure 4

Complex ovarian cyst

Review 2006;8:14–19 The Obstetrician & Gynaecologist


pregnant state.26 The usefulness of this marker in

pregnancy is still restricted and if an ovarian mass is

thought to look suspicious, further evaluation with

MRI may be preferable. Certain malignant germ

cell tumours, such as ovarian dysgerminomas, have

been found to be associated with raised serum

lactate dehydrogenase (LDH) levels.27 However,

due to the rarity of this neoplasm, data regarding

this association are sparse.

The role of Doppler studiesThe use of colour flow Doppler imaging to

distinguish benign from malignant ovarian masses

in the non-pregnant state has been studied.28,29

Malignant masses are usually vascular while

benign lesions demonstrate little or no blood flow.

In tumours that have malignant potential, the

resistance and pulsatility indices are usually less

than 1, but this pattern is also seen in many benign

conditions such as endometriomas, corpus luteal

cysts and other benign complex ovarian masses. In

addition, due to increased pelvic vascularity in

pregnancy, the degree of overlap of these indices

in both benign and malignant lesions makes

Doppler imaging unreliable in this setting.30

Management in pregnancyManagement in pregnancy depends on the size of

the adnexal mass, its sonographic appearance and

any associated clinical symptoms, although the

majority of women are likely to be asymptomatic.

Simple cysts that are less than 5 cm in diameter do

not need further evaluation and rescanning is only

required if there is a clinical indication, such as

pelvic pain. The majority of simple cysts resolve

spontaneously during the course of pregnancy7,31

and women should be reassured as such. Cysts

that have a complex nature, i.e. solid and cystic

elements, need further evaluation irrespective of

size. Further ultrasound assessment should take

place at 4-week intervals to determine whether the

cyst is becoming larger. In the majority of cases,

both simple cysts larger than 6 cm and all complex

cysts resolve during the course of the pregnancy.7

Adnexal masses that undergo torsion are usually

dermoids or cystadenomas. If this complication

occurs, it does so during the first trimester or in

the immediate puerperium (up to 14 days after

delivery) and more commonly on the right side.

Ovarian dermoids that measure less than 6 cm are

unlikely to grow significantly in pregnancy and

can be managed conservatively as the risk of

complications, such as torsion, is thought to be

low.32 The woman should be rescanned in the

postnatal period to determine further

management of any ovarian dermoid that has not

resolved spontaneously.

Persistent, simple, unilocular cysts without any

solid elements that are larger than 10 cm can be

aspirated either transvaginally or abdominally

under ultrasound guidance using a fine needle

(greater than 20 gauge).33 This procedure is only

indicated if the cyst is causing pain or thought to

be increasing the risks of fetal malpresentation or

obstructed labour due to its location in the

pelvis.13,33 Although not commonly employed,

this technique seems to be a reasonable alternative

to surgery in suitable women and appears to be

Author Year

Number of

women with

adnexal mass

(surgical)

Incidence per

live births Commonest lesion found

Number of women

with

malignant

tumours* (%)

Table 3

Summary of published studies of adnexal

masses in pregnancy

Hasan42 1983 10 (10) 1 in 900 Benign cystic teratoma 1 (10)

Ballard40 1984 93 (93) 1 in 594 Benign cystic teratoma 2 (2.2)

Struyk41 1984 90 (69) 1 in 640 Benign cystic teratoma 3 (4)

Hopkins43 1986 23 (23) 1 in 556 Benign cystic teratoma –

Nelson1 1986 38 (5) 1 in 88 Corpus luteal cyst –

Hogston5 1986 137 (21) 1 in 191 Simple cyst 1 (0.73)

Ashkenazy6 1987 38 (38) 1 in 2328 Benign cystic teratoma 2 (5.3)

Thornton31 1987 131 (81) 1 in 346 Benign cystic teratoma 7 (8.6)

Tchabo10 1987 12 (12) 1 in 2334 Benign cystic teratoma 1 (8.3)

Hess17 1988 54 (54) 1 in 1300 Benign cystic teratoma/cystadenoma 2 (5.9)

Koonings2 1988 91 (91) 1 in 197 Benign cystic teratoma –

Sunoo44 1990 228 (228) 1 in 163 Hydatid cyst of Morgagni –

El-Yahia45 1991 67 (67) 1 in 653 Benign cystic teratoma 3 (4.5)

Platek13 1995 31 (19) 1 in 1399 Functional cyst (simple/haemorrhagic) –

Ueda38 1996 106 (106) 1 in 79 Benign cystic teratoma 5 (4.7)

Bromley15 1997 125 (96) Not recorded Benign cystic teratoma 1 (0.8)

Hill12 1998 328 (18) 1 in 444 Benign cystic teratoma –

Whitecar3 1999 130 (130) 1 in 1312 Benign cystic teratoma 8 (6.1)

Bernhard7 1999 432 (25) 1 in 43 Benign cystic teratoma 1 (0.23)

Zanetta16 2003 82 (23) 1 in 84 Benign cystic teratoma 3 (3.6)

Sherard4 2003 56 (56) 1 in 602 Benign cystic teratoma 8 (14.2)

Condous14 2004 161 (7) 1 in 19 Serous cystadenoma 1 (0.62)

Lee39 2004 89 (89) Not recorded Benign cystic teratoma 2 (2.2)

Schmeler46 2005 63 (59) 1 in 2000 Benign cystic teratoma 5/59{ (8.5)

*Including borderline tumours

Immature teratomaSerous/mucinous cystadenocarcinomaDysgerminomaGranulosa cell tumourSertoli-Leydig cell tumour (androblastoma,

arrhenoblastoma)Burkitt’s lymphoma

Box 2Histology type of invasiveovarian cancer in adnexalmasses



well tolerated and without short or long-term

complications. Local anaesthesia is normally used

for the skin and antibiotic cover given. All fluid

aspirated should be sent for cytological analysis

and the woman subsequently rescanned to

determine whether cyst recurrence has taken place.

The risk of this is thought to be in the region of

33–50%33 and the mother should therefore be

counselled that further aspirations can be required

during the rest of the pregnancy. Fine needle

aspirations should be done after 14 weeks of

gestation in order to minimise disturbance to the

corpus luteum.

The indications for surgery will depend on the

degree of suspicion of malignancy in the mass or

the development of cyst complications (Box 3). If

there is doubt regarding the diagnosis, MRI can

prove useful as a tool to help distinguish dermoids

and endometriomas from malignant neoplasms. If

elective surgery is embarked upon, this should be

done after 14 weeks gestation to minimise the risk

of fetal loss due to miscarriage, although this risk

is very small.34,35 This recommendation is based

on the principle that the developing pregnancy is

dependent on the corpus luteum during the first

trimester and much less so after 12 weeks. The

standard approach is to perform the surgery via a

laparotomy but laparoscopic surgery has been

used, although it is skill-dependent and more time

consuming than open surgery.36 If laparoscopic

surgery is performed during the second trimester,

an ‘open’ method (Hasson) is preferred to avoid

uterine injury from the primary trocar

introduction.37 The routine use of tocolytic drugs

is not thought to be necessary, but if uterine

irritability occurs, then standard tocolytic

regimens can be employed.

Adnexal pathology detected for the first time at

caesarean section has been reported in the region

of 0.5%,2 but this figure is likely to be lower in

areas where routine antenatal ultrasound is

employed for dating and fetal anatomy assessment

purposes. If adnexal pathology is discovered at

caesarean section, the options include:

conservative management, ovarian cystectomy or

oophorectomy. Simple cysts that are smaller than

5 cm in diameter can be left alone but larger cysts

or those appearing complex should be treated by

cystectomy.

Care should be exercised in removing cysts in

order to avoid intra-abdominal contamination.

The most common lesions found are dermoid

cysts, paratubal cysts, cystadenomas,

endometriotic cysts and corpus luteal cysts.2 After

cyst removal, the contents should be inspected

thoroughly before closing the mother’s abdomen.

If there are any signs of malignancy, such as the

presence of solid excrescences, the ovary should be

removed completely or, if available, rapid frozen

section assessment performed. The contralateral

ovary should be examined thoroughly and, if

indicated, biopsied accordingly.

ConclusionsOver the last 20 years, the use of ultrasound in

pregnancy has dramatically increased and many

centres now offer early dating scans as well as 20-

week fetal anomaly scans. Consequently, the

numbers of ovarian cysts diagnosed has increased,

leading to a greater probability of operative

intervention. The majority of these ovarian cysts

in pregnancy either resolve spontaneously or are

Figure 5

Clinical algorithm for the management of ovarian

cysts in pregnancy.

Box 3Complications of ovariancysts in pregnancy

Cyst ruptureCyst haemorrhageTorsion (up to 5%)Obstructed labourFetal malpresentation

Review 2006;8:14–19 The Obstetrician & Gynaecologist


due to benign conditions, such as dermoids or

endometriomas. Ovarian cancer is extremely rare

in women of childbearing age and thus most of

these cysts can be managed conservatively. In

terms of malignancy potential, those that are

malignant are likely to be borderline. Unless there

is a suspicion of malignancy or there is a

significant cyst complication, such as torsion,

surgery is not indicated. MRI is a safe and useful

tool to help evaluate cysts in more detail in

situations where ultrasound provides an

inconclusive answer. If surgery is planned, this

should take place during the second trimester to

minimise the risk of miscarriage. Whether surgery

is done laparoscopically or using a traditional

open approach is largely dependent on operator

experience and patient preference. In some

situations, there may be grounds for performing

an elective caesarean section at term in addition to

dealing with a large, complex ovarian tumour that

has persisted during the pregnancy but which has

not required earlier operative intervention.

Aspiration of ovarian cysts is only indicated where

they appear simple on ultrasound and where they

are causing pain or are thought to be obstructing

the birth canal. If surgery does not take place, then

ultrasound follow-up during and after pregnancy

may be advised accordingly. Figure 5 provides a

clinical algorithm for the management of ovarian

cysts in pregnancy.

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