Key content
Adnexal masses are commonly identified in pregnancy but they are rarely malignant.
Most adnexal masses either resolve spontaneously or can be managed conservatively during pregnancy.
Pregnancy may alter the serum levels of tumour markers, making the interpretation of results difficult.
Surgery in pregnancy is indicated in cases of an acute abdomen and high suspicion of malignancy.
In cases where there is a high suspicion of malignancy, a multidisciplinary approach is required taking into account the woman’s age, gestation, parity, desire for fertility and the likely stage of disease.
Learning objectives
To be aware of the clinical presentation and ultrasound characteristics of clinically significant adnexal masses in pregnancy.
To understand the limitations of investigations in pregnancy and the importance of a multidisciplinary approach in the management of complex adnexal masses.
To be aware of the indications for surgery and evaluate the appropriateness, mode and timing of surgery in pregnancy.
Keywords: adnexal mass / malignancy / management / pregnancy
Introduction
Clinically significant adnexal masses in pregnancy
Corpus luteal cyst
Follicular cyst
Haemorrhagic cyst
Hyperstimulated ovaries
Classification of adnexal masses3
Classification Mass
Benign
Gynaecological Follicular cyst
Corpus luteal
Haemorrhagic cyst
Serous
Mucinous
Mature cystic teratoma
Fibroma
Endometrioma
Fibroid (pedunculated)
Para-ovarian cyst
Hydrosalpinx
Tubo-ovarian abscess
Non-gynaecological Appendicular mass
Mesenteric cysts
Diverticular mass
Pelvic kidney
Malignant
Borderline Serous
Mucinous
Epithelial Serous
Mucinous
Endometroid
Clear cell
Germ cell Dysgerminoma
Immature teratoma
Endodermal sinus
Embryonal carcinoma.
Sex cord stroma Granulosa-theca cell
Sertoli-leydig
Mesenchyma
Sarcoma
Lymphoma
Metastatic Gastrointestinal
Breast
Unique to pregnancy Hyperstimulated ovaries
Hyperreactio luteinalis
Theca lutein cysts
Luteoma of pregnancy
Ectopic/heterotropic pregnancy
Assessment of adnexal masses
Ultrasound
Colour Doppler
Magnetic resonance imaging and computerised tomography scans
Tumour marker studies
Management
Conservative management
Role of ultrasound-guided fine needle aspiration
Role of surgery
Conclusion
The principal goals of assessment are to diagnose acute conditions such as adnexal torsion, and to determine whether a mass might be malignant, necessitating intervention during pregnancy. As the first-line investigation, an ultrasound scan can reliably characterise most benign and malignant masses. MRI can be used to characterise indeterminate or suspicious lesions.
Most simple adnexal cysts resolve spontaneously by the second trimester. The main predictors of persistence are a cyst diameter of greater than 5 cm and complex morphology at imaging. Surgery is indicated in cases of an acute abdomen or high suspicion of malignancy. Laparoscopic surgery is appropriate in most cases depending on the tumour diameter, gestational age and surgical expertise.