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Pregnant Women with an Adnexal Mass

Jun 2009 – by P. DiSaia, MD

Essentially every pregnant woman has an adnexal mass during pregnancy. Usually it is a 3-5 centimeter corpus luteum. These functional cysts can get as large as 11 centimeters in diameter but almost always they disappear by the 14th week of gestation. It appears that the size of the adnexal mass at the time of diagnosis after the 14th week is related to the likelihood of spontaneous regression. In addition the complication rate increases with the increasing size of the mass. The most pressing problems associated with ovarian tumors in pregnancy are the initial discovery and the differential diagnosis. The use of ultrasound during pregnancy has revealed masses that were previously hidden behind the growing uterus. Analysis of serum tumor markers (e.g. CA 125) is distorted by pregnancy because pregnancy itself often elevates these serum markers. Any mass that persists beyond 18 weeks of gestation should be considered as an indication for laparotomy. Indeed, the likelihood for an ovarian malignancy is low (3-6%) but these masses can produce pain, torsion, dystacia and other problems in the post partum period even if they are of a benign nature. Approximately 10-15% of ovarian tumors in pregnancy undergo torsion. Most torsions occur in the early second trimester when the uterus is rising out of the pelvis. The usual sequence of events is the sudden occurrence of lower abdominal pain nausea, vomiting and in some cases shock-like symptoms. These ovarian neoplasms are similar in histology to those that occur in the non-pregnant women of a similar age group with teratoma being most common.

Surgical exploration during the second trimester of pregnancy is possible; and if this exploration is done between the 18th and 23rd week of pregnancy, fetal loss is minimal. Obviously the exploration has to be done with care and of course the "no touch" technique is best employed. The "no touch" technique calls for deliverance of the adnexal mass and it's excision with minimal manipulation of the uterus and other intra abdominal contents. Should the patient have disseminated malignant disease at the time of exploration, the surgery should still be brief and further discussion with the patient and family commence in the postoperative period with the possibility of pregnancy termination and re-operation. Fortunately the malignancy rate is low (3.5%) so that removal of the mass and the brief surgical intervention almost always results in a good outcome for mother and fetus. In so doing the patient is spared the need for surgery during the post partum period when many women are bonding and nursing their child.