Adnexal Mass in Pregnancy
Karen Y. Oh, MD
DIFFERENTIAL DIAGNOSIS
Common
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Corpus Luteum Cyst
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Teratoma
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Theca Lutein Cysts
Less Common
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Other Ovarian Masses
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Endometrioma
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Cystadenoma
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Epithelial Ovarian Carcinoma
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Sex-Cord Stromal Tumor
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Non-Ovarian Adnexal Masses
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Paraovarian Cyst
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Pedunculated Fibroid
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Ectopic Pregnancy
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Hydrosalpinx
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Abscess
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ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Adnexa should be routinely evaluated during pregnancy
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Usually with transvaginal ultrasound in the first trimester
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Identify and characterize ovaries
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If not visible in pelvis, use transabdominal approach
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Ovary can be displaced by large associated mass or torsion
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If mass present, characterize as ovarian versus paraovarian in location
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Ovarian mass
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Cystic ovarian mass usually related to corpus luteum
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Most often simple cyst of varying sizes
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Can be complicated or even solid-appearing
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If large, consider close follow-up and postpartum ultrasound to exclude benign ovarian tumor
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Solid ovarian mass most often a dermoid
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Should have classic appearance
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May be bilateral
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If ovarian mass is suspicious with cystic and solid components, consider removal during pregnancy
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Paraovarian cysts will not change over time and may have been seen on prior pelvic ultrasounds
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If in the right lower quadrant, assess for appendicitis/appendiceal abscess
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Adnexal mass in 1st trimester
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Could this be an ectopic or heterotopic pregnancy?
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Correlate with any history of in vitro fertilization or reproductive assistance
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Helpful Clues for Common Diagnoses
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Corpus Luteum Cyst
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May be anechoic or hemorrhagic
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Commonly complicated by hemorrhage
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Can have thick, vascular, hyperechoic cyst wall
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May be mistaken for ectopic gestational sac with decidual reaction
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Ovarian ectopic pregnancy is exceedingly rare
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Should decrease in size over pregnancy
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Some functional cysts may persist
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Can follow expectantly if no malignant features
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Postpartum pelvic ultrasound to exclude benign ovarian neoplasm
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Check for any prior pelvic ultrasounds to see if present before pregnancy
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Teratoma
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Most common incidental ovarian mass seen in pregnancy
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10% bilateral
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May see hair, teeth, osseous structures which gives characteristic complex sonographic appearance
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Dermoid plug often present
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Echogenic keratin “plug”
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Posterior acoustic shadowing
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If large, risk of ovarian torsion
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Theca Lutein Cysts
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Multiple cysts within enlarged ovaries bilaterally
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May see typical “spoke-wheel” appearance
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Occasionally unilateral
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Reaction of ovaries to elevated hormone levels
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Multiple gestation pregnancies
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Assisted reproduction patients
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Rarely singleton pregnancy with underlying high level of beta hCG
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Associated pregnancy may be abnormal
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Look for signs of hyperstimulation syndrome
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Maternal effusions, ascites, oliguria
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Seen in the setting of in vitro fertilization due to hormonal stimulation
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May occur before intrauterine pregnancy identified
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Helpful Clues for Less Common Diagnoses
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Endometrioma
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Homogeneous, low-level echoes
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Cystadenoma
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Serous – unilocular anechoic cyst, thin septations
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Mucinous – hypoechoic with internal mucin, more often multilocular with thicker septations
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Epithelial Ovarian Carcinoma
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Complex cystic ovarian mass
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Vascularized, thick, irregular septations with soft tissue masses
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Look for ascites or other indications of peritoneal spread
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Sex-Cord Stromal Tumor
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Solid, homogeneous ovarian mass
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May be hormonally active
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Non-Ovarian Adnexal Masses
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Paraovarian Cyst
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Located in broad ligament
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Does not change in size with hormonal fluctuations
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