Adnexal Mass in Pregnancy

Adnexal Mass in Pregnancy
Karen Y. Oh, MD
DIFFERENTIAL DIAGNOSIS
Common
  • Corpus Luteum Cyst
  • Teratoma
  • Theca Lutein Cysts
Less Common
  • Other Ovarian Masses
    • Endometrioma
    • Cystadenoma
    • Epithelial Ovarian Carcinoma
    • Sex-Cord Stromal Tumor
  • Non-Ovarian Adnexal Masses
    • Paraovarian Cyst
    • Pedunculated Fibroid
    • Ectopic Pregnancy
    • Hydrosalpinx
    • Abscess
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
  • Adnexa should be routinely evaluated during pregnancy
    • Usually with transvaginal ultrasound in the first trimester
    • Identify and characterize ovaries
      • If not visible in pelvis, use transabdominal approach
      • Ovary can be displaced by large associated mass or torsion
    • If mass present, characterize as ovarian versus paraovarian in location
  • Ovarian mass
    • Cystic ovarian mass usually related to corpus luteum
      • Most often simple cyst of varying sizes
      • Can be complicated or even solid-appearing
      • If large, consider close follow-up and postpartum ultrasound to exclude benign ovarian tumor
    • Solid ovarian mass most often a dermoid
      • Should have classic appearance
      • May be bilateral
    • If ovarian mass is suspicious with cystic and solid components, consider removal during pregnancy
  • Paraovarian cysts will not change over time and may have been seen on prior pelvic ultrasounds
  • If in the right lower quadrant, assess for appendicitis/appendiceal abscess
  • Adnexal mass in 1st trimester
    • Could this be an ectopic or heterotopic pregnancy?
    • Correlate with any history of in vitro fertilization or reproductive assistance
Helpful Clues for Common Diagnoses
  • Corpus Luteum Cyst
    • May be anechoic or hemorrhagic
      • Commonly complicated by hemorrhage
    • Can have thick, vascular, hyperechoic cyst wall
      • May be mistaken for ectopic gestational sac with decidual reaction
      • Ovarian ectopic pregnancy is exceedingly rare
    • Should decrease in size over pregnancy
      • Some functional cysts may persist
    • Can follow expectantly if no malignant features
      • Postpartum pelvic ultrasound to exclude benign ovarian neoplasm
      • Check for any prior pelvic ultrasounds to see if present before pregnancy
  • Teratoma
    • Most common incidental ovarian mass seen in pregnancy
      • 10% bilateral
    • May see hair, teeth, osseous structures which gives characteristic complex sonographic appearance
    • Dermoid plug often present
      • Echogenic keratin “plug”
      • Posterior acoustic shadowing
    • If large, risk of ovarian torsion
  • Theca Lutein Cysts
    • Multiple cysts within enlarged ovaries bilaterally
      • May see typical “spoke-wheel” appearance
      • Occasionally unilateral
    • Reaction of ovaries to elevated hormone levels
      • Multiple gestation pregnancies
      • Assisted reproduction patients
      • Rarely singleton pregnancy with underlying high level of beta hCG
    • Associated pregnancy may be abnormal
      • Molar pregnancy – partial or complete mole
      • Hydrops – skin edema, ascites, pleural effusions
      • Triploidy – multiple fetal anomalies, IUGR
    • Look for signs of hyperstimulation syndrome
      • Maternal effusions, ascites, oliguria
      • Seen in the setting of in vitro fertilization due to hormonal stimulation
      • May occur before intrauterine pregnancy identified
Helpful Clues for Less Common Diagnoses
Aug 10, 2016 | Posted by in OBSTETRICS | Comments Off on Adnexal Mass in Pregnancy

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