With widespread use of ultrasound in early pregnancy, incidental adnexal masses are detected frequently. This article reviews the differential diagnosis, appropriate evaluation, and current treatment options for adnexal masses in pregnancy. With the increased sophistication of ultrasound, observation has become a more viable option. However, for those masses suspicious for malignancy, at risk for torsion, or clinically symptomatic, surgical management is warranted. With increasing numbers of successful laparoscopic procedures reported in pregnancy, laparoscopy appears to be a safe option with trained and experienced providers.
The reported incidence of adnexal masses in pregnancy ranges from 1 in 81 to 1 in 8000 pregnancies. Most of these adnexal masses are diagnosed incidentally at the time of a screening first-trimester ultrasound. Prior to widespread use of early antenatal ultrasound, adnexal masses in pregnancy were documented with less frequency on physical examination. The overall incidence of malignancy in an adnexal mass noted in pregnancy is 1-8%. However, malignancy is not the only risk associated with an adnexal mass in pregnancy. Masses that persist into the second trimester are at risk for torsion, rupture, or labor obstruction.
The traditional management of an adnexal mass in pregnancy has been surgical. However, surgery in pregnancy includes the added risks of fetal loss, preterm contractions, and an increased risk of embolic events. Furthermore, the most appropriate surgical route, laparotomy or laparoscopy, has not been defined, and in many cases observation can be warranted. Therefore, this article will review the differential diagnosis of adnexal masses in pregnancy, evaluate the appropriate workup necessary to determine whether intervention is necessary, and determine the appropriate management of adnexal masses in pregnancy.
A clinical review was conducted by searching Medline and PubMed using the terms ovarian masses, adnexal masses, tumor markers, ultrasound, pregnancy, laparoscopy, and laparotomy. Articles were reviewed for inclusion by both authors. The bibliography of each article was reviewed in an effort to determine any further articles that could be included in this review. Original research articles were included if they dealt with the diagnosis, evaluation, or treatment of adnexal masses in pregnancy. No unpublished works or abstracts were included.
Differential diagnosis
Similar to the nonpregnant state, a functional cyst is the most common adnexal mass in pregnancy. A corpus luteum persisting into the second trimester accounts for 13-17% of all cystic adnexal masses. However, the differential diagnosis throughout pregnancy also includes benign masses such as the benign cystic teratoma (7-37% incidence), serous cystadenoma (5-28% incidence) and mucinous cystadenoma (3-24% incidence), endometrioma (0.8-27% incidence), paraovarian cysts (<5%), and leiomyoma (1-2.5% incidence). Ovarian malignancy (including those of low malignant potential) accounts for approximately 1-8% of adnexal masses in pregnancy ( Table ).
| Type of mass | % |
|---|---|
| Dermoid | 25 |
| Corpus luteal cyst, functional cyst, paraovarian | 17 |
| Serous cystadenoma | 14 |
| Mucinous cystadenoma | 11 |
| Enodmetrioma | 8 |
| Carcinoma | 2.8 |
| Low malignant potential tumor | 3 |
| Leiyomyoma | 2 |
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