Surgical Management of Adnexal Masses in Pregnancy
Eva Hoffmann
Maria Andrikopoulou
Andrea Tinelli
Farr Nezhat
GENERAL PRINCIPLES
Definition
Adnexal masses include cystic (Figure 3.5.1) or solid (Figure 3.5.2) pathology of ovarian, fallopian tube, uterine, peritoneal, and occasionally bowel (appendix or small bowel) origin. Ovarian masses may include corpus luteal cysts, simple cysts, hemorrhagic cysts (Figure 3.5.3), dermoid cysts (Figure 3.5.4), endometriomas, and rarely malignancy (Figure 3.5.5). The most common adnexal masses in pregnancy are functional cysts (Figure 3.5.6) and dermoid cysts (Figure 3.5.7). Adnexal masses can also include germ cell, sex cord-stromal, and epithelial tumors (Figure 3.5.8). Fallopian tube masses include hydrosalpinx, heterotopic pregnancies, tubo-ovarian abscesses (TOAs) (Figure 3.5.9), and paratubal cysts (Figure 3.5.10). Uterine masses may include fibroids (Figure 3.5.11), specifically pedunculated fibroids.
Adnexal masses in pregnancy are mostly benign (Figure 3.5.12) but can also be malignant in rare cases. The incidence of ovarian malignancy in pregnancy is 1/10,000 to 1/25,000 or 1/200 of all adnexal masses diagnosed in pregnancy (1,2). Malignant adnexal masses may include epithelial adenocarcinoma, germ cell, and sex cord-stromal tumors.
 Figure 3.5.1. Large cystic ovarian mass after laparotomic removal. |
 Figure 3.5.2. Ovarian solid mass showed during laparoscopy. |
Adnexal Pathology
Functional Cysts
Simple (Figure 3.5.13) and hemorrhagic cysts are the most common cysts diagnosed during pregnancy (3). On ultrasound, simple cysts appear as anechoic, unilocular structures with smooth thin walls (Figure 3.5.14). Hemorrhagic cysts may have different appearances on ultrasound owing to the changing structure of blood clots that are usually present. They can appear as anechoic masses with hypoechoic material within the adnexal mass. They can also appear as echoic masses with internal echoes that are more hyperechoic than the surrounding normal ovarian tissue. Both simple and hemorrhagic cysts will usually regress as the pregnancy progresses (3).
Dermoid Mass
Dermoid cysts have distinct ultrasound characteristics. They often contain solid and cystic components (Figure 3.5.15). On ultrasound, they have a complex echo pattern and can
have acoustic shadowing because of the fat content and calcified nature of their structures. In most cases, ultrasound is sufficient to characterize a dermoid cyst, but magnetic resonance imaging (MRI) may also be useful in getting more information and differentiating from other pelvic masses. Dermoid cysts can be associated with complications such as adnexal torsion (Figure 3.5.16), given their dense structure; they can also rupture, causing peritonitis.
 Figure 3.5.3. Laparoscopic image of hemoperitoneum after rupture of a large hemorrhagic ovarian cyst. |
 Figure 3.5.4. Ultrasonographic image of a left ovarian dermoid cyst. |
 Figure 3.5.5. Laparoscopic image of a left ovarian cancer; the fleshy ovarian neoplastic neoformation covers part of the left ovary. |
 Figure 3.5.6. Ultrasonographic image of a left ovarian functional cyst at 7 weeks of pregnancy. |
 Figure 3.5.7. Ultrasonographic image of a right ovarian dermoid cyst at early pregnancy (gestational sac not yet visible, only beta-hCG positive). |
 Figure 3.5.8. Ultrasonographic image of an ovarian epithelial tumor. |
 Figure 3.5.9. Laparoscopic image of a left tubo-ovarian abscess. |
 Figure 3.5.10. Ultrasonographic image of paratubal cysts. |
 Figure 3.5.11. Ultrasonographic image of anterior fibroma previo at 23 weeks of pregnancy, clearly visible above the fetal head. |
 Figure 3.5.12. Ultrasonographic image of a benign ovarian cyst at 23 weeks of pregnancy. |
 Figure 3.5.13. Ultrasonographic image of a left simple ovarian cyst in pregnancy at 8 weeks. |
 Figure 3.5.14. Ultrasonographic pattern of simple ovarian cysts in pregnancy (at 9 weeks): Anechoic, unilocular structure with smooth thin walls. |
 Figure 3.5.15. Ultrasonographic pattern of a dermoid cyst with a solid avascular component. |
Endometrioma
Endometriomas are relatively uncommon to diagnose for the first time in pregnancy on routine imaging. They are most commonly seen in women with a history of endometriosis and subsequent infertility. On imaging, endometriomas appear as a uniform cyst with diffuse internal low-level echoes (3).
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