Adnexal Mass In Pregnancy

Adnexal Masses in Pregnancy

Adnexal Masses in
Pregnancy
By Alpa M Nick, MD and Kathleen Schmeler, MD
Introduction
Incidence
Diagnosis
Management
Histology
Pregnancy Outcomes
Oncologic Outcomes
Conclusion
References
Perinatology 2010; 1:13-19

Dr. Alpa Nick is a Fellow in the Department of Gynecologic Oncology at the University of Texas M.D. Anderson Cancer
Center and Dr.Schmeler* is Assistant Professor Department of Gynecologic Oncology at the University of Texas M. D.
Anderson Cancer Center, Houston, TX.
*To whom correspondence and reprint requests should be addressed. Department of Gynecologic Oncology, Unit 1362, The
University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030. Phone (713) 745-3518. E-mail:
kschmele@mdanderson.org.Introduction
With increasing use of first trimester aneuploidy screening, the incidental discovery of adnexal masses during
early gestation is a clinically relevant problem that requires careful consideration. The purpose of this review
is to summarize pertinent clinical issues surrounding women diagnosed with adnexal masses during
pregnancy.

The overall estimated incidence of adnexal massesin pregnancy ranges from 2% to 10% [1]. Factors that
impact the overall incidence of pregnancy related adnexal masses include method of diagnosis, criteria for
defining a “mass,” and the gestational age of the pregnancy. Prior to the use of routine first trimester
ultrasound, adnexal masses only became clinically relevant if symptomatic or if they were large enough to
palpate on physicalexamination. As ultrasound has become more commonly used in the first trimester, the
reported incidence of adnexal masses has increased. Furthermore, as gestational age advances, the
incidence of adnexal masses gradually decreases likely secondary to spontaneous resolution of many of
these masses [2].
Observational studies evaluating adnexal pathology during pregnancy estimate a 1% - 4% incidenceof
sonographically detectable adnexal masses, with the majority of masses resolving spontaneously [3, 4]. A
large retrospective analysis of three large population databases and estimated the incidence of pregnancy
associated ovarian masses to be 9375 out of 4,846,605 (0.14%) [5]. Cases were identified in the prenatal,
intrapartum and postpartum period. Of these 9375 masses, 2.1% (202/9375)were tumors of low malignant
potential or ovarian malignancies. Studies that report surgical outcome data on patients with adnexal masses
in pregnancy estimate the rate of malignancy or borderline tumors to be approximately 6% [6, 7].

Diagnosis
Ultrasound

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Adnexal Massesin Pregnancy

Ultrasound serves a dual purpose during pregnancies complicated by adnexal masses, one is to
characterize the mass and the second is to provide diagnostic assessment of a patient’s symptoms in the
acute setting. The majority of adnexal masses in pregnancy are incidentally discovered on routine prenatal
sonographic examination. Despite numerous attempts, there is no reproduciblesonographic scoring system
with a high enough sensitivity to reliably diagnose ovarian malignancy on the basis of ultrasound alone [810]. However, there are numerous sonographic characteristics of adnexal masses that have been associated
with increased risk of malignancy including size, solid components or heterogeneous/complex appearance,
excrescences/papillary structures, internal septations,bilaterality, irregular borders, increased vascularity,
low resistance blood flow and presence of ascites [1, 11, 12]. Taken alone each of these characteristics has
been shown to have relatively reasonable specificity and/or negative predictive value for raising suspicion for
malignancy; however, combinations of these factors are often more sensitive in predicting malignancy.
Furthermore,...