Review
Obstetrics
Evaluation and management of adnexal mass in pregnancy

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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.

Section snippets

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.5, 6 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

Evaluation

Most adnexal masses in pregnancy are diagnosed incidentally during a screening ultrasound in the first trimester.5 If an adnexal mass is palpated on examination, ultrasound is the preferred radiological method of confirmation because of its ability to differentiate morphology. This will ultimately allow stratification of risk without compromising maternal and fetal safety.10 The ultimate goal of an ultrasound evaluation is to aid the physician in determining those adnexal masses in which

Management

Currently there is disagreement among authors regarding the best management of adnexal masses in pregnancy, with some investigators recommending observation, and others, surgical management.1, 4, 5, 22 Most ovarian masses identified in pregnancy will spontaneously resolve, and aggressive surgical management is not required. Characteristics favorable for resolution include masses that are simple in nature by ultrasound, less than 5-6 cm in diameter, and diagnosed before 16 weeks.3 Larger masses

Observation

Observational management of adnexal masses in pregnancy is supported by several small retrospective, observational studies.1, 4, 5, 12 These studies demonstrated good maternal and fetal outcomes comparable with those seen in older studies.15, 26 Observational management is also supported by the fact that up to 71% of benign appearing ovarian masses will either decrease in size or resolve spontaneously. Some masses with more complex features have also been shown to resolve.15, 26

A consensus

Surgical approach

Traditionally, surgery for adnexal masses in pregnancy has been performed by laparotomy. However, recently there has been a great deal of debate about the role of laparoscopy in the management of adnexal masses in pregnancy.8, 23, 25 Those authors in favor of a laparotomic approach raise several concerns regarding laparoscopy in pregnancy including the lack of data regarding the effects of a pneumoperitoneum; possible injection of carbon dioxide into the uterine cavity; possible injury to the

Conclusion

Because of the widespread use of antenatal ultrasound for pregnancy dating and aneuploidy screening, the diagnosis of adnexal masses in pregnancy has become more common. Therefore, it is imperative that the obstetrician be skilled in the diagnosis and management of adnexal masses in pregnancy. The use of ultrasound to characterize the malignant potential of a mass provides the patient with the potential for several management options. Observation is a viable option for those who are

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