Management of Adenxal Mass during Pregnancy Prof. Aboubakr Elnashar Benha University Hospital...

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Transcript of Management of Adenxal Mass during Pregnancy Prof. Aboubakr Elnashar Benha University Hospital...

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  • Management of Adenxal Mass during Pregnancy Prof. Aboubakr Elnashar Benha University Hospital [email protected]
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  • Adnexa refers to the appendages of an organ An adnexal mass is a lump in tissue near the uterus, usually in the ovary or fallopian tube
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  • Contents Incidence Causes Characters Diagnosis Management Conclusion
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  • Incidence Increase Detection Rate Routine U/S in early pregnancy: 4% At CS: 0.5%
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  • Causes I. Ovarian 1.Simple cyst 2.Haemorrhagic cyst 3.OHSS 4.Endometrioma 5.Luteoma 6.Brenner tumour 7.Epithelial tumours: serous and mucinous; endometrioid and clear-cell carcinomas
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  • 8. Germ cell tumours: mature and immature teratomas, dysgerminomas, endodermal sinus tumours, embryonal carcinomas 9. Sex cord-stromal tumours: fibrothecomas; granulosa cell, sclerosing stromal and Sertoli- Leydig cell tumours 10. Metastatic tumours: Krukenberg,Lymphoma
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  • II. Tubal Hydrosalpinx Heterotopic pregnancy IV. Paratubal cyst III. Fibroid Pedunculated or located in the broad lig IV. Non-gynaecological Mesenteric cyst Appendix mass Diverticular disease Pelvic kidney Urachal cyst
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  • Characters 1. Nearly all are benign Ovarian cancer: 0.0040.04%. Most are borderline with a low malignant potential
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  • 2. High possibility of regression -Ovarian cysts: Most ovarian cyst are undetectable at 14 w (mostly C.Luteum) Simple (6cm: 60% Persistent: 75% are complex
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  • 3. Complications of ovarian cysts in pregnancy 1.Rupture 2.Haemorrhage 3.Torsion (up to 5%) 4.Obstructed labour 5.Fetal malpresentation
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  • Diagnosis 1.Bimanual examination 2.US 3.MRI 4.Color Doppler 5.CT 6.Tumor markers
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  • 1.Bimanual examination: detected if it is at least 5 cm
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  • 2.US: Abd & TV Diagnostic in most cases (> 90%) Types: I.Simple cyst II.Low level echo cyst III.Complex cyst IV.Solid Complex (Solidcystic) lesions are more likely to be malignant. Purely solid or purely cystic lesions are more likely to be benign.
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  • II. Low-level echo cysts Endometrioma 95% Hemorrhagic cyst 50% Teratoma 18% Malignant Neoplasm 12% Patel et al (Radiology. 1999;210:739-745.)
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  • IV. Solid Adnexal Masses Subserous Fibroid Luteoma of pregnancy Ovarian Fibroma Dysgerminoma Gonadal stromal tumors
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  • 3. MRI: Indications: Suspicious Poorly visualized Inadequately localized Disadvantages: More expensive More time consuming than US
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  • Advantages: 1.Safely used in pregnancy {lack of ionising radiation compared with CT}. 2. Good at defining endometriotic & dermoid cysts 3. Superior resolution when compared with CT 4. Create images in several planes
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  • 4. Colour flow Doppler { Malignant lesions are vascular Benign lesions demonstrate little or no blood flow}. Malignant lesions: Resistance and pulsatility indices < 1 Benign conditions (endometriomas, corpus luteal cysts& other benign complex ovarian masses) have the same picture {increased pelvic vascularity in pregnancy}: overlap of these indices in both benign& malignant lesions: Doppler imaging unreliable.
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  • 5. CT Has little place in pregnancy in modern obstetrics
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  • 6. Tumour markers In the non-pregnant state: a. CA125 most reliable serum marker for epithelial ovarian carcinoma as it is raised in over 75% of cases. b. Serum alphafetoprotein (AFP)& beta-hCG useful in the preoperative evaluation& management of ovarian germ cell tumours. c. Serum inhibin levels: can be detected in women with granulosa cell tumours of the ovary and mucinous carcinomas. d. Serum lactate dehydrogenase: Raised in ovarian dysgerminomas {rarity of this neoplasm} data regarding this association are sparse.
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  • During pregnancy: a. Serum AFP, BhCG& inhibin levels: all raised {placental synthesis}: its use is limited. b. Serum CA125 levels: elevated during pregnancy {decidual cell production, with levels rising as pregnancy progresses}. Some researchers have suggested using a cut-off level of 112 U/ml as the upper limit of normal, compared with 35 U/ml in the non-pregnant state. The usefulness of this marker in pregnancy is still restricted and if an ovarian mass is thought to look suspicious, further evaluation with MRI may be preferable.
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  • Management Depends on: 1.Size 2.Sonographic appearance 3.Symptoms A.Observation B.Aspiration C.Surgery
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  • A.Observation Simple cysts 10 cm Causing pain or thought to be increasing the risks of fetal malpresentation or">
  • B. Aspiration: Indications Persistent, simple, unilocular cysts, >10 cm Causing pain or thought to be increasing the risks of fetal malpresentation or obstructed labour Timing after 14 w {minimise disturbance to the corpus luteum}.
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  • Method 1. Transvaginally or abdominally 2. US guidance 3. Fine needle (>20 gauge). 4. Local anaesthesia for the skin 5. Antibiotic 6. Fluid aspirated should be sent for cytology 7. Rescan to determine recurrence
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  • Complications 1. Well tolerated& without short or long- term complications. 2. Recurrence 3350% Further aspirations can be required during the rest of the pregnancy.
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  • C. Surgery Indication depend on: 1.Degree of suspicion of malignancy 2.Development of complications. Timing: after 14 weeks gestation { minimise the risk of fetal loss due to miscarriage, although this risk is very small. Pregnancy is dependent on the corpus luteum during the first trimester & much less so after 12 w}.
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  • Approach: 1.Laparotomy 2.Laparoscopy skill-dependent more time consuming than open surgery. performed during 2nd trimester an open method (Hasson) {avoid uterine injury from the primary trocar introduction}. Tocolytics: not routinely necessary, but if uterine irritability: tocolytic regimens can be employed.
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  • Adnexal mass discovered at CS: The most common lesions: Dermoid cysts Paratubal cysts Cystadenomas Endometriotic cysts Corpus luteal cysts.
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  • Management: 1.Simple cysts 5 cm or complex cysts: cystectomy. 3.After cyst removal contents should be inspected: any signs of malignancy (solid excrescences): Oovarectomy or, if available, rapid frozen section.
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  • Precaution: 1.Avoid intra-abdominal contamination. 2.The contralateral ovary should be examined & if indicated, biopsied accordingly.
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  • Ovarian Cyst Simple cyst < 5 cm. No further action No increase in size Rescan 6 weeks postnatal Complex or simple cyst > 5 cm. Rescan in 4 weeks MRI in suspicious US Resolution Sever pain/ torsion/pressure symptoms Rapid increase in size or High ? Malignancy Surgery Aspiration if simple cyst Clinical Algorithm For The Management Of Ovarian Cysts In Pregnancy
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  • Conclusions The majority of ovarian cysts are benign and resolve spontaneously Ovarian cancer is extremely rare & thus most of these cysts can be managed conservatively. Unless there is a suspicion of malignancy or there is a significant cyst complication, such as torsion, surgery is not indicated.
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  • MRI is a safe & useful tool when ultrasound provides an inconclusive answer. Surgery is done through laparoscopy or laparotomy depending on operator experience & patient preference. Aspiration is only indicated in simple cyst, causing pain or thought to be obstructing the birth canal.