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]

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

Management of Adenxal

Mass during Pregnancy

Prof. Aboubakr ElnasharBenha University [email protected]

Adnexa refers to the appendages of an organAn adnexal mass is a lump in tissue near the uterus, usually in the ovary or fallopian tube

ContentsIncidenceCausesCharactersDiagnosisManagementConclusion

IncidenceIncrease Detection Rate Routine U/S in early pregnancy: 4% At CS: 0.5%

CausesI. Ovarian

1. Simple cyst2. Haemorrhagic cyst3. OHSS4. Endometrioma5. Luteoma6. Brenner tumour7. Epithelial tumours: serous and mucinous;

endometrioid and clear-cell carcinomas

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

II. TubalHydrosalpinxHeterotopic pregnancy

IV. Paratubal cystIII. Fibroid

Pedunculated or located in the broad ligIV. Non-gynaecological

Mesenteric cystAppendix massDiverticular diseasePelvic kidneyUrachal cyst

Characters1. Nearly all are benign Ovarian cancer: 0.004–0.04%.Most are borderline with a low malignant potential

2. High possibility of regression-Ovarian cysts: Most ovarian cyst are undetectable

at 14 w (mostly C.Luteum)Simple (<5 cm), hemorrhagic, OHSS: 90-100%-Ovarian mass:< 6cm: 95% >6cm: 60%Persistent: 75% are complex

3. Complications of ovarian cysts in pregnancy1. Rupture2. Haemorrhage3. Torsion (up to 5%)4. Obstructed labour5. Fetal malpresentation

Diagnosis1. Bimanual examination2. US 3. MRI4. Color Doppler5. CT6. Tumor markers

1.Bimanual examination: detected if it is at least 5 cm

2.US: • Abd & TV• Diagnostic in most cases (> 90%)• Types:I. Simple cystII. Low level echo cystIII. Complex cystIV. Solid

•Complex (Solid–cystic) lesions are more likely to be malignant.

Purely solid or purely cystic lesions are more likely to be benign.

II. Low-level echo cystsEndometrioma 95% Hemorrhagic cyst 50%Teratoma 18%Malignant Neoplasm 12%Patel et al (Radiology. 1999;210:739-745.)

IV. Solid Adnexal Masses•Subserous Fibroid Luteoma of pregnancyOvarian FibromaDysgerminomaGonadal stromal tumors

3. MRI:Indications: Suspicious Poorly visualized Inadequately localizedDisadvantages:More expensiveMore time consuming than US

• 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 CT4. Create images in several planes

4. Colour flow Doppler•{Malignant lesions are vascularBenign 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.

5. CT Has little place in

pregnancy in modern obstetrics

6. Tumour markers •In the non-pregnant state:a. CA125most reliable serum marker for epithelial ovarian carcinoma as

it is raised in over 75% of cases. b. Serum alphafetoprotein (AFP)& beta-hCGuseful 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.

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.

Management •Depends on:1.Size 2.Sonographic appearance3.Symptoms

A. ObservationB. AspirationC. Surgery

A.Observation• Simple cysts <5 cm: No further evaluationRescanning if pelvic pain{Majority resolve

spontaneously}• Complex cysts: US/4W{determine whether the cyst is becoming larger}. In the majority of cases, resolve during the course of the pregnancy.

•Adnexal masses that undergo torsion:Usually dermoids or cystadenomas. Usually during 1st trimester or in the immediate puerperium (up to 14 days after delivery)More commonly on the right side.

•Dermoids <6 cm Can be managed conservatively{1. unlikely to grow significantly in pregnancy2. risk of complications e.g. torsion, is low}Rescan in the postnatal period to determine further management

Why The New Conservative Concept?

1. Torsion is rare till postnatal

2. Most malignancy are Border line or LMP

3. MRI cane differentiate most malignancy.

4. Surgery: PTL in10% at 2nd trimester

B. Aspiration:•IndicationsPersistent, simple, unilocular cysts, >10 cm Causing pain or thought to be increasing the risks of fetal malpresentation or obstructed labour•Timingafter 14 w {minimise disturbance to the corpus luteum}.

•Method1. 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 cytology7. Rescan to determine recurrence

•Complications1. Well tolerated& without short or long-term complications. 2. Recurrence 33–50%Further aspirations can be required during the rest of the pregnancy.

C. Surgery •Indication depend on:1. Degree of suspicion of malignancy2. 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}.

• Approach:1. Laparotomy2. Laparoscopyskill-dependentmore time consuming than open surgery. performed during 2nd trimesteran ‘open’ method (Hasson) {avoid uterine injury from the primary trocar introduction}.

•Tocolytics:not routinely necessary, but if uterine irritability: tocolytic regimens can be employed.

•Adnexal mass discovered at CS:The most common lesions: Dermoid cystsParatubal cystsCystadenomasEndometriotic cystsCorpus luteal cysts.

Management:1. Simple cysts <5 cm: left alone2. 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.

Precaution:1.Avoid intra-abdominal contamination.2.The contralateral ovary should be examined & if indicated, biopsied accordingly.

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/pres

sure symptoms Rapid increase in

size or High ? Malignancy

Surgery Aspiration if simple cyst

Clinical Algorithm For The Management

Of Ovarian Cysts In Pregnancy

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.

•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.