Management of Adnexal Masses in Pregnancy
The overall prevalence of adnexal pathology in pregnancy is 1-6%, depending on the gestational age at presentation. The most common pathologic diagnoses include mature cystic teratomas, paraovarian cysts and corpus luteum cysts. Malignancy is only diagnosed in 3-7% of patients with persistent masses in pregnancy, with the majority being early stage germ cell and stromal tumors, or epithelial tumors of low malignant potential.
Most adnexal masses in pregnancy are asymptomatic and are found incidentally at the time of routine pelvic ultrasound. Gray-scale transvaginal ultrasonography is the imaging modality of choice, but depending on the gestational age, transabdominal approach may be necessary to adequately image the adnexa. Features suggestive of malignancy include abnormal wall structure, thick septations, solid components, papillary projections and increasing size. Magnetic resonance imaging may also be considered when the mass is not well defined, as there is no radiation exposure to the fetus.
Serum tumor markers may be used to determine risk of malignancy, but have limited sensitivity and specificity in the pregnancy. CA 125 is most useful in non-mucinous epithelial cell tumors, but the majority of malignancies in reproductive age women are of the germ cell and sex cord-stromal type. Furthermore, CA 125 levels are only elevated in 50% of patients with Stage 1 epithelial cancers. CA 125 is often elevated normally in pregnancy. Levels peak in the first trimester and decrease consistently thereafter. Other tumor markers are more consistently elevated in non-epithelial ovarian malignancies (β-hCG, LDH, AFP, and Inhibin) but have limited utility as they may also be elevated in normal pregnancy.
Complications of persistent adnexal masses in pregnancy include torsion, rupture, and labor obstruction. The risk of torsion is increased due to the displacement of the ovaries outside of the pelvis by the enlarging gravid uterus. The risk is highest for masses 6-8 cm in size and from 10-16 weeks gestation, as the uterus undergoes rapid growth. Rupture in pregnancy is rare, with most case series demonstrating a risk of <1%. In both torsion and rupture, the patient will often present with acute onset pain, nausea and vomiting. These are common complaints in pregnancy, so the provider must maintain a high index of suspicion.
In the setting of acute torsion, rupture or labor obstruction, pregnant women should be managed as non-pregnant women, with surgery. However, the majority of patients will remain asymptomatic and may be managed expectantly. Studies have shown that 51-92% of adnexal masses will spontaneously resolve during pregnancy. Predictors of persistence include size > 5cm and complex morphology with solid features on pelvic imaging. In the setting of an acute complication or if malignancy risk is deemed high, surgery is recommended. Less than 2% of patients will experience acute complications. Surgical approach is generally with laparoscopy in the first and early second trimester, and laparotomy in the late second trimester or if malignancy is suspected.
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology, Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol. 2016 Nov;128(5):e210-e226.
Webb k, Sakhel K, Chauhan S, Abuhamad A, Adnexal Mass during Pregnancy: A Review. Am J Perinatol. 2015 Sep;32(11):1010-6. doi: 10.1055/s-0035-1549216. Epub 2015 May 22.
Initial Approval: September 2015, Reviewed November 2016, Revised: November 2018; Reaffirmed November 2019. Minor Revision July 2021
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