My Physician Guide to Ovarian Cysts: What You Need to Know

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Rule 1: If one or more M features are present in absence of B feature, mass is classified as malignant.

What You Need to Know About Ovarian Cysts

Rule 2: If one or more B features are present in absence of M feature, mass is classified as benign. Rule 3: If both M features and B features are present, or if no B or M features are present, result is inconclusive and second stage test is recommended. Magnetic resonance imaging MRI can be safely used during the second and third trimester of pregnancy, although the use of gadolinium-based contrast material should be avoided because fetal safety has not been established.

What you should know about ovarian cysts

MRI is particularly useful in making 3-dimensional images, distinguishing between different morphologic characteristics like bone of muscular tissue, e. Although MRI can provide valuable diagnostic information beyond the ability of ultrasound, the use of MRI is only advised when ultrasound diagnosis is uncertain, masses are too big to fully assess by ultrasound or when there is a high probability of malignancy to evaluate possible extra-ovarian spread Glanc et al. It is also important to keep in mind that even though imaging by ultrasound and, in additional cases, by MRI have a high sensitivity and specificity pathologic examination only will reveal the true nature of the mass.

The reliability of tumour markers in the diagnosis and characterization of tumours during pregnancy is often debated. During pregnancy elevations of tumour markers are mostly associated with the normal physiologic changes of pregnancy and presence of obstetric complications miscarriage, preeclampsia, HELLP Han et al. When an ovarian mass is diagnosed in pregnancy, CA levels may help to distinguish between a benign or malign lesion and can be used to evaluate treatment Giuntoli et al. However, decidua- and amnion cells also produce CA resulting in higher CA levels during pregnancy especially in the first and third trimester respectively because of trophoblast invasion and detachment of the placenta.

Tumour markers associated with germ cell tumours e. An asymptomatic adnexal mass presenting as a simple cyst of five centimetre or smaller or a cyst with unequivocal benign features as stated above is very likely to resolve by itself and no further follow-up or treatment during pregnancy is necessary.

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Patients with asymptomatic cysts over five centimetres or with a less reassuring appearance must be reviewed after 16 weeks of pregnancy. If these cysts are persistent, further follow-up is advised to determine the need for surgical exploration Whitecar et al.

The clinician needs to make a careful decision when to operate since both too early risk of miscarriage and loss of luteal function before the fourth month of pregnancy and too late complications as torsion, rupture or bleeding, progression in case of malignancy, premature labour can affect the patient and fetus. Retrospective reviews assessing the outcome of adnexal masses following conservative management show higher fetal morbidity and mortality as well as the risk of spilling by spontaneous rupture.

Para-ovarian lesions are likely to be benign and do not require intervention in pregnancy Glanc et al. Figure 1 presents a flowchart to aid the decision-making for optimal management of an adnexal mass during pregnancy. A midline laparotomy with minimal uterine manipulation is preferred in case of an open approach. Laparoscopy is safe and feasible when specific guidelines are followed. Laparoscopic management should be optimally scheduled between 16 and 20 weeks of gestation, based on the time allowed for spontaneous resolution, the optimized visualisation of the mass in contrast with the enlarged uterus, and the decreased ratio of premature labour Amant et al.

Important to consider is the position of the patient to avoid hypovolemia, hypotension and hypoxemia by the slowly change to Trendelenburg allowing only mild inclination, and from 20 weeks of gestation onwards, using the left lateral tilt position. The preferred method for primary trocar insertion should be the open laparoscopy and supra-umbilical port placement to limit the possibility of uterine perforation by insertion of a Veress needle.

The CO2 pneumo-peritoneum and CO production during electrocoagulation do not seem to be detrimental to the fetus when a maximum pressure of mmHg, an experienced surgeon and limited operation time is considered Han et al.

Management of ovarian cysts and cancer in pregnancy

The fetus is surrounded by amniotic fluid that absorbs the electrical current. Next to these preventive measures in case of laparoscopic procedures during pregnancy, general guidelines for surgery during pregnancy need to be considered. Maternal and fetal heart monitoring, thrombosis and antibiotic prophylaxis, knowledge of the side- effects of the anaesthetic drugs and in selective cases the use of corticoids should be considered Jackson et al. Data on the use of tocolytic drugs are not available.

Ovarian cyst

Therefore it is recommended to use them in case of uterine manipulation, which is present during surgery for ovarian masses Amant et al. Mathevet et al. The results show minimal risk for both the mother and fetus considering the possible technical problems and correct approach by the surgeon and specialized team. The incidence of a malignant adnexal mass during pregnancy is reported between four and eight in pregnancies Amant et al. Most frequently reported are the non-epithelial tumours germ-cell and sex-cord followed by ovarian tumours of low malignant potential LMP, e.

As stated above, diagnosis is usually made by routine prenatal ultrasound examination. The presence of ascites, peritoneal seeding or an omental cake indicates advanced disease. Of all malignant tumours of the ovary ten percent are metastases of other organs, mainly gastrointestinal or breast tumours. They are usually solid and bilateral Glanc et al. When the probability of malignancy is high or if there is a high risk of developing complications rupture, torsion surgery is indicated.

For early stage disease, fertility- and pregnancy preserving treatment may be considered. In these selected cases surgery includes removal of the adnex and surgical staging cytology, peritoneal biopsies, omentectomy and appendectomy in mucinous tumours. In unilateral borderline tumours, a laparoscopic procedure without spilling is possible. Restaging after delivery may be considered because of occult extra-ovarian disease, which may not be assessed adequately during pregnancy Amant et al. For high-grade stage I and any stage II disease, standard adjuvant chemotherapy carboplatin-paclitaxel can be considered.

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  • When there is a high probability of advanced stage ovarian cancer, further imaging besides ultrasound is required to evaluate the stage. As stated above, in pregnant women the use of MRI after the first trimester is considered safe and allows accurate evaluation of the mass and its possible spread.

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    Since chemotherapy is not effective for borderline disease and given the indolent nature, an otherwise conservative approach during pregnancy is advised. Similar, the performance of complete cytoreductive surgery for advanced stage invasive FIGO stage III ovarian cancer is not possible during pregnancy.

    In most reported cases of advanced invasive disease, patients chose to terminate pregnancy when diagnosis has been made early in the first trimester of pregnancy Mancari et al. When the patient wants to proceed the pregnancy, neoadjuvant chemotherapy carboplatin and paclitaxel until fetal maturity and complete cytoreductive surgery after delivery is recommended from midpregnancy onwards Amant et al.

    However, experience is limited and the proposed approach still has an experimental character. A vaginal delivery is aimed for. Ovarian cysts or masses during pregnancy should be accurately evaluated to decide the most appropriate treatment option. Ultrasound and MRI are safe and allow distinguishing between benign and malignant lesions.

    A wait-and-see strategy is advised for an ovarian cyst with benign features. Masses with septa, solid components, papillae or nodules, or when persisting after 16 weeks of pregnancy should be further investigated. Treatment options including surgical procedures should be discussed for each patient individually. When advanced stage invasive ovarian cancer is diagnosed, termination of pregnancy may be considered in early pregnancy, otherwise chemotherapy can be administered during second and third trimester.

    When there is high suspicion of malignancy, a multidisciplinary approach is necessary, and preferably patients should be referred to centres with specialized experience. National Center for Biotechnology Information , U. Facts Views Vis Obgyn. Author information Copyright and License information Disclaimer.

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    Correspondence at: eb. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC.

    Abstract Adnexal masses during pregnancy are not uncommon. Keywords: Adnexal mass, pregnancy, diagnosis, management. Introduction Since the introduction of routine obstetric ultrasound examination adnexal masses are diagnosed more frequently than before. Benign ovarian masses In the premenopausal population adnexal masses found on examination are often incidentally, mostly benign and of little clinical significance.

    Table I. Benign adnexal masses discovered during early pregnancy sonography with their morphologic appearance on ultrasound. Giuntoli et al. Type of mass Sonographic features 1. No flow with Doppler. Dermoid cyst — Rokitansky nodule; a hyperechoic nodule with acoustic shadowing in a background of low-level echoes. Endometrioma — Round thick regular wall; diffuse homogenous low-level internal echoes chocolate cyst.

    Leiomyomas — Not attached to the ovary. Paraovarian cyst — cm simple cysts. Open in a separate window. Pregnancy-associated changes of ovarian masses During pregnancy the same ovarian masses can be found as those diagnosed in the non-pregnant population. Imaging Ultrasound As stated above, most of the adnexal masses during pregnancy will be discovered as an incidental finding on routine obstetrical ultrasound.

    Table II. IOTA simple rules. Adjusted from Timmerman et al. MRI Magnetic resonance imaging MRI can be safely used during the second and third trimester of pregnancy, although the use of gadolinium-based contrast material should be avoided because fetal safety has not been established.