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7.8 Treatment
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tion [36]. Third, reducing unnecessary oophorec­tomies prevents medicolegal issues when the histology shows normal ovarian parenchyma.
7.8.1 Abdominal Entry
7.8.1.1 Laparoscopy
In the general population, laparotomy is com­mon [8, 10, 37, 40, 41, 43, 72], but laparoscopic surgery is steadily increasing [9, 14]. It is recom­mended as access of choice in the general popu­lation [88]. Generally, laparoscopic surgery is safe in all trimesters of pregnancy. Successful cases of IFTT were performed during the rst [55], the second [29, 51, 54], and the third tri­mester [26, 27, 33, 49]. The advantages of the laparoscopic approach are (1) faster recovery, (2) better cosmesis, and (3) fewer pelvic adhe­sions, which are particularly important for women of reproductive age who wish to preserve fertility.
During the rst and second trimesters, trocars are positioned in standard fashion. In the third tri­mester, depending on the height of the uterus, the Veress needle should be inserted 2–4cm crani­ally from the upper border of the uterus, or in Palmer’s point [27, 54] or open approach with Hasson trocar [29]. The position of other trocars depends on the uterus size and the position of the abnormal ndings (Fig.7.4). Usually, both work­ing trocars are in the right hemiabdomen. The rst 5-mm trocar is in the right middle abdominal quadrant, and the second 10 cm above in the midaxillary line [26].
7.8.1.2 Laparotomy
Laparoscopy can be used in the third trimester [26, 27, 33], but the patient’s large uterus makes the operation more difcult. Therefore, laparot­omy is common in the third trimester, primarily when the preoperative diagnosis is unclear. The pararectal incision directly exposes the adnexal eld, minimizing or eliminating uterine manipu­lation, inevitable through an inferior median lap­arotomy [19]. Another excellent option with preoperative diagnosis is a gridiron incision. It
179
Fig. 7.4 Trocar position for laparoscopic access to the twisted Fallopian tube during pregnancy on the right side
results in a short operation, minimal abdominal wall trauma, minimal uterine manipulation, and simultaneous appendectomy [43, 50].
With McBurney (gridiron) incision, it is advisable to make an appendectomy because this incision is reserved for an appendectomy.
After McBurney’s incision and appendec­tomy, there are no diagnostic complexities with right lower quadrant pain in future life. Also, in many IFTT cases, the appendix had gross changes necessitating its removal along with tubal pathol­ogy [43, 50]. If the appendix appears inamed or changed, it should be removed through every incision or laparoscopy [62].
7.8.2 Operative Procedures
7.8.2.1 Detorsion (Untwisting)
Indications for untwisting (detorsion) are [8, 10,
16, 37, 41, 72]:
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• twisting is incomplete or recent,
• ischemic damage appears to be reversible,
• no malignancy or ectopic pregnancy (suspected).
The presence of ischemic changes in twisted FT does not dene vitality (Fig. 7.5a). After untwisting, the operator estimates FT vitality (Fig.7.5b). In some cases, the leading pathology, most commonly the tubal cyst, causes IFTT. Without an indication of salpingectomy, the leading pathology should be resected to elim­inate recurrent torsions [19] and provide tissue for histologic analysis. Excision can be per­formed by bipolar electrocoagulation or with ultrasonic frictional heating instruments. The excision line should be sutured.
7 Isolated Fallopian Tube Torsion
suturing with the uterus. Fixation may change the normal anatomy of the pelvis—either moving the adnexa outside the pelvis or distorting the impor­tant close relationship between the ovary and the mbrial portion of the tube. Branches of the uter­ine and the ovarian arteries provide circulation to the FT. Shortening a ‘billowing’ mesosalpinx may impair the blood supply to the adjacent ovary.
Tubal detorsion may help preserve fertility, but it may also increase ectopic pregnancy risk, especially in recurrent IFTT [77] due to irrevers­ibly distorted FT with narrowing or obstruction of the lumen due to ischemia or inammation (see Sect. 7.3.2). The paratubal pathology that leads to IFTT should be excised. A benign cyst could be opened and drained [27].
7.8.2.2 Salpingectomy
There are three indications for total salpingec­tomy (Fig.7.6) [17, 23, 32, 36, 42, 76] or partial salpingectomy [22, 80]:
Untwisting the pedicle of the cyst should be avoided to prevent emboli and toxic sub­stances related to hypoxia from entering peripheral circulation.
• the tube is beyond recovery (gangre­nous, suspected malignancy),
• distended tube causes other organ impairment, such as ureteric
With conservation of the affected adnexa, the inferior surface of the tube is sutured to the round ligament by one or two interrupted atraumatic
compression,
• the tube twisting is associated with ecto­pic pregnancy.
sutures, and the ovarian ligament is shortened by
ab
Fig. 7.5 (a) An edematous and purple left Fallopian tube showed a three-fold torsion around its long axis (white arrow). The tubal mbriae were also purple and enlarged
(asterisk). (b) After detorsion of the vital Fallopian tube, prompt revascularization occurred. (Reproduced with per­mission from [45] under the CC BY 4.0)
ab
7.9 Prognosis
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181
Fig. 7.6 (a) 720° left tubal torsion (T). (O) Normal- looking ovary, (GA) congested and gangrenous-looking tube lateral to the torsion, (F) mbrial end of the tube appearing blocked, leading to hematosalpinx and torsion.
(b) Site of the resection after salpingectomy (arrow) and normal-appearing medial end of the tube (FT). (Reproduced with permission from [30] under the CC BY 2.5)
The second indication is not absolute. If the ureteric ow is normalized during detorsion, untwisting (resection of leading pathology if present) could be performed. Ovaries should always be preserved unless their perfusions severely deteriorate and necrosis develops. If
Cesarean section performed rst mini­mizes the hematogenous spread of toxins and eventually bacteria during adnexal manipulation, detorsion, or salpingectomy [46].
doubtful, an intraoperative FT biopsy (and ova­ries) increases the possibility for tubal preserva­tion if histology shows viable tissue. This is important in women without the contralateral FT for preserving future fertility. After laparoscopic (partial) salpingectomy, the specimen is placed in an endobag to minimize the inoculation of potential endometriotic or malignant tissue [29,
7.8.3.2 Pregnancy Follow-Up
If the pregnancy is undisturbed, all patients should be monitored clinically and by the abdom­inal US performed 2 and 4weeks after discharge [17].
54].
7.9 Prognosis
7.8.3 Obstetric Management
7.9.1 Maternal Outcome
7.8.3.1 Cesarean Section
Indications for Cesarean section (CS) are mostly obstetric. In near-term or term pregnancy, it can be performed with the treatment of IFTT (Fig.7.7), especially when fetal distress is pres­ent [39, 56, 58, 78]. After 32–34weeks’ gesta­tion, a laparotomy could result in (1) the disruption of the abdominal wall wound during (difcult) vaginal delivery and (2) postoperative complications from IFTT surgery on both mother and fetus [22, 46].
Even with the necrosis of the FT, maternal out­comes are good. The English language literature concerning twisting or torsion of the FT and pregnancy reported no associated ndings during operation in 26.7% of cases. In comparison, asso­ciated ndings were paratubal cyst in 20%, ovar­ian cyst in 13.3%, a cyst in the mesosalpinx in
6.7%, a cyst in the broad ligament, sactosalpinx, hydrosalpinx, hematosalpinx, and unruptured tubal ectopic pregnancy. Most cases were treated
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Fig. 7.7 Intraoperative ndings of a right ischemic fallo­pian tubal mass (T) and a grossly normal ovary (O) beside the uterus (U). The isolated torsion of the right Fallopian tube (arrow) was observed at midportion. The suture line of the completed Cesarean section is seen. (Reproduced with permission from [46] under the CC BY 4.0)
with a salpingectomy of the affected FT.In all cases, the pregnancies ended with a favorable outcome (except ectopic tubal pregnancy). Due to the rarity of IFTT in pregnancy, there are no data about the recurrence of IFTT after detorsion. However, recurrence after pregnancy is possible [77].
7.9.2 Fetal Outcome
Even with the necrosis of the FT, fetal outcomes are excellent. Even the rst known description of IFTT in pregnancy from 1899 resulted in the con­tinuation of pregnancy [3]. There is only one case of miscarriage [53] among 50 published cases.
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7 Isolated Fallopian Tube Torsion
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29. Sidiropoulou AZS. Acute abdomen in pregnancy due to isolated fallopian tube torsion: the laparo­scopic treatment of a rare case. World J Clin Cases. 2014;2:724–7.
30. Shakuntala SR, Poornima M, Padmalatha VVPR.A rare case of isolated torsion of haematosalphinx pre­senting as acute abdomen during pregnancy. Online J Health Allied Sci. 2012;11:1–3.
31. Bakacak ZMB. Isolated torsion of fallopian tube complicating pregnancy: case report. Clin Exp Obstet Gynecol. 2014;41:362–3.
32. Simsek Y, Kaymak O, et al. Hydronephrosis of pregnancy associated with torsion of the fallopian tube: a case report. Eur Rev Med Pharmacol Sci. 2011;15:448–51.
33. Duncan MMRS.Laparoscopic salpingectomy for iso­lated fallopian tube torsion in the third trimester. Case Rep Obstet Gynecol. 2012;2012:239352, 1.
34. Yildirim AG, Akdemir A, etal. Isolated torsion of the Fallopian tube with ectopic pregnancy: case report. Turkiye Klinikleri J Gynecol Obstet. 2014;24:120–2.
35. Shirokane F, Satomi M, Suzuki SMK.Isolated torsion of a left normal fallopian tube during pregnancy. J Nippon Med Sch. 2011;78:40–1.
36. Choudhary R, Nigam ADB.Isolated fallopian tube torsion in early pregnancy presenting as resolving appendicular lump. Eur Rev Med Pharmacol Sci. 2011;15:446–7.
37. Chambers S, Kitchin JDJT III. Torsion of the nor­mal fallopian tube in pregnancy. Obstet Gynecol. 1979;54:487–9.
38. Ellison JSWNC. Torsion of fallopian tube during pregnancy. BMJ. 1952;1:694.
39. Işçi N, Gönenç G, Basgul AYHG.Isolated tubal tor­sion in pregnancy—a rare case. Clin Exp Obstet Gynecol. 2011;38:272–3.
40. Isager-Sally TLW. Torsion of the fallopian tube during pregnancy. Acta Obstet Gynecol Scand. 1985;64:349–51.
41. McKenna KHPG. Isolated torsion of the uterine tube in pregnancy. A case report. J Reprod Med. 1989;34:187–8.
42. Kaur C, Awala AKV.Isolated fallopian-tube torsion: a case series. J Gynecol Surg. 2014;30:184–6.
43. Walker P. A case of torsion of the fallopian tube in pregnancy. J Obstet Gynaecol Br Commonw. 1962;69:117–8.
44. Lewis E. Torsion of a fallopian tube complicating pregnancy. Br J Clin Pract. 1962;16:540–3.
45. ten Cate S, Vliegen AS, etal. Conservative surgery for left-sided isolated tubal torsion in pregnancy. JBR­BTR. 2011;94:212–3.
46. Park SN.Isolated tubal torsion in the third trimester of pregnancy managed with simultaneous salpingec­tomy and cesarean section. Yeungnam Univ J Med. 2019;36:59–62.
47. Ouassour S, Alami MH, Tazi Z, Filali AA, Bezad R. Isolated fallopian tube torsion in pregnancy: an uncommon event. MOJ Clin Med Case Rep. 2017;7:186–8.
48. Popescu D, Chicea R, Turcanu D, Lodromanean D, Popescu C.Rare case of fallopian tube torsion asso­ciated with hematosalpinx in the last trimester of pregnacy. 5th Romanian Congress of the Romanian Society of Ultrasound in Obstetrics and Gynecology.
2017.
49. Kondo S, Uno K, Tano S, Yoshihara M, Mayama M, Ukai M, et al. Isolated fallopian tube torsion dur­ing pregnancy successfully diagnosed with laparos­copy: a case report. Jap J Gynecol Obstet Endosc. 2016;32:214–9.
50. Gundabattula SR, Surampudi K, Pochiraju M, Yerrapragada S, Sarvotham K, Paineni S. Torsion of the fallopian tube: two contrasting presenta­tions and review of the literature. J Gynecol Surg. 2014;30:28–31.
51. Haerizadeh H, Lord J, Bates S.Laparoscopic manage­ment of isolated fallopian tube torsion in the second trimester of pregnancy. Hum Fertil. 2010;13(S1):18.
52. Güraslan H, Kanawati A, Güven E, Kaya C.Successful treatment of an isolated torsion of a fallopian tube in pregnancy with laparoscopic surgery: a case report. J Turk Ger Gynecol Assoc. 2016;17(Suppl):S247–8.
53. Stack JJ, Davi SE, Ellepola H, Haran M.A suspected ectopic pregnancy masking fallopian tube torsion. Sri Lanka J Obstet Gynaecol. 2013;34:163–4.
54. Shore EM, Vlachou PA, Yudin MH. Laparoscopic treatment of tubal torsion in pregnancy. J Gynecol Surg. 2018;34:174–6.
55. Khan S, Donnelly J, Abbas M. Isolated fallopian tube torsion with pregnancy. New Indian J OBGYN. 2016;2:119–20.
56. Naghshineh E, Tavakoli M. Isolated fallopian tube torsion in a pregnant woman due to a carcinoid tumor: a case report. J Isfahan Med Sch. 2014;32:292–7.
57. Polat I, Ekiz A, Atis A, Ozkose B, Ustun B, Gedikbasi A.Advanced tubal ectopic pregnancy with tubal tor­sion. J Gynecol Surg. 2015;31:296–8.
58. Yarandi F, Ahmadi FS, Alaghi S, Ghaseminejad A, Abbasi S.Isolated fallopian tube torsion after eating origan and fennel during pregnancy. Glob J Med Clin Case Rep. 2015;2:10–2.
59. Ergenoglu M, Ozgur Y, Nuri P, Volkan T, Nedim K. Tubal torsion during pregnancy–case report. Ginekol Pol. 2011;82:287.
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76. Chandrasekar D, Chupi J, Agarwal N, Odejinmi F.Case study-isolated torsion of the fallopian tube as a reason for ectopic pregnancy; Pierre dionis revis­ited? BJOG. 2014;121(Suppl):15–6.
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79. Krissi W, Dicker D, etal. Torsion of a fallopian tube following Pomeroy tubal ligation: a rare case report and review of the literature. Eur J Obstet Gynecol Reprod Biol. 1997;72:107–9.
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Complex Ovarian Mass
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8
Abstract
Complex ovarian mass is a separate entity from adnexal torsion, which is only one pre­sentation due to ovarian mass and is described in detail in a separate chapter. Complex ovar­ian mass found in pregnancy is important for several reasons: (1) adnexal torsion, as a result, should be detorsed immediately to pre­serve ovarian function, (2) persistent pain, (3) ovarian mass rupture and bleeding, and (4) tumor with malignant potential. Persistent pain or compression of surrounding structures is important because it commonly does not subside without surgical intervention. The timing of the operation is critical because intervention during the second trimester car­ries the lowest risk of obstetric complications. Intra-abdominal bleeding is difcult to diag­nose initially, especially if the bleeding is small. Bleeding from the ovarian mass is always the indication for immediate opera­tion. The most difcult issue is asymptomatic and small ovarian mass. Small ovarian mass can commonly be treated conservatively if the malignancy is excluded. There are different imaging and non-imaging methods for conr­mation of malignancy. Malignancy status determines the timing and the type of treat­ment intervention.
During pregnancy, complex ovarian mass repre­sents the mass effect and complications of the mass/tumor during pregnancy—adnexal torsion (see Chap. 12), rupture, bleeding, or obstetric complications such as obstruction of labor. Borgfeldt and Andolf dened an adnexal lesion as a simple cyst with the largest diameter of at least 25mm or a complex cyst of any size.
8.1 Incidence andClassication
Adnexal masses detected during pregnancy are the same as those found outside of pregnancy, with the addition of several of them unique to pregnancy (Table8.1).
The incidence of sonographically (US)
detected ovarian masses during pregnancy is
0.05–3.2% [1–5]. A higher incidence of detected
adnexal masses is due to the widespread use of the antenatal US and improved imaging technol­ogy [6] and possibly a higher mean age of partu­rients. Outside of pregnancy, the prevalence of an asymptomatic adnexal mass on US is 7.8% in premenopausal women and 2.5% in postmeno­pausal women [7, 8].
Most cysts are functional (<5cm) and disap­pear in 90% by the second trimester of pregnancy [2, 9]. Thus, while 6–17% of adnexal masses resected in the general population are functional
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 G. Augustin, Acute Abdomen During Pregnancy, https://doi.org/10.1007/978-3-031-26021-6_8
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8 Complex Ovarian Mass
cysts, these are more frequent in pregnancy [10]. The incidence of histopathologically conrmed benign ovarian masses during pregnancy differs (Table 8.2). The most common benign ovarian tumors during pregnancy are cystic teratomas (36–37%), followed by cystadenomas (15–20%) [11–14]. The major concern of an adnexal mass is its potential for malignancy. The incidence of malignancy of these masses during pregnancy is 2–4% [2, 9, 11, 15, 16], and even slightly higher (3.6–6.8%) with persistent masses [3–6, 9, 17,
18], although recent meta-analysis claims 1%
[14]. There is a trend of low-stage and low-grade cancers; almost all malignant tumors were grade I and stage IA-IC [2, 11, 19, 20].
There is an equal distribution of benign tumors among part Hawaiian (22.1%), white (18.5%), Filipino (17%), and Japanese (16%). There is an increased incidence of benign cystic teratomas in Filipinas. There is no signicant predisposition for nonneoplastic or other neoplastic lesions among the other ethnic groups studied [18].
Table 8.1 Adnexal masses unique to pregnancy
Hyperstimulated ovaries Hyperreaction luteinalis Theca lutein cysts Luteoma of pregnancy Ectopic/heterotropic pregnancy
The risk of adnexal mass rupture in pregnancy is 2% [6]. No articles focused on the risk of rupture concerning size, morphologic appear­ance, or gestational age.
8.1.1 Ovarian Cysts
Follicular cysts occur when follicles do not rup­ture to release an ovum and appear smooth, uni­locular cysts with thin walls and clear lled. These typically resolve spontaneously by the mid-second trimester [5, 21]. Corpus luteum cysts are less common than follicular cysts, but are more associated with clinical symptoms. A corpus luteum cyst forms after an egg is released from a follicle. It produces progesterone to sup­port a pregnancy until the placenta has formed and lasts until 5–9weeks of pregnancy. Corpus luteum cysts should resolve around 8–9weeks of pregnancy, and persistence beyond this should prompt consideration of alternative diagnosis [22]. These resolving cysts are classied as cystic or hemorrhagic corpora lutea based on their appearance on the grey-scale US [3]. Therefore, in the rst trimester of pregnancy, ovarian cysts are often functional and generally resolve with­out complications, and consequently, these were assumed to be physiological [3, 23, 24].
Table 8.2 Pathology of benign tumors during pregnancy in decreasing incidence
Type of tumor Torsion Elective Cesarean section Total Teratoma 9 (3) 22 45 (9) 76 (37%) Mucinous cystadenoma 1 14 26 (6) 41 (20%) Endometrioma 1 8 11 20 (10%) Corpus luteum cyst 6 (1) 4 8 (5) 18 (9%) Simple cyst 2 6 2 (1) 10 (5%) Serous cystadenoma 1 1 7 (4) 9 (5%) Follicular cyst 1 3 4 8 (4%) Infarction 7 (3) 0 0 7 (3%) Paratubal cyst 3 (2) 0 3 6 (2%) Thecoma/broma 0 1 3 (2) 4 Hyperstimulated ovary 1 0 1 2 Cystadenobroma 1 0 1 2 Brenner tumor 0 0 1 1 Multiple luteinized follicular cyst 0 0 1 (1) 1 Struma ovarii 0 1 0 1 Total 33 (9) 60 113 (28) 206
Reproduced with permission from [11] Parentheses indicate the number of patients with adnexal tumors undiagnosed before surgery
8.1 Incidence andClassication
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Eiss, in 1930, reports a case of bilateral tumors, each of which ruptured in pregnancy. Their frequency varies with reports of different series. In Sloane Hospital (1931), the incidence was 1/500 pregnancies; in the University of California Hospital, 1/1500; in McKerron’s compilations (1903), it was 1/2500 pregnancies [25]. The number of diagnosed ovarian cysts during pregnancy has increased mainly due to the widespread use of US screening for fetal malformations. Adnexal cysts are found in 4.1–
24.9% of pregnant women [26, 27]. Around 92% of ovarian masses are simple, unilocular cysts, and of these, 81.6% are <3 cm in diameter.
The presence of an uncomplicated ovarian
cyst is compatible with normal pregnancy,
labor, or puerperium [23].
After 16weeks of gestation, the prevalence of ovarian cysts is 0.5–3.0% [3, 24]. Interestingly, of the ovarian cysts that persisted at 20weeks gestation, 78.6% were present at the 6-week postnatal scan, and all of these were pathological [3]. Zanetta etal. assessed the prevalence of ovar­ian cysts at various stages of pregnancy, i.e., in the rst, second, and third trimesters [3]. Only
1.2% of the women had an ovarian cyst >3cm. This gure is signicantly lower than the 5.4% published by Condous etal., probably reecting different population groups. The earlier in gesta­tion US is performed, the more ovarian cysts, particularly functional corpora lutea, will be detected.
As thin-walled vascular structures, such cysts are predisposed to rupture. Bleeding can cause rupture but also can follow the rupture. Also, a torsion can cause the cyst to rupture [28]. Rupture of adnexal torsion during pregnancy may occur secondary to softening of the lesion following stromal decidualization [29]. Bleeding in the cor­pus luteum is rare and occurs more frequently in younger women [30], primarily when associated with pregnancy [31].
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The best predictors of the persistence of adnexal masses during pregnancy are com­plex masses on US and size >5cm [6, 32].
8.1.2 Ovarian Teratoma
The frequency of ovarian tumors is 1/1000 preg­nancies [15] and malignancy in 1/15,000– 1/32,000 pregnancies [24]. Mature cystic teratoma (dermoid cyst) is the most common benign ovarian neoplasm discovered during preg­nancy (24–40%) [13, 33, 34]. The word teratoma is derived from the Greek word teraton, meaning monster, and was used initially by Virchow in the rst edition of his book on tumors, published in 1863 [33]. Since mature cystic teratomas are composed of all three germ cell layers, the term “dermoid” is a misnomer. Most of these tumors occur during the reproductive years providing further support for the germ cell theory [33]. It occurs at all stages of life, with most cases between 20 and 30 years of age [13]. In preg­nancy, complications increase signicantly, including rupture, torsion, infection, and malig­nant degeneration. As BCT tends to remain in the connes of the true pelvis, it could lead to dysto­cia and obstructed labor [13].
8.1.3 Ovarian Carcinoma
The age shift of childbearing women could cause a change in the histological distribution pattern. Jubb reported 34 cases of primary ovarian carci­noma associated with a pregnancy between 1882 and 1963 [35]; only 54% were of epithelial type [36]. Additional 22 cases between 1963 and 1988 revealed 27% of the epithelial type [37, 38]. In contrast to those previous reports, Dobashi etal. showed that the most common histological types were 80% epithelial, 60% invasive, and 20% bor- derline ovarian tumors (BOT). Of note were the two clear cell carcinomas (20%), which is a rela­tively high incidence compared to other studies outside Japan; the incidence of ovarian clear cell carcinoma in Japan is the most frequent in the
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8 Complex Ovarian Mass
Table 8.3 FIGO stage of histologic subtypes of pregnant patients with borderline ovarian tumors [42]
FIGO stage Serous Mucinous Seromucinous IA 19 4 20 IB 1 1 0 IC 5 0 1 II 3 0 1 III 3 1 0
world [39]. The characteristic age group was 30–35, with a high incidence of nulliparity [35]. The age range in Creasman etal. was 18–34, and around 50% were primigravidas [40]. Among pregnancies complicated by ovarian tumors, approximately 8% involve BOT [41] mostly within stage I (Table8.3). The overall incidence of ovarian cancer in pregnancy is 1/12,500– 25,000 pregnancies [43].
8.1.4 Ovarian Endometrioma
Decidualization is the process of endometrial change caused by high progesterone levels, which increase glandular epithelial secretion, accumulation of glycogen, and stromal vascular­ity. These changes create conditions that facilitate the implantation and development of early gesta­tion. The formation of ectopic decidua (deciduo­sis) during pregnancy is caused by progesterone’s effect on the ectopic endometrium, resulting in endometriosis [44].
Ovarian endometriomas account for 4–5% of ovarian cysts diagnosed in early pregnancy [3] and 11.5% of all adnexal masses during preg­nancy [5]. Endometriomas have features com­mon with neoplasia, such as clonal proliferation, consistent with the endometriosis disease theory, and associated with subtypes of ovarian malig­nancy, such as endometrioid and clear cell carci­noma [29].
8.2 Clinical Presentation
Presentations include (1) (a)symptomatic mass, (2) mass or adnexal torsion (see Chap. 6), (3) mass rupture, (4) mass bleeding, (5) malignancy,
or (6) labor obstruction. Adnexal torsions, mass ruptures, or mass bleeding are acute abdominal conditions.
Simple or functional cysts commonly do not cause symptoms and other smaller adnexal masses. Most of these adnexal masses are diag­nosed incidentally during the rst-trimester screening US [45]. Symptoms were noted in
56.2% during pregnancy and 6.8% during the puerperium [46]. The large tumor may cause pressure symptoms (mass effect), varying from discomfort, dyspnea [47], bladder irritability, etc., to actual pain. Both symptoms and cyst com­plications during pregnancy and the puerperium were far more frequent with abdominal than with pelvic ovarian tumors and more frequent with cysts of other sorts than dermoids. Cyst compli­cations occur in 20% of patients [46]. Torsion is an essential concern of pregnancy-associated adnexal masses, with a higher incidence (13.8%) than malignancy (3.4%) [11].
Corpus luteum cysts more frequently attain a larger size than follicular cysts. Corpus luteum cysts often delay the onset of the menstrual period, and when it occurs, they may be heavy (Halban’s syndrome). Because the cysts are usu- ally larger than follicular cysts and associated with intraluminal bleeding, pain may be a com­mon complaint. The cysts usually regress sponta­neously and resolve in 4–8weeks. Corpus luteum cysts are very vascular, and severe life- threatening bleeding may occur with rupture. On the con­trary, rupture of a follicular cyst may cause an acute onset of pain that is usually short-lived. A delayed menstrual period, acute pain, pelvic mass, and hemoperitoneum suggest a ruptured corpus luteum cyst.
Common symptoms of malignant ovarian tumors during pregnancy are excessive general­ized enlargement of the abdomen and lower abdominal pain. Approximately 21% present with an acute abdomen from carcinoma compli­cations such as rupture, torsion, or strangulation [35]. Around 66% of ovarian carcinomas are asymptomatic [48]. McKerron collected 1290 cases in 1903, with 80% of small tumors occupy­ing the pelvis during pelvic examinations in labor [25]. The absence of symptoms in 25% shows the
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