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8.4 Diagnosis
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189
necessity of routine antepartum examinations
[46]. The physical ndings are often misleading.
Hard semisolid dermoids or cystic tumors made
tense by pressure may be mistaken for broids or
vice versa. The abdominal distention with large
accid cysts and fat abdomen may be confusing.
Ascites is common with cysts but rarely occur
with broids. Pelvic examination usually reveals
diffuse pelvic tenderness, often lateralized to the
side of the cyst, with a palpable mass. A palpable
mass on pelvic examination should be characterized by contour, rmness, size, location, and
mobility. The rectovaginal examination with palpation of the uterosacral ligaments and cul-desac assesses metastatic disease, nodularity, or
obliteration of the cul-de-sac.
Severe bleeding results in abdominal disten-
tion and shock.
8.3 Dierential Diagnosis
The acute pain associated with a blood-lled corpus luteum cyst rupture is indistinguishable from
a ruptured ectopic pregnancy. A βHCG level may
help distinguish these two entities. Differential
diagnosis is presented in Table 6.2.
8.4 Diagnosis
8.4.1 Laboratory Findings
WBC and CRP help to diagnose the infection and
its severity. Hemoglobin and hematocrit help in
the diagnosis of intra-abdominal bleeding and its
severity. In early pregnancy or when the patient is
still unaware of the pregnancy, diagnosis of the
hemorrhagic ovarian cyst and ruptured ectopic
pregnancy can be difcult. The distinction
between these entities largely depends on the
serum beta-human chorionic gonadotropin
(βHCG) level. Elevated serum βHCG levels with
no intrauterine pregnancy suggest the adnexal
ring heralding an ectopic gestation. In contrast, a
negative serum βHCG level makes a hemorrhagic
ovarian cyst more likely [49].
For a suspected ovarian tumor, tumor mark-
ers should be checked (Table8.4). The role of
Table 8.4 Tumor markers in ovarian tumors
Tumor marker Ovarian neoplasm
CA-125 Epithelial ovarian cancer
CEA Mucinous ovarian cancer
βHCG
Inhibin A/B Granulosa cell tumor
Lactate dehydrogenase Dysgerminoma
α-fetoprotein
CA cancer antigen, CEA carcinoembryonic antigen, HCG
human chorionic gonadotropin
Embryonal carcinoma
Choriocarcinoma
Endodermal sinus tumor
Embryonal carcinoma
tumor markers is limited in cancer during pregnancy or pregnancy after cancer, mainly due to
their low specicity rate. Elevations are not
always correlated with malignancy, but are more
often associated with normal physiologic
changes of pregnancy. Moreover, obstetrical
complications can induce even more variations.
For example, elevated CA-125 has been related
to imminent miscarriage [50], and LDH is
known to increase with severe preeclampsia and
HELLP syndrome (hemolysis, elevated liver
function tests, low platelets) [51]. A high
CA-125 has been found in amniotic uid [52]. It
is the oncofetal antigen that is tumor-associated,
not tumor-specic. The occurrence of elevated
CA-125 levels in PID limits the usefulness of
the assay as a cancer test in young women. The
normal curve during pregnancy is presented in
Fig.8.1. Measuring CA-125 around the delivery
is not recommended [54]. The evaluation of
CA-125 is advised for a suspected or indeterminate adnexal mass as a baseline test. It is grossly
elevated with malignancy. Its serum level is also
valuable for monitoring ovarian cancer treatment responses.
Only CA-125 values can be raised during
normal pregnancy, while other tumor
marker levels generally remain below the
cut-off values [55].
Tumor markers are helpful for both establishing the diagnosis and monitoring the response to
treatment.
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Mean CA-125 Levels Throughout Pregnancy
s
postpartum
CA-125 (U / mL)
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Fig. 8.1 Mean CA-125
levels throughout
pregnancy [53]
60
50
40
30
20
10
0
71115182226
29 32 35 40
Weeks Gestation
8 Complex Ovarian Mass
Within 24 hours
of delivery
2 to 10 work
8.4.2 Abdominal Ultrasound
dominal and transvaginal US is indicated. The
mass is easily detected in the pelvis but is often
missed if small and behind the uterus, when its
presence may not be revealed until after labor. It
is essential to dene malignancy if the patient is
stable, without symptoms and signs of peritonitis or massive bleeding. Three criteria distinguish benign from malignant masses on US:
tumor volume, cyst wall structure, and septa
structure [45]. Adnexal mass malignancy during
pregnancy is commonly described only according to its complex US character, criticized as an
oversimplication with a low-positive predictive
value for malignancies [57]. Because of morphological similarities, it is unhelpful in distinguishing tumors of low malignant potential from
benign neoplasms [9]. Internal papillary excres-
cences can be visualized in 50% of malignancies
[41].
Pelvic ultrasonography remains the rst- line
examination for the detection and characterization
of adnexal masses during pregnancy.
(Grade C) ([56]. French National College of
Obstetricians and Gynecologists, 2021)
In a hemodynamically stable patient, transab-
There are pitfalls in applying the abovementioned criteria to adnexal masses in pregnancy.
First, obtaining good images of adnexal masses
after the 20th week of gestation is hard unless the
mass is large. Second, technical difculties exist
in evaluating velocimetric features during pregnancy. The vessels and blood ow surrounding
the gravid uterus mainly have high velocity and
low resistance characteristics with a false- positive
rate of nearly 50% [58], but a pulsatility index
<1.0 is associated with an increased risk of malignancy [59]. Third, during pregnancy, the major
tumor type is of germ cell origin. US characteristics, although not necessarily different from those
of epithelial-origin tumors, could be incompatible with the scoring criteria developed for epithelial ovarian cancers. Signicantly higher US
tumor growth rates are found in ovarian pregnancies. Even growth of 0.35 cm/week has been
found [11].
The hemorrhagic ovarian cyst exhibits a myriad of US appearances; most commonly, as a
rounded hypoechoic mass containing low-level
echoes, ne strands, or septations; however, other
patterns are so frequent that the hemorrhagic
ovarian cyst has been termed “the great imitator”
[60, 61]. Occasionally, a hemorrhagic ovarian
cyst presents as a thick echogenic wall surround-
8.4 Diagnosis
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ing a central rounded echolucent area—a pattern
remarkably similar to the adnexal ring sign
(Fig.8.2) of an ectopic pregnancy. Identifying an
intrauterine gestational sac excludes ectopic
pregnancy and permits expectant management
even with intraperitoneal bleeding [49, 63].
Elevated βHCG can be misleading. In such cases,
intrauterine pregnancy (heterotopic pregnancy)
should be ruled out.
US and color Doppler of decidualized ovarian
endometrioma document rapidly growing and
abundantly vascularized intracystic excrescences.
Conversely, the septations or signicant free uid
were never reported (Fig.8.3). Such masses are
difcult to distinguish from BOT (Fig.8.4a).
For pyosalpinx US characteristics, see Sect.
13.8.2.
In one study, correct US diagnoses included
95% of dermoid cysts, 80% of endometriomas,
and 71% of simple cysts. Ten percent of adnexal
masses had US characteristics concerning malignancy, but only one was ovarian cancer [5]. The
IOTA protocol has recognized US characteristics
that accurately predict the risk of ovarian cancer.
Another study reviewed 130 cases of adnexal
191
Fig. 8.3 US of ovarian endometrioma in pregnancy mimicking malignancy. The irregular solid part of the endometrioma protrudes within the lumen of the cyst. Above this
excrescence, echogenic debris, mobile under probe
manipulation, is noted (upper panel). Color Doppler
detected multiple vascularization signals index within the
solid part (lower panel). The resistance index was 0.37.
(Reproduced with permission from [64])
Fig. 8.2 Hemorrhagic ovarian cyst simulating a ruptured
ectopic pregnancy with severe acute pelvic pain and a
positive βHCG. The coronal right adnexal US shows a
mass with an irregular thick rind (arrows). This was mistaken for a ruptured ectopic pregnancy, but was identied
as a ruptured hemorrhagic cyst at laparoscopy. The patient
had a concurrent, early intrauterine pregnancy.
(Reproduced with permission from [62])
masses in pregnancy that required excision or
were found incidentally during CS.They found
that 89 of 91 resected masses were correctly
diagnosed as benign using US [9].
Though some tumors are large, nearly 20% of
adnexal tumors are discovered when tumor torsion occurs or incidentally during CS. This
underscores the possibility that some patients
with vaginal delivery could have failed to have
their asymptomatic adnexal mass revealed, thus
making the true denominator of these events during pregnancy unknown [11].
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abc
8 Complex Ovarian Mass
Fig. 8.4 (a) Transvaginal US at 6 weeks of gestation
shows a right ovarian multilocular mass 14cm in diameter
with internal papillary pedunculated projections. (b) A
plain pelvic MRI (sagittal T2-weighted) reveals a multi-
8.4.3 Abdominal MRI
Pelvic MRI is recommended from the 12th week
of gestation in case of indeterminate adnexal
masses and should be concluded with a diagnostic score.
(ADNEX MR/O- RADS) (Grade C) ([56],
French National College of Obstetricians
and Gynecologists, 2021)
MRI is better at distinguishing paraovarian cystic lesions, which can be managed conservatively and provide better tissue characterization,
allowing for a more accurate evaluation of the
large masses that are difcult for visualization
on US. MRI can also determine the possible
extent of malignancy and aid in diagnosing
acute bowel processes such as appendicitis and
inammatory bowel disease [65]. On US, a
decidualized endometrioma appears as a loculated cystic mass with vascularized papillary
projections, resembling a malignancy [66]. In
these cases, MRI helps in the characterization of
the mass. MRI is also accurate for dening BOT
(Fig.8.4b, c). The following ndings of mural
nodules on MRI suggest seromucinous BOT
rather than endometriotic cysts with decidual
changes: (1) lower signal intensity ratios on
T1WI, (2) a higher nodule height, (3) lobulated
margins, (4) a pedunculated conguration, and
(5) a T2 hypointense core [67]. Gadolinium
enhancement is helpful but is contraindicated in
pregnancy.
locular cystic mass with papillary mural nodules. (c)
Coronal T2-weighted image shows relatively high, lobulated mural nodules with a pedunculated conguration
and hypointense core [42]
8.5 Treatment
8.5.1 Introduction
Approximately 51–70% of adnexal masses in
pregnancy will resolve spontaneously, and the risk
of acute complications is less than 2% [5, 21].
Because of increased complications of ovarian
surgery in pregnancy [68, 69], surgical management of ovarian cysts in pregnancy has been reconsidered [17]. Historically, pregnant women with
persistent adnexal masses underwent elective
removal of the masses in the second trimester [70];
this is no longer an acceptable practice in asymptomatic women, as surgical intervention, in an
emergency or after 24weeks gestation, is associated with a poorer obstetric outcome [16].
Obstetric complications include spontaneous miscarriage or preterm premature rupture of membranes [17].
8.5.2 Conservative Treatment
8.5.2.1 Observation
Asymptomatic
As only 0.13% of women with an ovarian cyst
required acute intervention during pregnancy, the
conclusion is that examining the ovaries at the
time of a rst-trimester scan is of limited value.
Expectant management is more common with
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193
regular use of imaging techniques like MRI and
transvaginal color Doppler.
Early in pregnancy, ovarian enlargement
<6cm in diameter is usually due to corpus luteum
formation. Asymptomatic patients with simple
unilocular cysts <6 cm, which do not change,
need only periodic US follow-up. Most resolve
spontaneously [26, 71]. Corpus luteal cysts
regress by 12–16weeks. For an ovarian cyst in
the rst trimester, it is better to wait until
14–16 weeks because (1) the implantation of
pregnancy is more secure, (2) the cyst may disappear spontaneously, (3) surgical access to the
mass is much easier, and (4) progesterone supplementation is mandatory for oophorectomy before
this period.
Abdominal Pain
Those women requiring intervention will present
with pain, while prior knowledge of the presence
of a cyst may only increase anxiety, even though
the risk of complication is very low. If a nonmalignant ovarian cyst is noted at the time of a rsttrimester US, a follow-up scan 6weeks after the
pregnancy is recommended. Although there are
no randomized clinical trials to determine the
optimal management of an adnexal mass in pregnancy, experience suggests that expectant management is safe and without severe adverse
outcomes for both mother and fetus [3].
Borderline Ovarian Tumors/Suspected
Malignancy
If a provisional diagnosis of hemorrhagic corpus
luteum cyst with minimal hemoperitoneum can
be made, expectant management with serial clinical examination and hemoglobin measurements
is indicated [30].
A growing understanding of the natural history of BOT allows a more conservative approach
(expectant management) as an alternative to surgical management, preserving fertility [72]. After
the pregnancy, these patients underwent surgery
[3, 73]. No guidelines have been issued regarding
the follow-up of suspicious non-operated BOTs
during pregnancy [56]. The issue with BOT is the
inaccuracy of preoperative diagnosis. Diagnosis
is conrmed histologically in only 33% with US
appearance and the presence of papillary projections, nonvascular on color Doppler [72]. The
additional surgical dilemma is the size of the
tumor. Despite benign characteristics, it can have
a high probability of torsion [72]. The review of
surgical and histopathological characteristics is
presented in Table8.5.
For treatment of BOTs during pregnancy,
the laparoscopic route should be preferred
if feasible (Grade C) [56]. (French National
College of Obstetricians and Gynecologists,
2021).
However, laparoscopy is performed only in
the rst trimester of pregnancy, while laparotomy
is performed throughout pregnancy. Given the
rarity of BOTs, there is no denite therapeutic
policy for BOTs in pregnancy. Conservative surgery, such as salpingo-oophorectomy or cystectomy, is used in most pregnant patients [42]. As
in the general population, the recurrence rate
increases for cystectomy (12.5%) compared to
salpingo-oophorectomy (3.7%). In addition,
recurrence is observed only in serous types and
not in mucinous or seromucionus.
If a serous BOT is suspected in pregnancy,
salpingo-oophorectomy rather than cystec-
tomy should be considered [42].
A similar issue is with decidualized ovar-
ian endometriomas during pregnancy. On the
one hand, expectant management appears rea-
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8 Complex Ovarian Mass
Table 8.5 Epidemiological,
surgical, and histological
characteristics of borderline
ovarian tumors detected
during pregnancy [42]
Mean age 30.4years (range 20–42)
Surgical approach Laparotomy 37 (62.7%)
Laparoscopy 16 (27.1%)
Laparoscopy + Laparotomy 6 (10.2%)
Type of surgery
Unilateral Cystectomy 25 (48.1%)
SO 27 (51.9%)
Bilateral Bi-cystectomy 1 (14.3%)
BSO 2 (28.6%)
Uni-cystectomy + Uni-SO 3 (42.9%)
Bi-biopsy 1 (14.3%)
Histologic type Serous 31 (52.5%)
Mucinous 22 (37.3%)
Seromucinous 6 (10.2%)
FIGO stage IA 43 (72.9%)
IB 2 (3.4%)
IC 6 (10.2%)
II 4 (6.8%)
III 4 (6.8%)
Restaging surgery No 33 (55.9%)
Fertility-preserving surgery 21 (35.6%)
Radical surgery 5 (8.5%)
Restaging
Upstage Yes 6 (23.1%)
No 20 (76.9%)
Recurrence Ye s 6 (10.2%)
sonable, considering that pain symptoms generally improve during pregnancy and that
surgery is more demanding and riskier due to
the enlarged and pregnant uterus. On the other
hand, concerns have been raised regarding the
accuracy of US in pregnancy. Of the 27 published cases, 19 (70%) were managed surgically, four were delayed till CS with
concomitant cyst excision, and eight were
managed conservatively with serial monitoring of the cyst, with spontaneous regression
following delivery [74].
8.5.2.2 Ultrasound-Guided Aspiration
Aspiration of simple ovarian cysts during pregnancy is safe and may prevent surgical intervention. In some cases, this is the denitive treatment
[75]. Neither anesthesia nor analgesia is required
for such intervention. The US-guided aspiration
to relieve pain generated by simple ovarian cysts
in nonpregnant women can be performed either
transvaginally or transabdominally, depending
on the location of the cyst [76]. After 14weeks’
gestation, the uterus is an abdominal organ, so
the ovaries are more easily targeted transabdominally. If the pain persists after the procedure
without other symptoms or complications, a laparoscopic ovarian cystectomy after delivery is
indicated [3]. Fine-needle aspiration is not
appropriate if the cyst has any suspicious morphological features. It is not a common diagnostic problem because the frequency of ovarian
cancer in pregnancy is 1/15,000–1/32,000 pregnancies [24].
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195
8.5.3 Surgical Treatment
Operative treatment is oriented toward treating
complications of ovarian masses during pregnancy. Approximately 1–2.3% of adnexal masses
in pregnancy require surgical intervention [77].
Indications for the operation are presented in
Table 8.6, while a complete diagnostictherapeutic algorithm of non-ruptured ovarian
cysts in pregnancy is presented in Fig. 8.5. In
short, if surgical removal of an adnexal mass is
necessary during pregnancy, it should be performed after the rst trimester. This recommen-
Adnexal mass
in pregnancy
• Acute abdomen
• Size >10 cm
• Rapid growth
Table 8.6 Indications for surgery of adnexal masses in
pregnancy
Emergent operation Early elective operation
Torsion of the cyst/
adnexa
Mass >6cm until the second
trimester unless uterine
leiomyoma
Rupture of the cyst Suspected/proven malignancy
Infected cyst Fetal malpresentation
Urinary retention due
Intrauterine growth retardation
to cystic impaction
Dyspnea due to giant
tumor
Obstructed labor
• Asymptomtic
• Size <10 cm
• Slow growth
Surgery
Simple +
size <5 cm
No further
Resolution
No further
action
action
Low suspicion
for malignancy
Consider rescan
Simple + size >5cm
OR
Complex
Rescan in 4-6
weeks
No change in
in 6 weeks
size
If cesarean deliver,
consider evaluation
intraoperatively
Indeterminate
Low suspicion
for malignancy
Consulation with
gynacologic
oncology
Consider imaging
(MRI)
Tumor markers*
High suspicion
for malignancy
High suspicion
for malignancy
Surgery
Fig. 8.5 Diagnostic-therapeutic algorithm of non-ruptured ovarian mass in pregnancy. Rapid growth—increase in size
≥3.5cm/week. (Reproduced with permission from [78])
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8 Complex Ovarian Mass
dation is based on the following: (1) most
functional cysts resolve by the second trimester,
and a persistent mass has a higher risk of malignancy; (2) surgery during the second trimester
has a decreased rate of preterm labor than at later
gestations; and (3) surgery during the third
trimester is more difcult as the enlarged uterus
may interfere with adequate visualization [79].
For adnexal/cyst torsion, see Chap. 6.
Intrauterine growth retardation may be either due
to the prominent vascularity of the tumor originating from the ovarian vessels or due to the
compressive effect of the tumor on the uterine
blood supply [80].
8.5.3.1 Emergency Laparotomy
A hemodynamically unstable patient or patient
with an acute abdomen requires emergent exploration. Emergency laparotomy, not laparoscopy,
is immediate and denitive surgery in hemodynamically unstable patients. The second indication for emergency laparotomy is fetal distress
when denitive surgery is performed after
CS.The third indication is obstructed labor due
to ovarian cyst/tumor when CS followed by
denitive surgery is recommended.
Rupture and bleeding with hemodynamic stability do not preclude diagnostic and therapeutic
laparoscopy.
Hemorrhagic Corpus Luteum
A hemorrhagic corpus luteum cyst with minimal
hemoperitoneum may be served expectantly [30].
However, massive or prolonged hemorrhage
requires emergent surgical intervention [31]. In
hemodynamically stable patients, laparoscopic
treatment is preferable [81, 82]. Further, utilizing
intraoperative autologous blood transfusion,
transfusion of bank blood can be avoided even
with massive hemoperitoneum due to ruptured
corpus luteum cyst in patients with ectopic pregnancy [81, 82].
Ovarian Teratoma
Ruptured BCT of the ovary mimicking gynecological malignancy is uncommon and could be
misdiagnosed [83]. Intra-abdominal peritoneal
seedlings, adhesions, or masses are a frequent
sequel. In most cases, abdominal seedlings are
essential for mature neuroglial elements, and the
long-term survival rate is good. Recognizing a
dermoid tumor associated with the glial seedling
is essential to avoid unnecessary debulking surgery. Conservative management seems to have a
good prognosis following postoperative adhesions, brous bands, or obstructions.
Obstructed Labor
As for any other cause, an indication for emergent CS and ovarian mass operation during pregnancy is the risk of obstructed labor by ovarian
mass, with an incidence of 17–21% [65].
8.5.3.2 Elective Laparotomy
Indications for early elective operations are cysts
>10 cm in diameter due to increased risk of
malignancy, rupture, or torsion. Management of
cysts ranging from 5 to 10cm is controversial.
Surgical intervention is recommended if the cysts
contain septae, nodules, papillary excrescences,
or solid components.
Ovarian Teratoma
Treatment of suspected ovarian teratoma is surgical removal as soon as possible after diagnosis to avoid complications. They may be
responsible for torsion, rupture, and obstruction
during labor. Over 200 cases of BCT in pregnancy have been reported, and many of them
ruptured spontaneously or iatrogenically. A
review of 47 cases showed minimal spillage in
42.5% during cyst extraction and none developed chemical peritonitis [84]. Rupture is rare
but can cause complications such as chemical
or granulomatous peritonitis, mimicking
advanced ovarian malignancy [13, 83]. The
rupture or leakage of cyst uid should be
avoided during the operation. If it happens
before or during the procedure, copious saline
washing should be performed to minimize
chemical peritonitis and its sequel, including
further surgeries to treat the complications [85,
86]. Granulomatous peritonitis from ruptured
ovarian teratomas results in numerous nodules
of mature glial tissue implant on the peritoneal
surface. This diffuse peritoneal reaction mimics
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197
advanced ovarian malignancy, and commonly
surgical staging is performed [13, 83].
Incidental BCT in the rst trimester of pregnancy should be surgically removed at
14–16 weeks of gestation to avoid the risk of
damage to the corpus luteum. If the diagnosis of
BCT occurs at 16–22weeks, surgery should be
performed as soon as possible. If discovered after
22 weeks of pregnancy, the treatment may be
deferred until delivery [13].
8.5.3.3 Minimally Invasive Surgery
General Considerations
The pathophysiology of laparoscopy is discussed
in Sects. 3.2.2.2 and 6.9.1.1. Ovarian tumors or
cysts can be easily removed until 28weeks of
gestation; manipulation is difcult in later gestation and may precipitate preterm labor.
Laparoscopic compared to open surgery for
removing adnexal masses in pregnancy had the
following outcomes: no difference in fetal loss or
operative time; decreased or similar blood loss,
similar rates of preterm labor and spontaneous
abortion, and shorter length of hospital stay [14,
87].
Gasless Laparoscopy
See Sect. 3.2.2.2.
Robotic or Single-Site Surgery
Robotic resection of adnexal masses during
pregnancy is safe and feasible, with similar surgical outcomes as laparoscopy. The robotic
cohort had a signicantly shorter hospital stay
and estimated blood loss [88]. Single-site/Single
port surgery for adnexal masses in pregnancy
demonstrated the feasibility, safety, and putative
benets. Resected ovarian mass can be extracted
through the same abdominal wall incision where
the port was introduced, eliminating the need for
additional abdominal wall trauma from additional stab incisions [89, 90]. This is particularly
important for the masses that cannot be decompressed or aspirated (see Sect. 8.5.3.3). For principles of single port surgery, see Sect. 6.9.2.1
and Sect. 8.5.4.2.
Cystectomy
Laparoscopy is a safe and effective treatment in gravid patients with symptomatic
ovarian cystic masses. Observation is
acceptable for all other cystic lesions, provided ultrasound is not concerning for
malignancy and tumor markers are normal. The initial observation is warranted
for more cystic lesions less than 6 cm in
size. (SAGES, 2011 [91])
Nezhat et al., in 1991, rst described laparoscopic cystectomy in pregnancy [92].
Conservative surgical therapy removes the cyst
and coagulates its base (Fig.8.6a, b). Large cystic masses may require decompression/aspiration to t through a small incision. Spillage can
be minimal or nonexistent by decompressing a
cyst into a laparoscopic bag. Copious irrigation
also helps to keep the residual content to a minimum (see Sect. 8.5.3.2). Another option to avoid
cyst rupture and spillage during surgery is the
transvaginal extraction of the specimen.
Minimizing the risk of disruption and fragmentation of the lesion during extraction is accomplished through posterior colpotomy due to the
elasticity of the vagina (Fig.8.6c, d). An additional benet is avoiding the extension of
abdominal wall incision for specimen extraction
resulting in reduced postoperative pain and better cosmesis [93].
After cystectomy, the ovarian incision can be
left open or approximated by three techniques:
• Fine monolament suture of the edges,
• Tissue glue,
• Coagulation of the ovarian cortex adjacent to
the surface.
Stitching is necessary to avoid adhesions
between the raw ovarian surface and the raw peritoneal surface left after bowel adhesiolysis in the
left adnexa [94].
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8 Complex Ovarian Mass
Fig. 8.6 (a) Laparoscopic appearance of the borderline
ovarian tumor. (b) Laparoscopic cystectomy without rupture of the capsule or spillage of the content. (c)
Delineation of the posterior fornix to perform colpotomy
for the introduction of the endobag and transvaginal
extraction of the specimen. (d) Final view of the pelvis at
the end of the operation. (Reproduced with permission
from [93])
receive IM 17-α hydroxyprogesterone caproate
8.5.3.4 Incidental Tumors
If an incidental adnexal mass during CS has char-
250mg weekly for 4weeks as progestogen sup-
port for the pregnancy [97].
acteristics suggestive of malignancy, it should be
removed and sent for a frozen section. Adnexal
masses >5 cm removed by cystectomy do not
have a higher rate of complications or increased
morbidity or mortality attributable to cystectomy
[95, 96].
Adnexal mass >5 cm should be removed
during CS [95].
8.5.4.2 Bilateral Ovariectomy
In 1931, after removing both ovaries, the preg-
nancy continued [98]. The corpus luteum is indis-
pensable to pregnancy for the rst 2months, and
removal during that time precipitates abortion.
After removing a corpus luteum of early
pregnancy (<12weeks) or bilateral ovariectomy, progesterone replacement is
advisable.
8.5.4 Anesthetic andPerioperative
Management
8.5.5 Adjuvant Chemotherapy
See Chap. 21.
8.5.4.1 First Trimester
After the corpus luteum cystectomy or ovariectomy during the rst trimester, the patient should
If the adnexal mass turns out to be ovarian can-
cer, the treatment is similar to that of the non-
pregnant women depending on the stage,
gestational age, and staging and grade of the
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