SURGICAL TREATMENT OF ADNEXAL MASSES IN PREGNANCY – THE ROLE OF LAPAROSCOPY MANAGEMENT
Abstract
Background. The aim of this retrospective study was to find the incidence and type of adnexal masses in pregnancy, reliability of preoperative ultrasound examination and the effect of the surgical approach used, duration of pregnancy at the time of surgery, and the effect of emergency or planned surgery on the outcome of pregnancy. The obtained results and the data from literature were to provide the basis of the guidelines for the management of pregnant women with adnexal masses.
Methods. In the study we enrolled 42 women, who underwent a surgery in pregnancy for adnexal masses. All surgeries were performed at the Department of Obstetrics and Gynecology in the period 1 January 1993–31 August 2000. The course of pregnancy was followed by 28 February 2001. The data were obtained from the records kept at the Department and from the questionnaire sent to the women. Statistical analysis was done using Chi-square test. Statistical significance was set at P ≤ 0.05.
Results. We found the incidence of adnexal masses in pregnancy, requiring surgical treatment, to be 1/1034 deliveries. There were 6 (14.3%) borderline malignant and malignant ovarian tumours, the incidence being 1/7239 deliveries. Preoperative ultrasound examination was not reliable enough to differentiate neither between benign and malignant adnexal masses, nor between adnexal masses and leiomyomas. Forty-two surgeries were made, 21 by laparoscopy and 21 by laparotomy. The size of removed tumours ranged between 4 and 30 cm (mean 9.4 cm), the most frequent type was mature cystic teratoma (n = 12). There were no differences in the outcome of pregnancy between the laparoscopy and laparotomy approach, between emergency and planned surgery, and between laparotomy performed by the 23rd and after the 23rd gestational week. Hemorrhagic shock due to heterotopic pregnancy lead to 1 spontaneous abortion. There were 2 preterm deliveries in the 37th week, 2 babies had intrauterine growth retardation, and 1 congenital malformations.
Conclusions. The incidence of adnexal masses found in this study resembles that found in literature. Laparoscopic surgery is at least as safe as laparotomy. Surgery performed in the first trimester of pregnancy did not increase the risk of worse outcome of pregnancy. A relatively high percentage of borderline malignant and malignant tumours and not enough sensitive ultrasound examination justify the use of invasive diagnostic and surgical treatment of adnexal masses in pregnancy, especially after laparoscopy has become extensively used. Tumours are recommended to be removed laparoscopically after the 12th gestational week, because in this period the removal of the ovary and corpus luteum is not dangerous, the effect of anesthetics on the fetus during organogenesis is avoided, and the uterine size is still appropriate for a safe procedure. For a relatively small number, the management of these cases is recommended to be carried out in centres with appropriate equipment and experience in laparoscopic management of adnexal masses.
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References
Whitecar P, Turner S, Higby K. Adnexal masses in pregnancy: A review of 130 cases undergoing surgical management. Am J Obstet Gynecol 1999; 181: 19–24.
Hess LW, Peaceman A, O’Brien WF, Winkel CA, Cruikshan DP, Morrison JC. Adnexal mass occuring with intrauterine pregnancy: Report of fifty-four patients requiring laparotomy for definitive management. Am J Obstet Gynecol 1988; 158: 1029–34.
Ashkenazy M, Kessler I, Czernobilsky B, Nashoni A, Lancet M. Ovarian tumors in pregnancy. Int J Gynecol Obstet 1988; 27: 79–83.
Usui R, Minakami H, Kosuge S, Iwasaki R, Ohwada M, Sato I. A retrospective survey of clinical, pathologic and prognostic features of adnexal masses operated on during pregnancy. J Obstet Gynecol Res 2000; 26: 89–93.
Nelson MJ, Cavalieri R, Graham D. Cysts in pregnancy discovered by sonography. J Clin Ultrasound 1986; 14: 509–12.
Struyk APHB, Treffers PE. Ovarian tumors in pregnancy. Acta Obstet Gynecol Scand 1984; 63: 421–4.
Hogston P, Lilford RJ. Ultrasound study of ovarian cysts in pregnancy: prevalence and significance. Br Obstet 1986; 93: 625–8.
Boulay R, Podczaski E. Ovarian cancer complicating pregnancy. Obstet Gynecol Clin North Am 1998; 25: 385–99.
Bromley B, Benacerraf B. Adnexal masses during pregnancy: accuracy of sonographic diagnosis and outcome. J Ultrasound Med 1997; 16: 447–52.
Moore RD, Smith WG. Laparascopic management of adnexal masses in pregnant women. J Reprod Med 1999; 44: 97–100.
Novak ER, Lambrou CD, Woodruff JD. Ovarian tumors in pregnancy: an ovarian tumor registry review. Obstet Gynecol 1975; 46: 401–6.
Roberts JA. Management of gynecologic tumors during pregnancy. Clin Perinatol 1983; 10: 369–82.
Soriano D, Yefet Y, Seidman DS, Goldenberg M, Mashiach S, Oelsner G. Laparascopy versus laparotomy in the management of adnexal masses during pregnancy. Fertil Steril 1999; 71: 955–60.
Reedy MB, Galan HL, Richards WE, Preece CK, Wetter PA, Kuehl TJ. Laparascopy during pregnancy. A survey of laparoendoscopic surgeons. J Reprod Med 1997; 42: 33–8.
Barnard JM, Chaffin D, Droste S, Tierney A, Phernetton T. Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol 1995; 85: 669–74.
Amos JD, Schorr SJ, Norman PF et al. Laparoscopic surgery during pregnancy. Am J Surg 1996; 171: 435–7.
Reedy MB, Kallen B, Kuehl TJ. Laparascopy during pregnancy: A study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol 1997; 177: 673–9.
Verdenik I, Pajntar M. Perinatologia Slovenica 1987–1996. Ljubljana: Združenje za perinatalno medicino SZD, 1998: 65–5.
Yuen PM, Chang AMZ. Laparascopic management of adnexal mass during pregnancy. Acta Obstet Gynecol Scand 1997; 76: 173–6.
Howard FM, Vill M. Laparascopic adnexal surgery during pregnancy. J Am Assoc Gynecol Laparosc 1994; 2: 91–3.
Della Badia CR, Asper R, Iddenden DA. Laparoscopic removal of a dermoid cyst in pregnancy. A case report. J Reprod Med 1995; 40: 797–9.
Ezeh UO, Lamb MP. Laparascopic ovarian cystectomy and oophorectomy in pregnancy. Gynecological Endoscopy 1995; 4: 273–6.
Mattei A, Giannone E, Di Renzo GC, Gerli S. Laparoscopic removal of benign uterine and adnexal masses during pregnancy. Gynecological Endoscopy 1999; 8: 21–3.
Morice P, Louis-Sylvestre C, Chapron C, Dubuisson JB. Laparoscopy for adnexal torsion in pregnant women. J Reprod Med 1997; 42: 435–9.
Louis-Sylvestre C, Morice P, Chapron C, Dubuisson JB. The role of laparoscopy in the diagnosis and management of heterotopic pregnancies. Hum Reprod 1997; 12: 1100–2.
Hernandez E, Miyazawa K. The pelvic mass. Patients’ ages and pathologic findings. J Reprod Med 1988; 33: 361–4.
Novaković S. Tumorski označevalci v klinični onkologiji. Onkologija 2000; 1: 8–14.
Ribič-Pucelj M, Tomaževič T, Vogler A, Kobal B, Omahen A, Vrtačnik-Bokal E. Laparoscopic treatment of adnexal masses. In: Ribič-Pucelj M, Tomaževič T, Keckstein J eds. 8th international basic and advanced course on gynecological endoscopic surgery – book of proceedings. Ljubljana: Slovene Society of Reproductive Medicine, 2001: 69–73.
Ribič-Pucelj M, Tomaževič T, Vogler A, Kobal B, Omahen A. Laparoskopske operacije na jajčnikih pri ženskah v reproduktivnem obdobju. In: Pajntar M, Trenkič M. Prvi kongres ginekologov in perinatologov Slovenije z mednarodno udeležbo – zbornik prispevkov. Portorož: Slovensko zdravniško društvo, Ginekološka sekcija, 1996: 99–101.
Thornton JG, Wells M. Ovarian cyst in pregnancy: does ultrasound make traditional management inappropriate? Obstet Gynecol 1987; 69: 717–21.
Platek DN, Henderson CE, Goldberg GL. The management of a persistent adnexal mass in pregnancy. Am J Obstet Gynecol 1995; 173: 1236–40.
Wheeler CT, Fleischer AC. Complex adnexal mass in pregnancy: Predictive value of color Doppler sonography. J Ultrasound Med 1997; 16: 425–8.
Kier R, McCarthy SM, Scoutt LM, Viscarella RR, Schwartz PE. Pelvic masses in pregnancy: MR imaging. Radiology 1990; 176: 709–13.
Curtis M, Jenison EL. Magnetic resonance imaging to avoid laparotomy in pregnancy. Obstet Gynecol 1993; 82: 833–6.
Berek JS. Novak’s Gynecology. 12th edition. Baltimore: Williams &Wilkins, 1996: 365–6.
Parker WP, Childers JM, Canis M, Phillips DR, Topel H. Laparoscopic management of benign cystic teratomas during pregnancy. Am J Obstet Gynecol 1996; 174: 1499–501.
Stržinar V, Fras AP, Baškovič M et al. Rak jajčnikov in jajcevodov. In: Ginekološki malignomi. Ljubljana: Onkološki inštitut, 1999.
Berek JS. Novak’s Gynecology. 12th edition. Baltimore: Williams &Wilkins, 1996: 1171–92.
Scott R, Navot D, Hung-Ching L, Rosenwaks Z. A human in vivo model for the luteal placental shift. Fertil Steril 1991; 56: 481–4.
Mazze RI, Källen B. Reproductive outcome after anesthesia and operation during pregnancy: A registry study of 5405 cases. Am J Obstet Gynecol 1989; 161: 1178–85.
Duncan PG, Pope WDB, Cohen MM. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986; 64: 790–4.
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