A giant symptomatic adnexal mass in pregnancy – a case report

Introduction:

Adnexal masses are a rare finding during pregnancy with an incidence from 0.1 to 2.4% and approximately 1 to 9% of these are malignant [1]. The management of these masses is discussed controversial.

Results:

A 28 year-old woman presented with spotting and abdominal pain at 30 weeks of gestation. A giant adnexal mass was detected on ultrasound (US)(figure 1a). Magnetic resonance imaging (MRI) showed a large cystic formation with septations originating from the right ovary, suspicious of cystadenoma (figure 1b). CA125, HE4 and LDH were within normal range and AFP was elevated. After fetal lung maturation an US-guided transabdominal puncture was performed at 31+6 weeks of gestation because of worsening of abdominal pain, dyspnea and the potential risk of prematurity and rupture. Analysis of 3850 ml serous fluid revealed no malignant cells. Puncture was repeated at 32+2 (4000 ml) and 34+3 (1700 ml) weeks of gestation. At 36+0 weeks of gestation labour was induced because of symptom augmentation. With regard to mechanism of labour and to make spontaneous delivery more likely we recommended repeating the puncture before inducing labour, which was rejected by the woman. On day 1 Dinoprostone 10 mg and on day 2 Misoprostol 200 µg were applied vaginal. Because of labour arrest (cervix 2 cm) a cesarean section and salpingo-oophorectomy on the right side were performed per Pfannenstiel laparotomy at 36+2 weeks of gestation. A healthy boy was delivered: W 2995 g, L 50 cm, HC 34 cm, APGAR 10/10/10, pH 7.33, BE -0.8. After adhesiolysis a purse-string suture was placed on the cyst and 4000 ml of fluid was punctured. Subsequent to the cyst closure, salpingo-oophorectomy was performed (figure 1c). Pathology was consistent with a large mucinous cystadenoma of the right ovary (18 × 16 cm) without evidence for malignancy (figure 1 d). The woman was discharged with her newborn in good general condition on the third day after surgery.

Discussion:

The majority of adnexal masses in pregnancy are benign. However, there is a potential risk of malignancy. The general consensus regarding management of adnexal masses in pregnancy is to surgically resect asymptomatic masses, which present after the first trimester and are > 10 cm in diameter, solid, contain solid, cystic or papillary areas or contain septations [1 – 5]. However, Schmeler et al reported that observation is a reasonable alternative to antepartum surgery in selected cases [1]. Our case report demonstrates that puncture of cystic adnexal masses in symptomatic women during pregnancy can be performed after best possible exclusion of malignancy by US, tumor markers and MRI, to avoid prematurity and improve fetal outcome.

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References:

[1] Schmeler KM et al. Obstet Gynecol. 2005:1098 – 103.

[2] Aggarwal P et al. Eur J Obstet Gynecol Reprod Biol. 2011:119 – 24.

[3] Wang PH et al. J Reprod Med. 1999:279 – 87.

[4] Leiserowitz GS. Obstet Gynecol Surv. 2006:463 – 70.

[5] Bernhard LM et al. Obstet Gynecol. 1999:585 – 9.