Adnexal masses during pregnancy: diagnosis, treatment and prognosis.

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. While most adnexal masses in pregnancy can be safely observed and around 70% spontaneously resolve, a minority warrant surgical intervention due to symptoms, risk of torsion, or suspicion for malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy due to accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis (IOTA) Simple Rules, and IOTA Assessment of Different NEoplasias in the adneXa (ADNEX) scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant versus surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible due to consistently demonstrated shorter hospital length of stay and less post-operative pain, as well as some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, pre-term birth, and low birth weight. Best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12-15 mm Hg, intraoperative maternal capnography, pre- and post-operative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxis. While planning surgery for the second trimester generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed due to gestational age. When performed at a facility with appropriate obstetric, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for mother and fetus. [ABSTRACT FROM AUTHOR]