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Nick Raine-Fenning · Posted: Fri Jul 28, 2006 6:51 pm Post subject: Adnexal Mass in Pregnancy

Just posted a few MCQs and thought I'd set you an essay to think over for the weekend.

Clara · Joined: 28 Jul 2006 Posts: 2

I sometimes find this type of questions difficult to ne answered. With the marks shown, you may have a better idea what should be included in the answer. But on the other hand, you may not be able to write it in an order you want. And sometimes, the first and second parts of the questions are intermingled with each other.

My small bubble is as follows:

Introduction:
Adnexal mass is not an uncommon finding during early scan.
Most are benign and will resolve (e.g. corpus luteal cyst). Other possibilities can be benign lesions like dermoid, serous etc.
Rarely it will be a malignant.
It can cause symptoms depends on size and nature of the cyst. It can also cause anxiety to patient.

Critical appraise the assessment:
History - Any symptoms (abdominal pain- because it may need operation, constitutional symptoms - it may suggest sinister disease), any previous scan before pregnancy (it may suggest known gyn problem e.g. endometriotic cyst), any family history of cancer (patient may be very worried because she has a strong FH).

Examination - Pallor , jaundice, lymph node, abdominal tenerness, mass, ascites, abdominal mass (it can suggest if operation may be needed, should the patient has abdominal pain or should it suggest malignancy).

USG -
Have to know the date, viability and the nuchal translucency of the fetus because it affects the management, e.g. patient may need suction evacuation for silent miscarriage or fetal abnormality. Correct date is needed as for the mode of TOP in case of fetal abnormality.

The features of the adnexal mass are important. If it is large (>5 cm), patient will likely to have complication like torsion and operation may be needed in 2nd trimester.
If the features suggest malignancy (multiloculated, with septum, solid area, ascites, involvement of contralateral ovary), should refer her to oncologist centre.
May have to be repeated in ~2 weeks' time to see if it's fast growing.

Serum -
Tumour marker (CA 125, AFP, HCG) is unhelpful during pregnancy.

Subsequent management (overlap a bit of what I said above) -
If fetus is viable and NT is normal, further management of the cyst depends on size, nature and wish of the patient.
Conservativec management can be an option. Needs to give the counselling with a balance on the benefits of intervention and its risks.
If it's likely to be benign and small, can be observed. If it'sl >5 cm, may better do operation at 15-16 weeks because chance of miscarriage is lower. There's no teratogenic effect of GA. Laparoscopic route may be feasible depends on the size and nature.
If malignancy is likely, refer to an oncologist centre for couselling. She can choose to be observed, to have TOP and start treatment (staging and chemo), or to continue the pregnancy while performing operation (e.g. laparotomy, cystectomy and frozen section, omental biopsy, peritoneal washing). Chemo (sinlge agent like carboplatin) can be given during pregnancy.

FU -
If she chooses to be observed, she has to be warned all the signs of complications like nausea, vomiting, sudden severe abdominal pain and possibility of emergency operation.
She should be checked regularly in antenatal clinic. Ultrasound should be done serially to check the size of the cyst, unless it is small and likely to be CL. If it is fast-growing or new features appear, may better operate.
If she has been operated, she should be seen and explained the pathology of the cyst.
If it is malignant, she should be referred to oncologists for need of adjuvant chemotherapy and disease monitoring.
Anomaly scan should be arranged at 18-20 weeks.

All discussion should be well-documented.
Written information, website, leaflets can be given for better understanding.

Nick Raine-Fenning · Posted: Sat Jul 29, 2006 11:53 am Post subject:

Hi Clara - Welcome to the Forum Smile

You raise a couple of very important points:

Nick Raine-Fenning · Posted: Sat Jul 29, 2006 12:13 pm Post subject:

I've just read your answer - it's very good.

You have used the schemes well and have started well.

You have got most of the points I can think of but I would add:

Introduction

Concept - you need to make a statement that in general these resolve and conservative management is recommended but that intervetion may be required for complications or if there are sinister features.

History & Examination

Hirsutism - luteoma
Say that examination is likely to be normal
Scars that may complicate laparoscopy or surgery in general
Breast exam as may be secondary
Vaginal examination

Investigation

CXR if suspicious features
Amnio if thick nuchal or other markers
Tumour markers are less helpful but be if use if very high
FBC - anaemia
LFTs - liver involvement

USS - your descriptions are very good

Treatment

Conservative - some debate as to whether follow up scans are necessary

If the cyst is left and gets large it may interfer with the fetal lie and engagement although this is unlikely

Type of treatment - aspiration, cystectomy, cystotomy, oophorectomy (all of which can be done as an open procedure or endoscopically although this may be difficult as the uterus enlarges.

If surgery is needed later on then a midline incision may be needed.

Can look at cyst and operate at CS if this is needed for other reasons.

Medical - progestogens if remove a corpus luteum ? evidence-based

Can re-assess post-natally and remove thereafter if necessary

Increased risk of torsion in the puerperium if not removed antenatally and persists.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Nick Raine-Fenning · Posted: Sat Jul 29, 2006 1:19 pm Post subject:

Just realised that we have had an almost identical question already Embarassed

Bronwyn set a question based on a real clinical situation.

Click here to see what happened and a similar but slightlty different approach to this type of question.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997