{"id":3416,"date":"2020-06-16T09:25:16","date_gmt":"2020-06-16T09:25:16","guid":{"rendered":"http:\/\/fetalradiology.in\/?p=3416"},"modified":"2020-11-23T01:41:38","modified_gmt":"2020-11-23T01:41:38","slug":"imaging-in-adnexal-mass-during-prengancy","status":"publish","type":"post","link":"https:\/\/fetalradiology.co.in\/?p=3416","title":{"rendered":"IMAGING IN ADNEXAL MASS DURING PREGNANCY"},"content":{"rendered":"\n<p><strong>Author<\/strong>: Avni KP Skandhan, Aster MIMS, Kottakkal, Kerala<\/p>\n\n\n\n<p> <\/p>\n\n\n\n<p><strong>INTRODUCTION\u00a0<\/strong><\/p>\n\n\n\n<p>The detection of adnexal masses in pregnancy, which are often incidental findings, has increased with the increased use of ultrasonography. <sup>(1-4)<\/sup>. The current incidence of adnexal masses during pregnancy is reportedly between 1 in 81 and 1 in 8000 pregnancies <sup>(5)<\/sup>. Earlier, adnexal masses were under detected due to a lack of technological advancements with a low discovery rate (<sup>6)<\/sup>. Most of patients with adnexal masses are asymptomatic; however, the adnexal mass may be complicated by torsion of the lesion, rupture of the cyst, bleeding into the cyst, infection of the cyst, or may cause an obstruction of labour <sup>(7)<\/sup>. Of the adnexal masses, the incidence of ovarian malignancy is 1 in 1500\u201332 000 pregnancies <sup>(8)<\/sup>.\u00a0 The ovarian masses are often borderline with a low malignant potential <sup>(7,9)<\/sup>.\u00a0<\/p>\n\n\n\n<p>Ultrasound is the most commonly used imaging modality in pregnant women <sup>(10)<\/sup>. There are stipulated guidelines for diagnosis and management of adnexal masses laid down by the American College of Obstetrics and Gynaecologists (ACOG); however, these apply for the non-pregnant patients and there are no definite guidelines for the adnexal masses in pregnant patients <sup>(11)<\/sup>. Decision making is difficult considering the foetal and maternal safety in pregnant women with lesions that are complicated or demonstrate malignant features however rare they are <sup>(11)<\/sup>.\u00a0<\/p>\n\n\n\n<p>The predominant adnexal lesions are unrelated to pregnancy. The pregnancy related lesions are corpus leuteum cyst, ectopic pregnancy and theca leutein cysts <sup>(14)<\/sup>. Lesions unrelated to pregnancy (see Table 1) can be classified based on source of origin <sup>(15)<\/sup>.<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img fetchpriority=\"high\" decoding=\"async\" width=\"768\" height=\"702\" src=\"http:\/\/fetalradiology.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-141724.jpg\" alt=\"\" class=\"wp-image-3419\" srcset=\"https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-141724.jpg 768w, https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-141724-300x274.jpg 300w\" sizes=\"(max-width: 768px) 100vw, 768px\" \/><\/figure>\n\n\n\n<p><strong>IMAGING:\u00a0<\/strong><\/p>\n\n\n\n<p>The predominant point of consideration in adnexal lesions during pregnancy are presence of complications and presence of imaging features of malignant potential. In such cases ultrasound serves to characterize the mass and to assess vascularity of the lesion and other emergent features <sup>(12)<\/sup>. There are many categorization systems to characterise these lesions, the latest updated one is the \u00a0 Ovarian-Adnexal Reporting and Data System (O-RADS)<sup> (16)<\/sup>. Proper use of these categorization systems helps us identify malignant risk features in adnexal lesions. (Figure 1, 2, 3 & 4). Based on O-RADS categorization, the suspicious features are:\u00a0<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>larger lesions (>10 cm),\u00a0<\/li><li>cysts with thick and irregular septations,\u00a0<\/li><li>cysts with irregular walls, papillary projections > 3 mm,\u00a0<\/li><li>lesions with solid areas having a higher vascularity (colour score), predominantly solid but lobulated and\/or irregular lesions or\u00a0<\/li><li>ancillary findings such as ascites or omental nodules<sup> (16)<\/sup>.\u00a0<\/li><\/ul>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" width=\"762\" height=\"839\" src=\"http:\/\/fetalradiology.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-142418.jpg\" alt=\"\" class=\"wp-image-3420\" srcset=\"https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-142418.jpg 762w, https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-142418-768x845.jpg 768w\" sizes=\"(max-width: 762px) 100vw, 762px\" \/><\/figure>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" width=\"485\" height=\"605\" src=\"http:\/\/fetalradiology.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-143843.jpg\" alt=\"\" class=\"wp-image-3423\" srcset=\"https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-143843.jpg 485w, https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-143843-768x958.jpg 768w\" sizes=\"(max-width: 485px) 100vw, 485px\" \/><figcaption>Figure 3 & 4 demonstrate a 30 year old female with an anembryonic pregnancy associated with an incidentally detected right ovarian lesions with fat within favouring an ovarian dermoid. <br> <strong><em>Image courtesy: Thank you Dr Alexandra Stanislavsky and Radiopaedia.<br> Image courtsey<\/em><\/strong><\/figcaption><\/figure>\n\n\n\n<p>When the ultrasound features are indeterminate, MR imaging can help to categorize the adnexal lesions better and help further management <sup>(17)<\/sup>.<\/p>\n\n\n\n<p>Ovarian torsion is another area where ultrasonography plays an important role especially when a patient presents with acute abdominal pain during pregnancy and an incidentally or otherwise known ovarian lesion <sup>(12)<\/sup>. On a 2D scan, the lesions demonstrate an enlarged and oedematous ovary with a lesion within. In certain cases, it may be possible to see multiple tiny cystic structures arranged in the periphery, possibly follicles, pushed peripherally due to oedema<sup> (18)<\/sup> (Image: Figure 5 & 6).\u00a0 On further Doppler investigation there is either absent\/poor or normal vascularity demonstrated based on the extent of the vascularity that is compromised<sup> (18, 19)<\/sup>. The venous flow within the adnexa is the first to be compromised followed by the arterial flow<sup> (18)<\/sup>. However, of all the Sonography and Doppler findings the most sensitive finding is the presence of a twisted vascular pedicle \u2013 whirlpool sign <sup>(20, 21, 22)<\/sup>.\u00a0<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img loading=\"lazy\" decoding=\"async\" width=\"499\" height=\"371\" src=\"http:\/\/fetalradiology.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-144506.jpg\" alt=\"\" class=\"wp-image-3424\" srcset=\"https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-144506.jpg 499w, https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-144506-768x570.jpg 768w\" sizes=\"(max-width: 499px) 100vw, 499px\" \/><figcaption>Figure 5 & 6 demonstrates a dichorionic diamniotic intrauterine pregnancy with an enlarged right ovary containing a simple cyst and edematous ovarian parenchyma and peripherally placed small follicles \u2013 a right ovarian torsion.<br> <strong><em>Image courtesy: Thank you Dr Alexandra Stanislavsky and Radiopaedia.<\/em><\/strong><\/figcaption><\/figure>\n\n\n\n<p>Cyst rupture is another encountered emergency secondary to an adnexal lesion in an otherwise healthy pregnancy. A rupture cyst, associated with hameoperitoneum and possibly a sentinel clot are the features found sonologically <sup>(23)<\/sup>. ( Image : Figure 7 & 8)<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img loading=\"lazy\" decoding=\"async\" width=\"396\" height=\"517\" src=\"http:\/\/fetalradiology.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-144829.jpg\" alt=\"\" class=\"wp-image-3425\" srcset=\"https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-144829.jpg 396w, https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-144829-768x1002.jpg 768w\" sizes=\"(max-width: 396px) 100vw, 396px\" \/><figcaption>Figure 7 & 8 shows a 27-year-old female with a single live intrauterine pregnancy of 11 weeks and an adnexal hematoma and minimal hemoperitoneum \u2013 a ruptured corpus leuteal cyst. <\/figcaption><\/figure>\n\n\n\n<figure class=\"wp-block-image\"><img loading=\"lazy\" decoding=\"async\" width=\"395\" height=\"520\" src=\"http:\/\/fetalradiology.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-145031.jpg\" alt=\"\" class=\"wp-image-3426\" srcset=\"https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-145031.jpg 395w, https:\/\/fetalradiology.co.in\/wp-content\/uploads\/2020\/06\/Screenshot_20200616-145031-768x1011.jpg 768w\" sizes=\"(max-width: 395px) 100vw, 395px\" \/><figcaption>Figure 9 & 10 demonstrate the presence of a live intrauterine pregnancy of 6 weeks in a 26-year-old primi gravida who presented with severe abdominal pain and incidentally a large right ovarian cyst with a volume of 890 cc was found. The patient went ahead to undergo laproscopy and cystectomy; with no intra operative features of torsion. Patient was symptom free post the cystectomy. <\/figcaption><\/figure>\n\n\n\n<p><strong>CONCLUSION:<\/strong><\/p>\n\n\n\n<p>Adnexal masses during pregnancy have to be diligently investigated.\u00a0 Imaging forms an important part of the investigative procedure.\u00a0 Image characterisation can help delineate masses that are suspicious of malignancy and in further workup and management of these patients. Imaging helps us in the diagnosis of emergencies such as torsion or rupture of the lesion in whom an emergency surgical treatment is warranted.<\/p>\n\n\n\n<p><strong>REFERENCES:<\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Yakasai I, Bappa L A. Diagnosis and Management of Adnexal Masses in Pregnancy. J Surg Tech Case Rep. 2012 Jul-Dec; 4(2): 79\u201385.<\/li><li>\u00a0Leiserowitz GS. Managing ovarian masses during pregnancy.\u00a0Obstet Gynecol Surv.\u00a02006;61:463\u201370.<\/li><li>Glanc P, Salem S, Farine D. Adnexal masses in the pregnant patient: A diagnostic and management challenge.\u00a0Ultrasound Q.\u00a02008;24:225\u201340.<\/li><li>Giuntoli RL, 2nd, Vang RS, Bristow RE. Evaluation and management of adnexal masses during pregnancy.\u00a0Clin Obstet Gynecol.\u00a02006;49:492\u2013505.\u00a0<\/li><li>Kumari I, Kaur S, Mohan H, Huria A. Adnexal masses in pregnancy: A 5 year review.\u00a0Aust N Z Obstet Gynecol.\u00a02006;46:52\u20134.<\/li><li>Aggarwal P, Kehoe S. Ovarian tumours in pregnancy: A literature review.\u00a0Eur J Obstet Gynecol Reprod Biol.\u00a02011;155:119\u201324.<\/li><li>Whitecar P, Turner S, Higby K. Adnexal masses in pregnancy: A review of 130 cases undergoing surgical amangement.\u00a0Am J Obstet Gynecol.\u00a01999;181:19\u201324.<\/li><li>Alalade AO, Maraj H. Management of adnexal masses in pregnancy. The Obstetrician & Gynaecologist. 2017;19:317\u201325. DOI: 10.1111\/tog.12417.<\/li><li>Dgani R, Shoham Z, Atar E, Zosmer A, Lancet M. Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the years 1960 and 1984. Gynecol Oncol 1989;33:326\u201331<\/li><li>Spencer CP, Robarts PJ. Management of adnexal masses in pregnancy. The Obstetrician & Gynaecologist 2006;8:14\u201319<\/li><li>Hakoun, A.M, Aboual-shaar, I, Salloum, M.N.\u00a0Adnexal masses in pregnancy: An updated review.\u00a0Avicenna Journal of Medicine.\u00a02017;7(4):\u00a0153-157.<\/li><li>Nick, A, Schmeler, K.\u00a0Adnexal Masses in Pregnancy.\u00a0Perinatologycom.\u00a0[Online]\u00a02010;1(2):\u00a013-19.\u00a0Available from: http:\/\/perinatology.com\/perinatology\/Volume1-Issue2\/Adnexal%20Masses%20in%20Pregnancy.htm\u00a0[Accessed 20 May 2020].<\/li><li>Schwartz, N., I.E. Timor-Tritsch, and E. Wang, Adnexal masses in pregnancy. Clin Obstet Gynecol, 2009. 52(4): p. 570-85.\u00a0<\/li><li>\u00a0NaseerA.\u00a0Https:\/\/eposmyesrorg\/esr\/viewing\/indexphp?module=viewing_poster&task=viewsection&pi=119488&ti=394671&si=1388&searchkey=.\u00a0[Online].\u00a0Available from: https:\/\/epos.myesr.org\/esr\/viewing\/index.php?module=viewing_poster&task=viewsection&pi=119488&ti=394671&si=1388&searchkey=\u00a0[Accessed 2014].<\/li><li>Givens V, Mitchell G, Harraway-Smith C, Reddy A, Maness D,<em> <\/em>Diagnosis and Management of Adnexal Masses. Am Fam Physician<em>.<\/em>\u00a02009\u00a0Oct\u00a015;80(8):815-820.<\/li><li>Andreotti R,\u00a0 Timmerman D,\u00a0Strachowski L M,\u00a0 Froyman W et al. <a href=\"https:\/\/pubs.rsna.org\/doi\/abs\/10.1148\/radiol.2019191150\">O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee<\/a>. Radiol\u00a02020\u00a0294:1,\u00a0168-185<\/li><li>\u00a0Naggara, I.T.\u00a0European journal of radiology.\u00a0[Online].\u00a0Available from: https:\/\/www.ejradiology.com\/article\/S0720-048X(17)30203-6\/fulltext#secsect0005\u00a0[Accessed 22 may 2017].<\/li><li>\u00a0Hannah C. Chang,\u00a0Shweta Bhatt, and\u00a0Vikram S. Dogra. <a href=\"https:\/\/pubs.rsna.org\/doi\/abs\/10.1148\/rg.285075130\">Pearls and Pitfalls in Diagnosis of Ovarian Torsion<\/a>. RadioGraphics\u00a02008\u00a028:5,\u00a01355-1368<\/li><li>\u00a0Chiou, S.Y., et al., Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging. J Ultrasound Med, 2007. 26(10): p. 1289-301.<\/li><li>Ssi-Yan-Kai G, Rivain AL, Trichot C, et al. What every radiologist should know about adnexal torsion.\u00a0<em>Emerg Radiol<\/em>. 2018;25(1):51\u201059. doi:10.1007\/s10140-017-1549-8<\/li><li>LeeEJ, Kwon HC, Joo HJ, Suh JH, Fleischer AC. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle.\u00a0J Ultrasound Med1998; 17(2): 83\u201389.<\/li><li>VijayaraghavanSB. Sonographic whirlpool sign in ovarian torsion.\u00a0J Ultrasound Med2004; 23(12): 1643\u20131649.<\/li><li>\u00a0McCort J. <a href=\"https:\/\/pubs.rsna.org\/doi\/abs\/10.1148\/116.1.65\">Ruptured Corpus Luteum with Hemoperitoneum<\/a>. Radiology\u00a01975\u00a0116:1,\u00a065-67<\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Author: Avni KP Skandhan, Aster MIMS, Kottakkal, Kerala INTRODUCTION\u00a0 The detection of adnexal masses in pregnancy, which are often incidental findings, has increased with the increased use of ultrasonography. (1-4). The current incidence of adnexal masses during pregnancy is reportedly between 1 in 81 and 1 in 8000 pregnancies (5). Earlier, adnexal masses were under [&hellip;]<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[15],"tags":[94,31,43],"class_list":["post-3416","post","type-post","status-publish","format-standard","hentry","category-review-article","tag-adnexal-mass","tag-pregnancy","tag-ultrasound"],"a3_pvc":{"activated":false,"total_views":0,"today_views":0},"_links":{"self":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/3416","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3416"}],"version-history":[{"count":5,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/3416\/revisions"}],"predecessor-version":[{"id":3703,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=\/wp\/v2\/posts\/3416\/revisions\/3703"}],"wp:attachment":[{"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3416"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3416"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/fetalradiology.co.in\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3416"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}