Analysis of adnexal mass managed during cesarean section

Results. The incidence of adnexal masses was 16.40 per 1000 CSs. The most common pathologic diagnosis was benign ovarian tumor, the 2nd was ovarian endometrioma and the 3rd was theca lutein cyst. Thirteen cases of ovarian malignancies were diagnosed during a CS. Only 388 cases (29.78%) were detected by an ultrasonography (USG) examination before a CS. Eight cases required emergency CS due to abdominal pain; all other patients were clinically asymptomatic. The reasons for abdominal pain included torsion (n = 5), rupture (n = 2) and ovarian enlargement (n = 1). In 13 cases with ovarian endometrioma, cysts ruptured during a CS without any clinical manifestation. No maternal and fetal complications related to surgery were observed.


Introduction
2][3][4][5] Improper management of an adnexal mass during pregnancy can endanger the maternal and neonatal safety, owing to the particularity of the pregnancy.Both the fetus and mother should be taken into account when the doctors try to manage the adnexal mass.Due to the development of ultrasonography (USG) technology and the awareness regarding prenatal health care, an increased number of adnexal masses are detected during pregnancy. 6,7As we know, the risk of malignancy of adnexal masses during pregnancy cannot be determined by an USG examination alone, and the true pathologic type can be determined only by surgical examination of the masses.Thus, the clinician sometimes would be caught in a dilemma concerning whether to choose surgery or expectant management.Moreover, despite the widespread use of USG technology, the incidence of adnexal masses incidentally discovered during cesarean section (CS) remains high.This would potentially carry risk for clinical management.The aim of the present study was to compare and report the clinical characteristics of adnexal masses with different pathologic types that were encountered during CS at Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.It is also the intention of this study to provide a reference for diagnosis and treatment of adnexal masses during pregnancy.

Material and methods
This is a clinical retrospective study of gravid women with an adnexal mass diagnosed during CS at our hospital in the 21-year period between January 1991 and December 2011.Approval from the Ethics Committee of the hospital was obtained before the study was conducted.Owing to the retrospective character of the study, informed consent was not needed.The following data was collected: patient's age, gestational age, gravidity and parity history, symptoms, USG records before CS, indication for CS, the size and site of the adnexal mass at CS, surgical procedure, pathologic diagnosis, perioperative complications, and neonatal outcome.Final diagnosis was confirmed by a routine paraffin section after surgery.The pathology specialists at our hospital reviewed all pathologic sections.The present conditions of the patients with malignancy were followed up and the information was retrospectively recorded up to the date of the last contact.For theca lutein cysts, the manifestations were followed up until the masses dissolved.Data was analyzed using the c 2 test.Statistical analysis was performed with SPSS v. 20.0 software (IBM Corp., Armonk, USA).The p-values below 0.05 were considered statistically significant.

Clinical manifestations
Most masses were clinically asymptomatic, except for 8 (0.61%) cases which required emergency CS due to acute abdominal pain.The reasons for abdominal pain included torsion (n = 5, 3 for benign ovarian tumor, 1 for ovarian endometrioma and 1 for theca lutein cyst), rupture (n = 2; 1 for benign ovarian tumor and 1 for ovarian endometrioma) and ovarian enlargement (n = 1; theca lutein cyst) (Table 2).In 13 patients with ovarian endometrioma, the cyst ruptured during CS without any obvious abdominal pain and discomfort during pregnancy.Among them, 4 masses were detected before pregnancy, 3 cases in the 1 st trimester and 6 cases at CS.Among 179 cases with theca lutein cyst, only 19 cases were secondary to assisted reproductive technologies.

Diagnosis and management
A frozen section was applied for suspected malignant mass.The final diagnosis was made according to the pathologic report by the paraffin section.The clinical characterstics and management are presented in Table 3 and the pathologic types of adnexal masses are shown in Fig 1 .In brief, the most common histological type was mature teratoma (390, 29.93%), the 2 nd was ovarian endometrioma (251, 19.26%), the 3 rd was theca lutein cyst (179, 13.74%), and the 4 th was serous cystadenoma (155, 11.90%); 13 (1.00%) were ovarian malignancies. 8The median adnexal mass size for benign ovarian tumor was 5 cm (range from 0.1 to 30 cm), 6 cm for theca lutein cyst (from 0.3 to 16 cm), 4 cm for ovarian endometrioma (from 0.5 to 13 cm), 3 cm for paraovarian-paratubal cyst (from 0.5 to 10 cm), and 5 cm for ovarian malignancy (from 2.5 to 30 cm).The frequencies of unilateral and bilateral of the adnexal mass were 1,117 (85.73%) and 186 (14.27%), respectively.After excluding the rare pathologic types, we found that most masses were unilateral (84.80%), except for theca lutein cysts (40.80%); the differences were significant (c 2 = 330.799,p = 0.000).Most masses had the size of 5 cm or less (65.70%), except for theca lutein cysts (45.30%); the differences were significant (c 2 = 142.134,p = 0.000).A cystectomy was performed in

Discussion
][3] In accordance with previous reports, we found that the incidence of adnexal masses diagnosed during CS was about 1.64%.As we know, a USG examination is the most helpful method in the detection and evaluation of an adnexal mass in women, regardless of whether the woman is pregnant or not.Moreover, it can detect masses smaller than those usually detected during a physical examination, especially during pregnancy. 3Aggarwal and Kehoe reviewed the studies conducted between 1984 and 2009 and found that a USG examination increased the detection of adnexal masses in pregnancies from 0.04-1.32%(1/76-1/2328) to 1.14-5.23%(1/19-1/88). 6The majority of masses found during pregnancies are small (<5 cm) and represent functional cysts that typically resolve spontaneously by the 2 nd trimester. 1Our data reflects the actual rate of adnexal masses in CS patients, which can explain why the rate is situated in the low limitation of the previous reports.Nevertheless, the incidence of masses discovered during CS was much higher than that (0.49%) detected before and during pregnancy in the present study.Only 29.78% of the adnexal masses were detected before CS, although about 99.00% gravida women received a prenatal examination.This means that more than half of the masses were diagnosed incidentally during CS.This is similar to the results of a study by Baser et al., which revealed that 83 (55.0%) adnexal masses were incidentally discovered during CS. 7he probable reasons for this low diagnostic rate during pregnancy were addressed here.Most adnexal masses were asymptomatic and small (≤5 cm); the pregnant patients refused a pelvic examination and a transvaginal USG examination for the fear of abortion during early pregnancy; some adnexal masses might emerge after pregnancy and gravid uterus may obscure the correct visualization and detection.Thus, it is important to promote the use of USG and improve the USG technique during preconception and prenatal visits in China.
Once the adnexal mass is detected during pregnancy, the obstetrician would have to make the clinical decision of how to manage the mass, since the masses can affect the pregnancy outcome due to the risk for torsion, rupture, bleeding, obstruction, or malignancy.0] While some obstetricians prefer elective removal in the 2 nd trimester, others state that a conservative approach results in the resolution of most masses and avoid unnecessary surgery. 6Surgery during pregnancy carries some inherent intraoperative and perioperative risks, including the added risks of fetal loss, preterm contractions and an increased risk of embolic events. 1,11However, observing a mass during pregnancy might delay the treatment if the adnexal mass is malignant or develops an acute event, such as ovarian torsion, cyst rupture or obstruction of labor, which often necessitates emergency intervention. 13][14] Owing to their characteristic USG appearance, the differential diagnosis for most masses is relatively easy with the improvement of the USG technique, especially for an experienced sonographer.However, some malignancies were still misdiagnosed before CSs in our study and in the reports from other researchers.The rate of malignancy in the present study was 1.00% (13/1303), including 8 low-malignant potential tumors, 3 invasive epithelial carcinomas and 2 malignant germ cell tumors. 8All malignancies were clinically asymptomatic and were diagnosed in stage I with good prognosis.Thus, we agree that delaying surgery may be feasible to avoid any unnecessary risks to the pregnancy, depending on the clinical suspicion of malignancy. 1 For asymptomatic adnexal masses, surgery should only be considered in a pregnancy for suspicious or obvious malignant tumors. 15No new malignances were diagnosed after 2008 in the present study.This might be due to the improved technique of USG and most suspicious adnexal masses receiving surgery before CS.Nevertheless, routine puerperium USG is strongly recommended for vaginal delivery, since it raises the possibility for delaying the diagnosis of an adnexal mass.
In the present study, we found that 20 (1.61%) cases experienced torsion or rupture.A previous study reported that ovarian torsion was most commonly (60% of the time) seen in pregnant women with an adnexal mass. 1 Interestingly, 75% of complications were connected to ruptures and most of them in the present study were ovarian endometriomas.However, the rate of torsion would be increased to 71.43% (5/7) if the asymptomatic ruptures of ovarian endometrioma were excluded.The complications managed during early or mid-pregnancy were excluded, because we only collected the information of the patients with an adnexal mass observed during CS; as a result, the actual rate of torsion or rupture here was lower than in previous reports.During the last decade, the increased use of assisted reproductive technologies has led to higher fertility rates in patients with ovarian endometrioma.Therefore, the number of pregnant women with ovarian endometrioma and associated complications may rise, despite most investigators reporting regression or cessation of growth of the endometriomas during pregnancy. 4,16,179][20] However, we found that 71.43% (15/21) of the masses with complications were ovarian endometriomas and most of them (14/15) were ruptures.This is concordant with a previous study, which reports that ovarian endometrioma is a major risk factor for spontaneous hemoperitoneum in pregnancy. 18Fortunately, no massive hemoperitoneum presented in this study.Of the 15 cases, only 2 received emergency CS due to acute abdomen pain.Other 13 cases with ruptures were asymptomatic and diagnosed at the time of the CS for other surgical indications.Although ovarian endometrioma is widely studied, little is known about the incidence of ovarian endometrioma complications during pregnancy.This study is the first detailed report on the rupture and torsion in ovarian endometrioma observed during a relatively large number of CSs.The possibility of spontaneous hemoperitoneum should be always kept in mind, since 7.97% of ovarian endometriomas experienced a rupture in the present study. 17unctional cysts usually resolve spontaneously by the 2 nd trimester, while we found that 179 (13.74%) were theca lutein cysts, which persisted until CS.Theca lutein cysts, also known as hyperreactio luteinalis (HL), are a type of functional ovarian cyst. 21,22They are typically multiple and bilateral, and are usually associated with gestational trophoblastic disease, ovulation induction and very rarely with a normal pregnancy.Interestingly, only 19 cases received ovulation induction in the present study.Production of high concentrations of human chorionic gonadotropin (HCG) and increased ovarian sensitivity to prolonged exposure to HCG may be manifested as an exaggerated ovarian response, leading to theca lutein cyst formation. 23,24n the present study, 1 case with HL was misdiagnosed as a malignancy during CS and received bilateral SO (Table 2).The bilateral masses were 10 cm in size and the surgeon did not recognize them.After that, all obstetricians in our hospital were alerted to the possibility that huge theca lutein cysts can exist through the whole trimester and mimic malignancy.That is why doctors should be aware that theca lutein cysts may mimic malignancies and lead to an unnecessary ovarian resection. 21,25Furthermore, most theca lutein cysts are bilateral (54.7%), which might be helpful for a differential diagnosis.In the present study, most theca lutein cysts were asymptomatic and were found incidentally with USG or during CS; 34.08% of cases were managed expectantly by experienced obstetricians and showed to resolve spontaneously postpartum.Thus, the management should be carefully chosen depending on the manifestation of the masses.It is important to exclude malignancies with a biopsy (or wedge resection) and then freeze the section in order to avoid unnecessary surgical excision. 21Paracentesis is acceptable for huge masses to minimize their volume and avoid complications if no malignancy signs are present, while a cystectomy and SO are not recommended unless there is a definite indication.

Conclusions
Based on our results and previous reports, an USG examination is still the preferred auxiliary examination to rule out the adnexal mass, although most masses in the present study were incidentally discovered during CS.Preconception care, routine prenatal care and puerperal checks, including USG examinations, may be used to optimize the detection and management of adnexal masses, since most masses are unilateral and ≤5 cm.Active treatment is advised for the persistent adnexal masses or presumptive ovarian endometriomas found before pregnancy, to avoid acute abdominal disease or other complications related to pregnancy that could threaten maternal-fetal safety.For the masses detected during pregnancy, expectant management is recommended if no malignancy is suspected and closer observation is recommended. 6,26The presumed risk of torsion or rupture should not be considered as an indication for surgery. 27Moreover, the patients should also be aware that antenatal surgery might become necessary once the mass becomes symptomatic or its features change. 6or the masses discovered during CS, surgical removal is preferred to prevent subsequent complications (torsion or rupture) or a future requirement for surgery, except for functional cysts such as theca lutein cysts. 6,28,29

Table 1 .
The indications for cesarean section (CS)

Table 2 .
Cases that received emergency cesarean section (CS) due to acute abdominal pain GA -gestational age; SO -salpingo-oophorectomy; R -right; L -left; Bi -bilateral; NA -not applicable.

Table 3 .
Clinical characteristics and management of 1,303 adnexal masses SO -salpingo-oophorectomy; Uni -unilateral; Bi -bilateral; * 103 theca lutein cysts were not listed in this table, they received biopsy (40), paracentesis(2)or were untreated (61); ** 1 patient with ovarian carcinoma, who received radical surgery, was not listed here (the detailed data of ovarian malignancy was published in Reference 8); categorical variables were expressed as number and percentage.