SURGICAL TREATMENT OF ADNEXAL MASSES IN PREGNANCY – THE ROLE OF LAPAROSCOPY MANAGEMENT

Abstract

Background. The aim of this retrospective study was to find the incidence and type of adnexal masses in pregnancy, reliability of preoperative ultrasound examination and the effect of the surgical approach used, duration of pregnancy at the time of surgery, and the effect of emergency or planned surgery on the outcome of pregnancy. The obtained results and the data from literature were to provide the basis of the guidelines for the management of pregnant women with adnexal masses. Methods. In the study we enrolled 42 women, who underwent a surgery in pregnancy for adnexal masses. All surgeries were performed at the Department of Obstetrics and Gynecology in the period 1 January 1993–31 August 2000. The course of pregnancy was followed by 28 February 2001. The data were obtained from the records kept at the Department and from the questionnaire sent to the women. Statistical analysis was done using Chi-square test. Statistical significance was set at P ≤ 0.05. Results. We found the incidence of adnexal masses in pregnancy, requiring surgical treatment, to be 1/1034 deliveries. There were 6 (14.3%) borderline malignant and malignant ovarian tumours, the incidence being 1/7239 deliveries. Preoperative ultrasound examination was not reliable enough to differentiate neither between benign and malignant adnexal masses, nor between adnexal masses and leiomyomas. Forty-two surgeries were made, 21 by laparoscopy and 21 by laparotomy. The size of removed tumours ranged between 4 and 30 cm (mean 9.4 cm), the most frequent type was mature cystic teratoma (n = 12). There were no differences in the outcome of pregnancy between the laparoscopy and laparotomy approach, between emergency and planned surgery, and between laparotomy performed by the 23rd and after the 23rd gestational week. Hemorrhagic shock due to heterotopic pregnancy lead to 1 spontaneous abortion. There were 2 preterm deliveries in the 37th week, 2 babies had intrauterine growth retardation, and 1 congenital malformations. Conclusions. The incidence of adnexal masses found in this study resembles that found in literature. Laparoscopic surgery is at least as safe as laparotomy. Surgery performed in the first trimester of pregnancy did not increase the risk of worse outcome of pregnancy. A relatively high percentage of borderline malignant and malignant tumours and not enough sensitive ultrasound examination justify the use of invasive diagnostic and surgical treatment of adnexal masses in pregnancy, especially after laparoscopy has become extensively used. Tumours are recommended to be removed laparoscopically after the 12th gestational week, because in this period the removal of the ovary and corpus luteum is not dangerous, the effect of anesthetics on the fetus during organogenesis is avoided, and the uterine size is still appropriate for a safe procedure. For a relatively small number, the management of these cases is recommended to be carried out in centres with appropriate equipment and experience in laparoscopic management of adnexal masses.