Adnexal masses and pregnancy: A 12-year experience

Gordon B. Sherard III, MD,a Charles A. Hodson, PhD,a H. James Williams, MD,b
Diane A. Semer, MD,a Hamid A. Hadi, MD,a and David L. Tait, MDa
Greenville, NC

OBJECTIVE: Our purpose was to describe pregnancy-associated adnexal masses in eastern North Carolina.
STUDY DESIGN: A retrospective study was performed of 60 adnexal masses resected during pregnancy at
a regional referral hospital from January 1990 to March 2002.
RESULTS: Adnexal masses occurred in 0.15% of pregnancies. Average gestational age at diagnosis and
surgery was 12 and 20 weeks, respectively. Fifty percent of ovarian tumors were mature cystic teratomas, 20%
were cystadenomas, and 13% were functional ovarian cysts. Malignancy occurred in 13%. Tumors with low
malignant potential comprised 63% of malignancies. Average cyst size was 11.5 cm for malignancies and
7.6 cm for benign lesions (P value <.05). The preterm birth rate was 9%, the miscarriage rate was 4.7%
after elective cases, and average Apgar scores were 7.5 and 8.7 at 1 and 5 minutes.
CONCLUSION: The incidence of malignancy in pregnancy-associated adnexal masses was high.
Ultrasonography detected internal excrescences in the majority of tumors with low malignant potential. Fetal
outcomes were not affected. (Am J Obstet Gynecol 2003;189:358-63.)

Key words: Adnexal masses, malignancy, pregnancy

The number of adnexal masses diagnosed concurrently
with pregnancy has increased as the routine use of
ultrasonography has increased. The use of ultrasonogra-
phy has resulted in the detection of asymptomatic and
clinically inapparent lesions.1 Historically, adnexal masses
were diagnosed on physical examination. Earlier diag-
nosis of pregnancy as a result of very sensitive home
pregnancy tests and increased access to prenatal care may
contribute to increased detection of pregnancy-associated
masses. As more women enter into prenatal care at earlier
gestational ages, the incidence of lesions increases as
more functional cysts are detected. Currently, adnexal
masses have been noted to occur in up to 1% of all
gestations.1
The management of adnexal masses associated with
pregnancy is variable. The two most common options are
operative extirpation of the mass or expectant manage-
ment. Cyst size, gestational age, and sonographic appear-
ance all need to be considered when evaluating adnexal
masses and formulating a treatment plan. Previous studies
have both supported and refuted complications associ-
ated with these options of therapy. The histologic
From the Departments of Obstetrics and Gynecology,a and Pathology,b
East Carolina University, Brody School of Medicine, Pitt County
Memorial Hospital.
Presented at Sixty-Fifth Annual Meeting of the South Atlantic
Association of Obstetricians and Gynecologists, Hot Springs, Va,
January 25-28, 2003.
Reprint requests: Gordon B. Sherard III, MD, 201 Pineville Rd,
Spartanburg, SC 29307. E-mail: gsherard@bellsouth.net
2003, Mosby, Inc. All rights reserved.
0002-9378/2003 $30.00 + 0
doi:10.1067/S0002-9378(03)00731-2
diagnoses most commonly reported for these persistent
masses are functional cysts and mature cystic teratomas.
The incidence of ovarian cancer associated with persistent
adnexal masses in pregnancy varies, with reports as high as
5.9%.2
The purpose of this article was to characterize the
adnexal masses associated with pregnancy at a tertiary
care facility and to report on the maternal and fetal
outcomes. The description of the mass will include
clinical presentation, ultrasound morphologic features,
and histologic diagnosis. Increased data on adnexal
masses in pregnancy will enhance the counseling of
patients regarding management options.
Material and methods
This was a retrospective study of all pregnancy-
associated adnexal masses that were surgically resected
at Pitt County Memorial Hospital, a tertiary care facility in
rural eastern North Carolina from January 1990 through
March 2002. The obstetric database was reviewed for
exploratory laparotomy, operative laparoscopy, adnexal
mass, and pelvic mass. The pathology database was also
searched for adnexal, ovarian, or pelvic mass associated
with pregnancy. Data collection included maternal age,
race, gravidity, parity, gestational age at diagnosis,
gestational age at surgery, gestational age at delivery,
ultrasonographic findings, site of lesion, pregnancy com-
plications, neonatal complications, birth weight, Apgar
scores, and histologic diagnosis of the adnexal masses.
Mean diameter of the mass was calculated as the sum
of three diameters divided by 3. Term deliveries were de-
fined as occurring after 37 weeks and up to 42 weeks of

358
Volume 189, Number 2 Sherard et al 359
Am J Obstet Gynecol

Table I. Maternal demographics (n = 56) Table II. Neonatal data (n = 42)

Average maternal age 27 y (15-41y) Gestational age at delivery 37.5 2.5 wk

Average gravidity 2.4 (1-7) Term delivery 69% (n = 29)
Average parity 0.9 (0-5) Preterm delivery 24% (n = 10)
Nulliparous 45% (n = 25) Spontaneous abortion 4.7% (n = 2)
Race Elective abortion 2.3% (n = 1)
African-American 59% (n = 33) Route of delivery
White 36% (n = 20) Vaginal delivery 44% (n = 19)
Other 5% (n = 3) Cesarean delivery 54% (n = 23)
Complications of pregnancy Curettage 2% (n = 1)
Diabetes 9% (n = 5) Average birth weight 2877 911 g
Hypertension 5% (n = 3) Average Apgar score
Asthma 2% (n = 1) 1 min 7.5 0.59
Sickle cell disease/trait 4% (n = 2) 5 min 8.7 0.19
Thyroid dysfunction 2% (n = 1)
Advanced maternal age 12.5% (n = 7)
Lupus erythematosus 2% (n = 1)
Rh negative (nonsensitized) 9% (n = 5)
Twins 3% (n = 3) Fifty-four operations (96%) were by laparotomy and the
Tobacco use 2% (n = 1) two most recent surgeries were laparoscopic procedures.
Pyelonephritis 2% (n = 1) Ninety-eight percent (55/56) of our cases were elective
cases. One emergency surgery for adnexal torsion was
preformed. Vertical midline incisions were used in the
gestation and preterm deliveries were defined as occur- majority of the laparotomy cases. The two laparoscopic
ring before 37 weeks of gestation. The decision on cases were preformed at 15 and 17 weeks gestation for one
whether to operate was determined by the staff physician mature cystic teratoma and one functional cyst, respec-
and/or maternal fetal medicine specialist. Microsoft tively. Traditional pressure values of 15 mm Hg were used
Excel statistical software was used to preform two-tailed for insufflation.
t tests on the mean cyst diameter. Neonatal information was only available for 42 of 56
patients (75%) as a result of patients returning to the
Results referring physicians after evaluation and management of
There were 37,929 deliveries during the study period. the adnexal mass. Term delivery occurred in 69% of
Sixty-three patients with adnexal masses were identified patients. Preterm deliveries included two sets of twins and
through our database searches. Of the 63 patients, 7 were two inductions of labor for nonreassuring fetal status.
lost to follow-up and not included in our study resulting in Mean 1 and 5 minute Apgar scores were 7.5 and 8.7
a final study group of 56 patients. After patients with (Table II).
bilateral disease were included, the total number of Fifty percent (30/60) of the lesions were mature cystic
adnexal masses was 60, giving an incidence of 0.15% teratomas, 13% were functional ovarian cysts, and 20%
(1/632 pregnancies) in our series. were benign cystadenomas. The incidence of cancer
Mean maternal age and parity were 27 years and 1, associated with adnexal masses in pregnancy was 13%.
respectively (Table I). The mean gestational age at Low malignant potential tumors comprised 63% (5/8) of
diagnosis of the adnexal mass was 12 weeks and the mean malignant neoplasms, whereas the remaining 37% (3/8)
gestational age at surgery was 20 weeks. Fourteen cases displayed stromal invasion (Table III).
(22%) were diagnosed during the first trimester at an The mean cyst size for nonmalignant masses was 7.6 cm
average gestational age of 9 weeks (6-11 weeks). After (range 3 cm to 15cm) and 11.5 cm for malignant masses
documenting no spontaneous resolution, these masses (range 6 cm to 17 cm). Septations were found equivalently
were removed at an average gestational age of 17 weeks. in malignant and nonmalignant processes. Internal
During the 12th to 20th gestational week, 17 more masses excrescences were found in 50% of malignant tumors
were discovered at an average gestational age of 16 weeks and not in any benign lesions (Table IV).
(12-20 weeks). The average gestational age at surgery was The Federation of International Gynecology and
23 weeks for these masses. Thirty-one of the 56 (55%) Obstetrics (FIGO) system was used to surgically stage
study patients underwent surgery on or before comple- the ovarian cancers. Cell washings, peritoneal biopsies,
tion of the 20th gestational week. The remainder had lymph node sampling, and partial omentectomies were
operations either at cesarean section or immediately post performed. At diagnosis, all the cancers were FIGO stage
partum. Nine patients were followed up expectantly after IA. Maternal data for patients with ovarian cancer is
diagnosis with the average length of antepartum follow-up presented in Table V. Ascites, a frequent coexisting con-
lasting 17 weeks (range 7-26 weeks). Seventeen patients dition with ovarian cancer, was detected by ultrasonogra-
had masses removed at cesarean section and 5 patients phy in two cases in our series. One case was a luteoma
had laparotomies in the immediate postpartum period. (functional cyst) and the other was an immature teratoma
360 Sherard et al August 2003
Am J Obstet Gynecol

Table III. Adnexal mass pathology Table V. Ovarian cancer demographics

Calculated mean cyst size Average maternal age 22 y (15-38y)

Histologic diagnosis % (cm) Average gravidity 2.3 (1-5)
Average parity 1 (0-3)
Mature cystic teratoma (n = 30) 50 6.2 2.1 (3-11) Nulliparous 57% (n = 4)
Cystadenoma (n = 12) 20 11 3.9 (4-13) Race
Functional (n = 8) 13 7.4 3 (4-13) African American 43% (n = 3)
Cancer (n = 8)* 13 11.5 3.9 (6-17) White 57% (n = 4)
Fibroma (n = 1) 2 3 Site
Paratubal (n = 1) 2 7 Right 57% (n = 4)
Left 29% (n = 2)
*Four papillary serous, low malignant potential; 1 mucinous, Bilateral 14% (n = 1)
low malignant potential; 2 immature teratomas; 1 dysgerminoma.

Table IV. Ultrasound data (n = 40)
Benign (n = 32) Malignant (n = 8)
Morphology
Complex 66% (n = 21) 87.5% (n = 7)
Solid 13% (n = 4) 12.5 (n = 1)
Cystic 22% (n = 7) 0%
Discriminator
Internal excrescences 0% 50% (n = 4)
Echogenic focus 3% (n = 1) 0%
Septated 9% (n = 3) 13% (n = 1)
that actually had an intact ovarian capsule at time of
operation. The ultrasound was misleading because of the
extremely large nature (>2 L) of the cystic component of
the neoplasm.
Comment
In our large series of adnexal masses in pregnancy, we
found the distribution of histology variable from other
reports. Although the incidence of cystadenomas asso-
ciated with adnexal masses in pregnancy was similar in
our study compared with prior studies, we had several
findings that differed from what had previously been
reported. The 50% incidence of mature cystic teratomas
in our series was increased over the previously reported
20% to 30% incidence. Functional cysts occurred in only
13% of our cases compared with previous ranges
between 22% to 54%. The most striking finding in our
series, however, was the increased incidence of malig-
nancy in persistent adnexal masses in pregnancy. The
13% incidence is over twice the previously reported
incidence of 2% to 6%.3
Pregnancy outcomes in our series are consistent with
previous reports. The postoperative spontaneous abor-
tion rate after elective removal was 4.6%. One emergency
surgery was preformed in a patient at 20 weeks gestational
age as a result of ovarian torsion; she was delivered
uneventfully at term. The overall incidence of preterm
birth was 24% (10/42). When adjusted for two pairs of
twins and two inductions of labor for fetal indications, the
rate of preterm delivery decreases to 9%.
Multiple authors have recommended conservative
management of adnexal masses #6 cm. Grimes et al4
reported 185 adnexal masses; 111 cysts were diagnosed
during pregnancy and expectantly managed. Ninety-two
of 98 (94%) cysts that were less than 6 cm spontaneously
resolved. These authors proposed that the pedicle is able
to resist torsion as long as the cyst is not greater than 6 cm.
A separate study reporting on 137 masses noted that 31 of
38 (82%) cysts less than 6 cm resolved.5 All cysts 5 cm or
less resolved in the largest series that described 131
pregnancy-associated adnexal masses.6
In addition to the possibility of spontaneous cyst
resolution, the decision to postpone surgery until after
the first trimester has been based on cases described in the
Emil Novak Tumor registry. One third of all surgeries
preformed in the first trimester ended in spontaneous
abortion in that series.7 These data are a common
guideline for timing elective operative removal of adnexal
masses in pregnancy.
Expectant management has been associated with
adverse pregnancy outcome if the mass undergoes
torsion, rupture, or hemorrhage. Hess et al2 reported 15
of 54 (28%) patients with adnexal masses found in
pregnancy required emergency laparotomy (6 acute
hemorrhage, 7 cyst torsion). Of these patients requiring
emergency surgery, 6 of 15 (40%) had adverse pregnancy
outcomes postoperatively, four spontaneous abortions
and two preterm births. Of the remaining 39 patients who
had elective removal of an adnexal mass, only 1 (2%) had
an adverse pregnancy outcome. Interestingly, seven cases
in this series involved the removal of a corpus luteum,
including five that had to have emergency surgery. Two
patients had postoperative spontaneous abortions for an
incidence of 29% (2/7).
In our study, 2 of 42 (4.7%) patients with available
delivery data had an adverse pregnancy outcome after
elective removal of an adnexal mass. One patient had
a spontaneous abortion immediately after surgery at 16
weeks. The other patient had premature rupture of
membranes at 18 weeks after amniocentesis for advanced
maternal age at 15 weeks and surgery at 15.3 weeks of
gestation.
Volume 189, Number 2
Am J Obstet Gynecol
The effect of pregnancy on mature cystic teratomas has
also been evaluated and one study noted increased
complications. Torsion occurred in 19% and rupture in
17% of these cysts in pregnancy.8 Because of the high
incidence of adverse pregnancy outcomes in association
with emergency surgery previously reported, some au-
thors recommend elective removal of all masses that
persist until 16 weeks and are 6 cm or greater regardless of
appearance on imaging studies, unless it is suspected to be
a leiomyoma.2
Conversely, torsion occurred in only 1 of 139 conserva-
tively managed patients in the study by Grimes et al.4 At
surgery, the ovarian pedicle was untwisted and a cys-
tectomy was performed on a 10-cm cyst. The patient had
no postoperative pregnancy-related complications. There
were no complications in a study that expectantly followed
up 49 patients with presumed dermoids. Pregnancy did
not affect the growth of mature cystic teratomas 6 cm or
less in these patients.9 Twelve patients were followed up,
and there was no incidence of torsion in another study.10
In the 9 patients we managed conservatively with mature
cystic teratomas (average cyst size 6.3 cm), torsion did not
occur. The length of follow-up for these patients ranged
from 7weeks to 26 weeks. Only 1 patient in our series was
diagnosed with torsion (on initial presentation for care at
20 weeks gestation) and taken to the operating room.
Postoperatively, she had no further antenatal com-
plications and was delivered at term.
Gross and microscopic examination to exclude a malig-
nant neoplasm is an indication for operative intervention.
The reported incidence of ovarian cancer in pregnancy
ranges from 1:5000 to 1:47,000 live births with 2% to 6% of
persistent adnexal masses being malignant.7,10 Tumors
with low malignant potential and epithelial cancers are
the most common ovarian cancers found in pregnancy.11
In our series, 13% (8/60) of persistent adnexal masses
were malignant. The malignancy rate in our series was 1 in
4741 pregnancies. In agreement with a previously re-
ported study describing ovarian cancer in pregnancy, the
majority of cancers in our series were tumors of low
malignant potential.12
Size has been used as an indicator for surgery in
nonpregnant patients. Historic recommendations have
been to remove masses that were larger than 8 cm or
masses between 5 and 8 cm that did not resolve after 8
weeks in menstruating women.13 In our series, the average
mean cyst size was 11.5 cm for malignant lesions and 11 cm
for cystadenomas (P value not significant) (Table III).
However, the average mean cyst size for all benign lesions
was 7.6 cm (P value <.05). Thus, using size alone as an
absolute discriminator does not appear to be predictive,
unless the lesion is less than 6 cm.
Ultrasound evaluation of adnexal masses has been
utilized in the attempt to differentiate between malignant
and benign tumors. Different evaluation techniques using
Sherard et al 361
weighted scoring systems (including septations, wall
structure, and echogenicity) exist. The difficulty in
differentiating certain benign conditions from malig-
nancy has yielded positive predictive values around
30%.14 In another study, the ultrasound in 15% of the
cases was frankly misleading.15 Included were 6% of
cases interpreted as benign when a malignancy was
documented by histologic study. Twenty-two percent of
ultrasonographic simple cysts were noted on pathologic
examination to be low malignant potential tumors in
a separate study.6 In our cases, 80% (4/5) of masses that
were of low malignant potential had ultrasonographic
morphologic features significant for papillary excres-
cences detected on the internal cyst wall.
Solid tumors are another frequently cited reason for
surgery over concerns for malignancy. Of the six solid
tumors in our series, four (66%) were benign, including
a luteoma, a fibroma, and two mature cystic teratomas.
There were two malignancies (33%), an immature
teratoma and a dysgerminoma (Table V). Color-flow
Doppler imaging has also been used as an adjunct in
evaluating adnexal masses. Building on the presence of
neovascularization and the associated low resistance
vessels (because of the absence of muscularis develop-
ment) in malignancy, descriptions of pulsatility and
resistance indices have been published.16 However, no
such data have been reported for adnexal masses in
pregnancy.
Magnetic resonance imaging (MRI) is another imaging
modality that has been used to assist in the characteriza-
tion of adnexal masses. In one published study, magnetic
resonance imaging (MRI) was used in the differentiation
between solid ovarian masses and leiomyoma.17 More
information and studies on the benefits of MRI are
needed before its routine use in the work-p of pregnancy-
associated adnexal masses.
In summation, we found a much higher than expected
malignancy rate. We postulate that as a regional center,
our malignancy rate is higher because lesions that are
smaller or more benign appearing are managed by private
practitioners and not referred. Importantly, the size of the
ovarian mass diagnosed in pregnancy was not absolutely
predictive of malignancy. However, all masses less than
6 cm were noted to be benign. Morphologic study, as
characterized by ultrasonography, detected internal
papillary excrescences in 50% of malignancies in our
series. Neonatal outcome was not adversely affected in
either elective cases or our only emergency surgery.
Our data support that of other published studies, to
manage masses conservatively, performing surgery in the
second trimester. We conclude that patients with persis-
tent adnexal masses greater than 6 cm should undergo
surgical removal, be appropriately counseled as to the
possibility of an underlying malignancy, and be prepared
for possible ovarian cancer staging.
362 Sherard et al
REFERENCES
1. Nelson MJ, Cavalieri R, Sanders RC. Cysts in pregnancy discovered by
sonography. J Clin Ultrasound 1986;14:509-12.
2. Hess LW, Peaceman A, OBrien WF, Winkel CA, Cruikshank DP,
Morrison JC. Adnexal mass occurring with intrauterine pregnancy:
report of fifty-four patients requiring laparotomy for definitive
management. Am J Obstet Gynecol 1988;158:1029-34.
3. Liu JR, Lilja JF, Johnston C. Adnexal masses and ovarian cancer in
pregnancy. In: Trimble EL, Trimble CL, editors. Cancer obstetrics
and gynecology. Philadelphia: Lippincott-Williams & Wilkins; 1999.
p. 239-48.
4. Grimes WH, Bartholomew RA, Colvin ED, Fish JS, Lester WM. Ovarian
cyst complicating pregnancy. Am J Obstet Gynecol 1954;68:594-603.
5. Hogston P, Lilford RJ. Ultrasound study of ovarian cysts in
pregnancy: prevalence and significance. BJOG 1986;93:625-8.
6. Thornton JG, Wells M. Ovarian cysts in pregnancy: does ultrasound
make traditional management inappropriate. Obstet Gynecol
1987;69:717-21.
7. Novak ER, Lambrou CD, Woodruff JD. Ovarian tumors in pregnancy:
an ovarian tumor registry review. Obstet Gynecol 1975;46:401-6.
8. Peterson WF, Prevost EC, Edmunds FT, Hundley JM, Morris FK. Benign
cystic teratomas of the ovary. Am J Obstet Gynecol 1955;70:368-82.
9. Caspi B, Levi R, Appelman Z, Rabinerson D, Goldman G, Hagay Z.
Conservative management of ovarian cystic teratoma during preg-
nancy and labor. Am J Obstet Gynecol 2000;182:503-5.
10. Platelek DN, Henderson CE, Goldberg GL. The management of
a persistent adnexal mass in pregnancy. Am J Obstet Gynecol
1995;173:1236-40.
11. Ovarian Tumor Panel of the Royal College of Obstetricians and
Gynecologists. Ovarian epithelial tumours of borderline malignancy:
pathological features and current status. BJOG 1983;90:743-50.
12. 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;33:326-31.
13. Droegemueller W. Benign gynecological lesions. In: Mishell DR,
Stenchever MA, Droegemueller W, Herbst AL, editors. Comprehen-
sive gynecology. 3rd ed. St. Louis: Mosby; 1997. p. 467-516.
14. Lerner JP, Timor-Tritsch IE, Federman A, Abramovich G. Transvaginal
ultrasonographic characterization of ovarian masses with an im-
proved, weighted scoring system. Am J Obstet Gynecol 1994;170:81-5.
15. Benacerraf BR, Finkler NJ, Wojciechowski C, Knapp RC. Sonographic
accuracy in the diagnosis of ovarian masses. J Reprod Med
1990;35:491-5.
16. Fleischer AC, Kepple DM. Color Doppler sonography of pelvic
masses. In: Fleischer AC, Manning FA, Jeanty P, Romero R, editors.
Sonography in obstetrics and gynecology. 6th ed. New York: McGraw-
Hill; 2001. p. 913-47.
17. Curtis M, Hopkins MP, Zarlingo T, Martino C, Graciansky-Lengyl M,
Jenison EL. Magnetic resonance imaging to avoid laparotomy in
pregnancy. Obstet Gynecol 1993;82:833-6.
Discussion
DR JERRY F. MATKINS JR, Gastonia, NC. The detection
of adnexal masses in pregnancy has become increasingly
more common, and therefore the dilemma of how to
manage these patients has become one that is faced more
frequently. In the era before ultrasound, when palpation
was relied on to diagnose adnexal masses, the detection
rate was reported to be 1 in 591 pregnancies.1 By 1986, as
ultrasound became more commonly used, the reported
incidence of adnexal masses in pregnancy was 1 in 190.2
Because ultrasound has become more precise over the
past 15 years, that detection rate has climbed to as high as
one mass detected in every 50 pregnancies.3 Certainly all
of these lesions are not clinically significant, so we cannot
say with assurance that our increased technologic
capabilities have resulted in better management of
patients. In fact, we may have only succeeded in raising
August 2003
Am J Obstet Gynecol
anxiety levels. It is in addressing the question of whether
what we can now detect is truly significant, and if so when,
that studies such as Dr Sherards are helpful.
The authors retrospectively reviewed the charts of all
patients who had pregnancy-associated adnexal masses
surgically removed at their institution over a 12-year
period. They found the incidence of surgical resection of
an adnexal mass in pregnancy to be 1 in 632 pregnancies.
This number is within the range of previously published
reports, which vary widely. They found a low rate of
complications associated with surgical excision of these
masses in either the immediate postoperative period or in
the remainder of the patients antepartum courses. In only
one case was surgery performed on an emergency basis as
a result of adnexal torsion. Interestingly, they found
a malignancy rate of 13%. This rate of ovarian cancer is
twice the highest previously reported rate of 6%.4 Half of
the cancerous masses were of low malignant potential.
Both surgical resection of adnexal masses in pregnancy
and expectant management of such masses carry with
them their own set of problems. The risks of expectant,
watchful management are 2-fold. First, there is the risk of
torsion or rupture necessitating emergency intervention.
Hess et al5 reported an increased risk of adverse
pregnancy outcomes40% spontaneous miscarriage or
preterm birthassociated with emergency surgery for
adnexal masses in pregnancy. Whitecar et al4 reported
a risk of poor perinatal outcomes greater than 50%
associated with laparotomy after 23 weeks gestationan
event that becomes more likely if expectant management
is persued. Second, there is a risk of delayed diagnosis
of malignancy. Ovarian cancer is the second most com-
mon gynecologic cancer diagnosed during pregnancy.
Fortunately, ovarian malignancy is rare in pregnancy,
reflecting the overall low rate of ovarian cancer in women
of childbearing age. It is not surprising that ovarian
cancers diagnosed in pregnancy are most commonly of
low malignant potential or of germ cell origin because
these match the prevalence of these tumors in similarly
aged nonpregnant patients.6 However, such reassuring
statistics may not be so comforting to patients who are told
that they may have an ovarian malignancy. Attempts have
been made to use noninvasive or minimally invasive
techniques to differentiate benign and malignant lesions.
Magnetic resonance imaging, color Doppler ultrasound,
and aspiration cytology, while sometimes helpful in
specific cases, have all been disappointing in providing
adequate predictive power on which to base management
decisions.7,8
The risks of active management of pregnancy-associ-
ated adnexal masses lie in the risk of surgical exploration
itself. Although laparotomy or laparoscopy in a nonemer-
gency setting has been shown to be fraught with fewer
complications than emergency procedures or those in the
second or third trimesters, adverse outcomes are not
unknown in these patients.4,5
As clinicians, many if not all of us have been faced with
this dilemma. Patients and their spouses are often equally
afraid of the consequences of aggressive and conservative