Pelvic masses that may present in pregnancy (© 2016 Elsevier Inc. All rights reserved. www.netterimages.com. Used with permission)
Para-ovarian cysts are often identified during routine obstetrical sonographic evaluations (© 2016 Elsevier Inc. All rights reserved. www.netterimages.com. Used with permission)
Due to the quantitative increase in many tumor markers in normal pregnancy, such as human chorionic gonadotropin hormone, CA-125, and alpha-fetoprotein, these markers are not considered reliable for diagnosis or followed up in pregnancy unless significant elevations are found. Also, one must be aware that certain conditions in pregnancy may render the finding of even significant elevations not useful, such as in cases of fetal aneuploidy, open neural tube defects, or preeclampsia . One tumor marker, human epididymis protein 4 (HE-4), appears to be unaffected by pregnancy . It is currently used for treatment follow-up rather than screening of ovarian cancer . However, note that the baseline normal reference values are changed in pregnancy .
The diagnosis of ovarian torsion is made clinically and aided with Doppler ultrasound. Sonographic detection rates vary in different studies from 46% to 74% [10, 11]. A high index of suspicion is necessary for diagnosis of ovarian torsion in pregnant women as well as in nonpregnant women. Torsion should be suspected in all patients with an acute onset of severe pelvic or abdominal pain, which may be accompanied by fever or nausea, especially in the setting of an adnexal mass in the first or second trimester (see Fig. 7.3).
The definitive management of adnexal masses is surgery. However, because of the low likelihood of malignancy and acute complications associated with surgery during pregnancy, the risks of surgery frequently outweigh the benefits. Therefore, most adnexal masses in pregnancy can be managed expectantly and observed through the postpartum period. With the appropriate patient selection, adverse outcomes are not increased with conservative management . Treatment should be tailored to the nature, symptoms, and clinical suspicion of the mass. Should there be a need for surgical excision, a minimally invasive approach in the early second trimester (around 14–16 weeks’ gestation) will minimize the risks of preterm labor or loss of the pregnancy.
Indications for surgery include suspicion for ovarian torsion or malignancy as suggested by history, physical examination, or sonographic features. Laparoscopic versus laparotomy approach should be individualized depending on size of mass, gestational age, suspected malignancy, and expertise of the surgeon. More extensive surgery may be indicated for ovarian malignancies. The extent of the surgery must be tailored to the clinical situation such as gestational age, desire for retention of the pregnancy, future fertility, histologic cell type, and extent of the disease. Some settings may be managed via minimally invasive surgery, while others might require a vertical skin incision, surgical staging, and cytoreduction .
The management of ovarian torsion is similar as that in nonpregnant patients, consisting of laparoscopic detorsion with or without ovarian cystectomy or oophorectomy. During the third trimester, the size of the gravid uterus may preclude a minimally invasive approach.
Ovarian cyst rupture is usually a self-limited event. However, significant hemoperitoneum leading to hemodynamic instability requires surgical exploration and source control of the bleeding.
Generally, a vaginal delivery is not contraindicated unless the mass is fixed in the pelvis resulting in pelvic outlet obstruction. Cesarean delivery should be reserved for appropriate obstetrical indications. If a conservative approach is chosen, follow-up is appropriate 6–12 weeks after delivery, which coincides with return to pre-pregnancy physiology and resolution of most functional masses.
Uterine Fibroids in Pregnancy
Uterine fibroids, or leiomyomata , are benign smooth muscle tumors of the uterus (see Figs. 7.4, 7.5, and 7.6). The prevalence of fibroids in pregnancy has been sited to be anywhere between 1.6% and 10% [14–16]. Fibroids are mainly asymptomatic and usually discovered during routine fetal ultrasound. Most fibroids will remain stable in size throughout pregnancy, while about 25% will increase and 10% will decrease in size. Enlargement occurs most commonly in the first trimester, with an average increase of approximately 12% [17, 18].
Types of uterine leiomyomata (© 2016 Elsevier Inc. All rights reserved. www.netterimages.com. Used with permission)
Consequences of uterine leiomyomata (© 2016 Elsevier Inc. All rights reserved. www.netterimages.com. Used with permission)
Most fibroids are asymptomatic. Gravid patients may present with pelvic pain, pressure, or vaginal bleeding. Acute abdominal pain can occur in rare situations, namely, carneous degeneration, torsion, or prolapse through the cervix.
Degeneration occurs as a result of rapid growth of the fibroid subsequently outgrowing its blood supply, leading to ischemia and prostaglandin release, producing significant pain . Other signs and symptoms may include low-grade fever, tenderness to palpation, or peritoneal signs. Torsion presents the same way, and should be suspected in the setting of a pedunculated or subserosal fibroid.
Studies regarding the increased predisposition to placental abruption are inconsistent. Regardless, abruption may cause significant pain and should be ruled out .
Ultrasound is usually sufficient to establish the presence of fibroids. Important characteristics to note are anatomic location, size, number, and blood supply. Torsion can be identified in pedunculated fibroids using Doppler sonography of the stalk, although this is not always possible . Pelvic magnetic resonance imaging (MRI) without contrast can also aid in diagnosis if it is unclear. Note that gadolinium has been shown to be teratogenic in animal studies, thus it is considered contraindicated in pregnancy unless absolutely necessary .
Although we recommend ultrasound or MRI for detecting fibroids, there is no imaging modality that is perfectly sensitive or specific for detecting complications of fibroids such as degeneration or torsion, and diagnosis therefore must rely on a thorough history and physical examination. In rare select cases, a diagnostic laparoscopy or laparotomy may be necessary.
Pain from degeneration of fibroids can be managed conservatively with oral analgesics, such as acetaminophen, a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or indomethacin prior to 32 weeks, or opioid analgesia. Adverse fetal effects of NSAIDs when given after 32 weeks’ gestation include premature closure of the ductus arteriosus, neonatal pulmonary hypertension, oligohydramnios, and fetal or neonatal platelet dysfunction and are best avoided . Prior to 32 weeks’ gestation, we suggest indomethacin dosing of 25 mg every 6 h for 48 h. Repeat courses can be administered as needed. Admission may be required for parenteral pain control.
Excision of a fibroid prolapsed into the vagina should only be performed in case of significant symptoms such as severe pain or bleeding, as intervention can lead to significant hemorrhage, rupture of membranes, and even fetal loss [24, 25]. In these cases, careful preoperative planning is crucial. Imaging to delineate the origin of fibroid, adequate anesthesia, and a blood type and cross-match should be available.
Torsion of a pedunculated fibroid is exceedingly rare. In a symptomatic patient, management of torsion is surgical. A laparoscopic approach is preferable if feasible, and it can be both diagnostic and therapeutic. In these cases, we recommend a myomectomy be carried out as detorsion is not usually sufficient .
Obstetrical complications of fibroids include spontaneous abortion, preterm delivery, fetal growth restriction, fetal malpresentation, and abnormal placentation (placenta previa or placental abruption) [20, 27–29]. In addition to counseling and routine prenatal care, there are no specific recommendations regarding follow-up of these patients. We recommend preemptive serial fetal growth ultrasounds in case of substantial fibroids that interfere with fundal height measurements. Neonatal outcomes are excellent overall. Poor outcomes are mainly related to prematurity.
Patients with fibroids are at increased risk for pre-labor cesarean delivery. Common reasons for cesarean delivery include fetal malpresentation, abnormal placentation, and presence of fibroid in the lower uterine segment. However, even after adjusting for the aforementioned factors, these patients still had a higher rate of cesarean delivery . Gravid women with fibroids of any size may undergo a vaginal delivery, and cesarean delivery should be reserved for appropriate obstetrical indications. Patients should also be reassured that their likelihood of a successful vaginal delivery does not differ from that of the general population.
Endometriosis (see Fig. 7.7)
The state of pregnancy will often improve or eliminate endometriosis lesions as well as their associated symptoms. This is attributed to the altered hormonal environment of pregnancy that results in decidualization of the endometriotic lesions . The decidualized lesions, however, may still be biologically active and produce symptoms and complications. There are reports in the literature that describe intestinal perforation  hemoperitoneum [33–35], uroperitoneum [36, 37], acute appendicitis [38, 39], and ruptured or infected ovarian endometrioma .
Endometriosis-induced complications that occur in pregnancy, albeit rare, may be associated with the expanding uterus putting traction on adhesions, increased friability of inflamed tissues, and alteration of vessel walls by decidualized lesions .
The rarity of these complications in pregnancy does not warrant additional monitoring or interventions in gravid women with an endometriosis history.
A retrospective populations-based study of more than 82,000 singleton pregnancies demonstrates a negative impact on pregnancy outcome in women with endometriosis. These adverse effects include an increased risk of preterm birth, preeclampsia, and abdominal delivery when compared to gravidas without endometriosis . Other studies have shown that endometriosis is associated with an increased risk of spontaneous abortion, ectopic pregnancy, placenta previa, unexplained antepartum hemorrhage, postpartum hemorrhage, and preterm delivery when compared with unaffected women .
Ovarian Malignancy in Pregnancy
The incidence of ovarian malignancy during pregnancy is generally lower than that of the general population, mainly because pregnancy occurs in a younger population . Currently, the most common ovarian malignancy in pregnancy is germ cell tumors, and up to 30% of all ovarian malignancies are dysgerminomas.
Presentation for ovarian malignancy is generally similar to that of all adnexal masses with some exceptions. Sex cord-stromal tumors, although rare in pregnancy, can lead to evidence of hormonal excess (hyperestrogenism or virilization). Advanced stage ovarian malignancy may lead to small bowel obstruction.
When ovarian malignancy is suspected, the patient should be immediately referred to a gynecologic oncologist. Ovarian cancer , like most gynecologic malignancies, is surgically staged. During pregnancy, if discovered in the first trimester, the best time for surgery is after 8-10 weeks, when placental function is established and the corpus luteum has involuted, should there be a need for an oophorectomy. Surgical staging during pregnancy usually entails a unilateral salpingo-oophorectomy, omentectomy, peritoneal biopsies, lymphadenectomy, and peritoneal washings. More comprehensive staging will include the aforementioned in addition to a total abdominal hysterectomy and bilateral salpingo-oophorectomy. If the contralateral ovary appears normal, there is no need for ovarian biopsies or resection on that side. If discovered in the third trimester, more complete staging can be completed at the time of cesarean or after delivery. Decisions regarding timing and choice of surgery as well as need for adjuvant or neoadjuvant chemotherapy are made in consultation with a gynecologic oncologist. Note that pregnancy is not a contraindication to most chemotherapeutic agents, especially after the first trimester.
Prognosis mainly depends on the stage of the disease at the time of diagnosis and histologic tumor type, and is similar to that in nonpregnant patients.
Timing of delivery should be individualized. Things to consider are the stage and type of cancer, timing in pregnancy, and patient wishes regarding treatment and continuation of pregnancy especially before viability.
Cervical Intraepithelial Neoplasia and Cervical Cancer
Although cervical cancer is the leading cause of gynecologic malignancy worldwide, it is rather uncommon in the developed world due to the Papanicolaou (Pap) smear . Cervical dysplasia, otherwise known as cervical intraepithelial neoplasia (CIN), is a pre-cancerous lesion that is not infrequently diagnosed, especially in pregnancy when women tend to have the most consistent medical care.
CIN is usually asymptomatic , but may present with abnormal vaginal or postcoital bleeding. Cervical malignancy is a rare cause of pain. However, advanced disease with local invasion can lead to pelvic or lower back pain or pressure .
Diagnosis is first suspected with a Pap smear and confirmed by directed colposcopic biopsies.
For cervical dysplasia found on Pap smear, we recommend following the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines . This generally leads to observation without therapy, which is appropriate for pregnant women with cervical dysplasia if invasive cervical cancer has been excluded by colposcopy with or without biopsies. Of note, endocervical curettage is contraindicated in pregnancy, although the evidence that it adversely affects pregnancy is poor .
Cervical cancer is the only gynecologic cancer that is clinically staged. Staging in the nonpregnant woman includes physical examination and imaging, which consists of chest and skeletal radiographs, intravenous pyelogram, and barium enema. Other imaging studies may not be used for staging purposes. However, there are limited recommendations for staging in the pregnant woman, and it should be individualized . Magnetic resonance imaging (MRI) and ultrasound may need to be used in this situation to plan management approach and can be repeated during pregnancy if necessary (see Table 7.1).
FIGO staging of cervical cancer 
Cervical carcinoma confined to the cervix
Invasive carcinoma diagnosed only by microscopy; stromal invasion with a maximum depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less; vascular space involvement, venous or lymphatic, does not affect classification
Measured stromal invasion ≤3.0 mm in depth and ≤7.0 mm in horizontal spread
Measured stromal invasion >3.0 mm and ≤5.0 mm with a horizontal spread ≤7.0 mm
Clinically visible lesion confined to the cervix or microscopic lesion greater than IA2
Clinically visible lesion ≤4.0 cm in greatest dimension
Clinically visible lesion >4.0 cm in greatest dimension
Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina
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