Differences Between Adnexal Torsion in Pregnant and Nonpregnant Women

Study ObjectiveTo compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women.DesignRetrospective case-control study (Canadian Task Force classification II-3).SettingTertiary care university hospital.PatientsSixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion.InterventionsSurgery to treat proved adnexal torsion.Measurements and Main ResultsThe mean (SD) gestational age in the pregnant group was 11.5 (7.7) weeks. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Sonographic demonstration of multicystic ovaries was more common in pregnant women with recurrent torsion than in women with a single episode of torsion (86% vs 31%; p = .009). Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001).ConclusionPregnancy after treatment for infertility is a risk factor for adnexal torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries.     

Adnexal Torsion in Pregnancy Managed by Laparoscopy Is Associated with Favorable Obstetric Outcomes

Study ObjectiveMost cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and preterm delivery. We sought to evaluate the obstetric outcomes of these women, with emphasis on their live birth rate and gestational age at delivery.DesignRetrospective cohort study and telephone questionnaire.SettingUniversity-affiliated obstetrics and gynecology department.PatientsAll pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetric outcomes were obtained by retrospective review of medical records and a telephone questionnaire.InterventionsLaparoscopy for adnexal detorsion, with or without cyst drainage or cystectomy.Measurements and Main ResultsThe study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, whereas 21 (22.3%) cases and 2 (2.1%) cases were diagnosed in the second and third trimesters, respectively. Conception was achieved by in vitro fertilization or by ovulation induction in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies, while 6 (6.5%) women had a spontaneous abortion, and 1 woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Preterm delivery before 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p = .002) and with conception following in vitro fertilization and ovulation induction (p = .03). On logistic regression analysis, preterm delivery was only associated with twin vs singleton gestation (odds ratio, 6.7; 95% confidence interval, 1.3–34.8; p = .02).ConclusionThe obstetric outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery, which is primarily associated with multiple gestations.     

Recurrent Ovarian Torsion: Risk Factors and Predictors for Outcome of Oophoropexy

Study ObjectiveTo identify risk factors for recurrent ovarian torsion and evaluation of the efficacy of oophoropexy techniques.DesignCase control study.SettingTertiary university-affiliated medical center.PatientsA total of 79 women with recurrent ovarian torsion (study group) were matched with 158 women with a single episode of ovarian torsion (control group).InterventionsLaparoscopic detorsion and oophoropexy.Measurements and Main ResultsDemographic data, clinical characteristics, ultrasound characteristics, surgical findings, surgical procedures, and torsion recurrence rates were analyzed and compared between the 2 groups between 2001 to 2020.ResultsThere was an inverse association between women's age and the risk of recurrent torsion (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.83–0.96, p = .003). Moreover, in women younger than 20 years, the risk of recurrent event was substantially higher (aOR, 5.0; 95% CI, 1.56–6.15, p = .007). In addition, the absence of ovarian pathology was associated with increased risk for recurrent torsion (aOR, 14.3; 95% CI, 6.15–33.42; p <.001). Oophoropexy was performed in 46 women in the study group. The risk of recurrent torsion after oophoropexy was 30%. A long duration of pain before admission was associated with oophoropexy failure (37.5 ± 6.3 hours vs 11.7 ± 6.0 hours, p = .003). No single fixation procedure was superior to the others in terms of therapeutic success.ConclusionRecurrent ovarian torsion is more common in young women with a normal-appearing ovary. Oophoropexy is a safe procedure with a risk of retorsion in 30% of the patients. We found no advantage for one fixation technique over the others.     

Laparoendoscopic single-site surgery for acute adnexal pathology during pregnancy: preliminary experience

Abstract

Objective: To report the feasibility of laparoendoscopic single port surgical approach for the management of huge adnexal cysts and adnexal torsion during pregnancy. To discuss the optimal method of entry into the peritoneal cavity for pregnant patients.

Design: Two case report.

Method and patient(s): Two pregnant patients with adnexal mass. First patient, suffering from persistent and progressive abdominal distention and pain on her 12th week of pregnancy, was diagnosed with an ovarian cyst in 18?cm diameter on left ovary. The other patient had IVF twin pregnancy and presented with left adnexal torsion on the 25th week of pregnancy

Intervention(s): Single-port laparoscopic ovarian cystectomy on the 12th week of pregnancy in patient one and single-port left adnexectomy in a twin pregnancy on the 25th week of pregnancy in patient two.

Main outcome measure(s): Feasibility of single port laparoscopic intervention during pregnancy for adnexal mass.

Result(s): Complete resolution of the symptoms for both pregnant women after the surgeries. No fetal and maternal complication was diagnosed during both pregnancies.

Conclusion(s): Single port laparoscopy with open-entry technique is feasible and might be a better surgical option for the pregnant patients with adnexal pathology. However, further studies with larger sample size are needed to reach clear conclusion.     

Isolated Fallopian Tube Torsion: An Underdiagnosed Entity with Debatable Management

Study ObjectiveTo study features of isolated fallopian tube torsion (IFTT) to promote early diagnosis of this entity and describe options for management.DesignRetrospective cohort study from October 2017 through October 2020.SettingTertiary care hospital.PatientsAll patients with surgically confirmed adnexal torsion or IFTT during the study period.InterventionsAll of the patients underwent gynecological examination, imaging, and laparoscopy.Measurements and Main ResultsDuring this 3-year period, 64 patients underwent laparoscopy owing to confirmed torsion, of which 55 had adnexal torsion, and 9 had IFTT. Patients with IFTT tended to be younger (21.2 years ± 8.2 vs 29.1 years ± 11.9, p = .06) and had more fever on admission (p = .007). On ultrasound examination, isolated hydrosalpinx was demonstrated only in patients with IFTT (p <.001). During surgery, more para-ovarian cysts were observed in patients with IFTT (44.4% vs 10.9%, p = .01), whereas patients with adnexal torsion had more ovarian cysts (52.7% vs 0%, p = .003). The most common procedure was detorsion in both groups. Most patients that underwent detorsion of the tube had a normal ultrasound scan on follow-up examination.ConclusionIFTT is probably underdiagnosed. Its clinical presentation is more equivocal than adnexal torsion, and ovaries are usually of normal size on ultrasonography. Hydrosalpinx or para-ovarian cysts should raise suspicion toward IFTT. Detorsion of the tube is probably a valid management option, although further research with long-term follow-up analyzing tubal patency is necessary to define the optimal management for this condition.     

Pelvic retroperitoneal cyst during pregnancy

ObjectiveThe diagnosis and treatment of adnexal mass during pregnancy is a major challenge for obstetricians. A rare case is reported of retroperitoneal cystic lesion during pregnancy.Case ReportA 31-year-old woman was diagnosed with an adnexal cystic lesion at 8 weeks of gestation and underwent laparoscopic surgery at 14 weeks of gestation. During laparoscopic surgery, the bilateral ovaries and tubes were normal, but the lesion was located on the right-side retroperitoneal area. Aspiration and enucleation were performed successfully by laparoscopy. The pathology report revealed mucinous cystadenoma. The patient had a smooth pregnancy course and delivered a healthy baby at 39 weeks of gestation.ConclusionLaparoscopic surgery is a safe procedure in the management of pregnant women with suspicious adnexal cystic lesions.     

Surgical intervention for maternal ovarian torsion in pregnancy

ObjectiveMaternal ovarian torsion in pregnancy is a rare complication. This study was conducted to review the clinical manifestations, and to compare the outcome between laparoscopy and laparotomy in women undergoing surgery for ovarian torsion (OT) during pregnancy.Materials and MethodsUsing the International Classification of Disease, Ninth Revision, and Clinical Modification, we reviewed the clinical records of patients with OT during pregnancy between 1997 and 2008 at a university hospital.ResultsTwenty pregnant women were identified with surgically proven OT, 10 in the first trimester, eight in the second, and two in the third. Thirteen (65%) cases were suspected before operation to be adnexal torsion. The most common symptom and sign were pelvic pain (95%) and an adnexal or pelvic mass (95%), followed by nausea and vomiting (65%), elevated white blood cell count >12 × 10⁹/L (45%), and fever (10%). Most patients in the first trimester (75%) and a minority in the second and third trimesters (37.5%) received management via laparoscopy. Patients undergoing laparoscopy treatment had smaller ovarian masses and a shorter postoperative hospital stay than those receiving laparotomy. None of these patients had significant complications during or after surgery. However, the outcomes of pregnancy varied: 12 (60%) term deliveries, three (15%) preterm deliveries at over 31 gestational weeks, one missed abortion and four elective abortions in the first trimester.ConclusionThe diagnosis of OT during pregnancy is often missed due to nonspecific clinical features and uncommon objective findings. Detorsion only or detorsion plus ancillary procedures via laparoscopy is recommended to treat pregnant women suffering from OT, owing to the advantages of a shorter hospital stay and favorable surgical and pregnancy outcomes.     

Hyperreactio luteinalis mimicking malignancy during pregnancy with elevated CA-125

ObjectiveTo report a case with benign bilateral ovarian tumor during pregnancy mimicking malignancy.Case reportA 32-year-old women at 20 weeks gestation with large bilateral adnexal masses found on prenatal ultrasound. The cysts had been growing gradually over the course of the pregnancy. MRI show huge multiple cysts in both ovaries. CA-125 was elevated at 260 U/mL. Due to initial impression was malignancy, an excisional surgery was done. Pathology revealed multiple luteinized granulosa cells with benign nature.ConclusionHyperreactio luteinalis (HL) is often asymptomatic and discovered incidentally on ultrasound or at the time of cesarean section. As the lesions are self-resolving, management is conservative and surgical intervention is required only in cases with severe complications. HL can be mistaken for malignancy, especially in cases in which the tumor marker CA-125 is elevated, leading to inadvertent surgery.     

Adnexal Torsion in Postmenopausal Women: Clinical Presentation and Risk of Ovarian Malignancy

Study ObjectiveTo investigate the clinical presentation, operative outcome, and incidence of malignancy in postmenopausal women who were diagnosed with adnexal torsion.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary university-affiliated hospital.PatientsPostmenopausal women diagnosed with adnexal torsion between 1995 and 2014 (study group) were reviewed and compared with 220 premenopausal patients diagnosed with adnexal torsion during the same time period.InterventionDemographic data, clinical signs and symptoms, and intra- and postoperative characteristics were compared between the 2 groups.Measurements and Main ResultsDuring the study period 44 postmenopausal women were diagnosed with adnexal torsion. Continuous dull pain was the most common presenting symptom in the postmenopausal group (57%), whereas acute-onset sharp pain was the predominant symptom in the premenopausal group (86%). The time interval from admission to surgery was significantly longer in the postmenopausal group (24 vs 6 hours, p < .001). Laparoscopic surgery was performed in 84.5% of the cases in the premenopausal group, whereas it was carried out in only 50% of cases in the postmenopausal group (p < .001). Four women in the postmenopausal group were diagnosed with malignancy, whereas only 1 case of malignancy was found in the premenopausal group (9% vs .4%, respectively; p = .003).ConclusionsAdnexal torsion in postmenopausal women is an uncommon event with a unique presentation. Because ovarian malignancy is not an uncommon finding in this group of patients, preparation for more extensive surgery should be contemplated.     

“Habitual Adnexal Torsions”—Recurrence after Two Oophoropexies in a Prepubertal Girl: A Case Report and Review of the Literature

BackgroundRecurrent adnexal torsion rarely affects girls. Various surgical techniques for its prevention are available. We describe a case of recurrent asynchronous bilateral torsions in a prepubertal patient.CaseAn 8-year-old girl first presented with a right adnexal torsion and underwent a laparoscopic untwisting. During the following 3 years, 4 additional laparoscopies were required for treatment of left adnexal torsions. Although undergoing bilateral utero-ovarian ligament plication twice, torsion recurred. After examining the various options, we fixated the left ovary to the sidewall just below the pelvic brim.Summary and ConclusionIn the absence of clear evidence, treatment should be flexible and dependent on the individual case. Thorough patient education is imperative in order to prevent a delay in diagnosis and treatment of recurrent adnexal torsion.     

Anti-annexin as a marker in patients with recurrent miscarriages

ObjectiveTo investigate the possible role of anti-annexin A5 antibodies in inducing recurrent miscarriage.DesignCross-sectional study.SettingBenha University Hospital.Participants and interventionsPregnant women during the first trimester of pregnancy with a history of three or more consecutive pregnancy losses were compared to Multigravidae women during the first trimester of pregnancy with no history of pregnancy losses for group II. Women were screened for anti-annexin A5 antibodies.ResultsThere were no statistically significant correlations between anti-annexin A5 antibodies in both groups (P>0.05).ConclusionThe present study did not confirm that anti-annexin A5 antibodies have significance in predicting RM when measured in healthy women.     

Pregnant Women’s Knowledge of Influenza and the Use and Safety of the Influenza Vaccine During Pregnancy

IntroductionWe wished to assess pregnant women’s knowledge of influenza, vaccine safety during pregnancy and breast feeding, and the recommendations for use of the influenza vaccine in pregnancy.MethodsWe performed a cross-sectional survey of postpartum women during influenza season in 2006.ResultsPregnant women’s overall knowledge of these subjects was poor. Most women (95%) knew that influenza is highly contagious, but almost 90% incorrectly believed that pregnant women have the same risk of complications as non-pregnant women. Only one half of the women were aware of national recommendations for vaccination during pregnancy and that the vaccine is safe during pregnancy and breast feeding, and 80% incorrectly believed that the vaccine can cause birth defects. Only 20% of women had been offered the vaccine during the current pregnancy or a prior pregnancy.ConclusionsPregnant women’s knowledge about influenza vaccine recommendations and safety during pregnancy is poor. There is substantial room for improvement among prenatal care providers in both patient education and offering the vaccine.     

Adnexal torsion in the first trimester of pregnancy: A case report

Adnexal torsion is a rare cause of acute abdominal pain during pregnancy. It is frequently associated with ovarian stimulation for in vitro fertilization (IVF) or with ovarian masses, mainly of functional origin. It is uncommon for a normal-sized ovary to undergo torsion. Torsion of the ovary during pregnancy is common during third trimester. Adnexal torsion is rarely bilateral and is more common on the right side, perhaps because the sigmoid colon leaves a limited space for left adnexal mobility. Here we report a case of 23-year-old primigravida with 8 weeks pregnancy presented with sever left abdominal pain. Left abdominal tenderness was detected. Transabdominal ultrasound scan reported left adnexal torsion. Laparotomy and then left salpingo-oophorectomy were performed.     

Oophoropexy to Prevent Adnexal Torsion: How,When, and for Whom?

Study ObjectiveTo assess the efficacy of oophoropexy in obviating recurrent torsion and its possible long-term effects.DesignCase series and review of the literature (Canadian Task Force classification III).SettingUniversity hospital.PatientsWomen who underwent oophoropexy for recurrent torsion of normal adnexa between 2003 and 2008.Measurements and Main ResultsRetrieved information included the indication for oophoropexy, surgical methods, recurrence, and follow-up. Seven women underwent oophoropexy during the study period because of recurrent torsion of normal adnexa. One additional patient had experienced 3 torsion events of cystic adnexa. Surgical methods included suturing of the ovary to the pelvic sidewall or to the round ligament and plication of the utero-ovarian ligaments. Recurrence occurred in 1 of 6 patients for whom follow-up was available. All 6 patients reported spontaneous menstruation, and 2 conceived spontaneously and gave birth. Ultrasound at long-term follow-up (9–58 months) demonstrated normal ovaries.ConclusionOophoropexy seems to be efficacious in preventing recurrent torsion. It is our impression that plication of the utero-ovarian ligaments has advantages over other approaches insofar as surgical feasibility and anatomical conservation.     

Does she have adnexal torsion? Prediction of adnexal torsion in reproductive age women

Purpose

The aim of this study was to investigate the association of clinical, laboratory and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion.

Methods

The study included 199 reproductive age women > 16-year-old who underwent urgent laparoscopy for suspected adnexal torsion between January 2008 and December 2014. The association of various parameters with adnexal torsion was analyzed with a multivariate logistic regression analysis and described as odds ratios (OR) ± 95% confidence intervals (CI).

Results

Adnexal torsion was surgically diagnosed in 111/199 (55.8%) cases. On the multivariate logistic regression analysis, complaints of nausea/vomiting (OR 4.5, 95% CI 1.8–11.1), peritoneal irritation signs (OR 100.9, 95% CI 4.2–2421.9), elevated white blood cell count > 11,000 cells/mL (OR 3.7, 95% CI 1.3–10.8), presence of free pelvic fluid on ultrasound (OR 34.4, 95% CI 6.7–177.9), ultrasound findings suggestive of ovarian edema (OR 4.2, 95% CI 1.5–11.6), ultrasound findings suggestive of benign cystic teratoma (OR 7.8. 95% CI 1.2–49.4) and location of the ultrasound pathology on the right side (OR 4.7. 95% CI 1.9–11.9) were positively associated with adnexal torsion, while ultrasound findings suggestive of hemorrhagic corpus luteum cyst (OR 0.04, 95% CI 0.008–0.2) were negatively associated with adnexal torsion. By combining these eight parameters, the ROC curve was calculated, yielding an area under the curve of 0.93, 95% CI 0.90–0.97 (p < 0.0001).

Conclusion

Routine clinical, laboratory and grayscale ultrasound findings may be incorporated into the emergency room workup of women with suspected adnexal torsion. Laparoscopy should be considered in all patients with suspected adnexal torsion.

     

Recurrent Postmenopausal Bleeding: a Prospective Cohort Study

Study ObjectiveTo estimate the prevalence of genital tract diseases in women with initial and recurrent postmenopausal bleeding (PMB) to help inform diagnostic pathways.DesignProspective cohort study (Canadian Task Force classification: II-2).SettingLarge urban teaching hospital.PatientsOf 1938 consecutive women with postmenopausal bleeding, 106 (5%) were investigated for a recurrent episode after having normal findings of previous investigations.InterventionsAll women underwent pelvic examination and ultrasound scanning. An endometrial biopsy was performed when endometrial thickness was >4 mm in women with a first episode of PMB, with recourse to outpatient hysteroscopy after correlation between clinical and pathologic findings. All women with a recurrent PMB episode underwent endometrial biopsy and outpatient hysteroscopy.Measurements and Main ResultsThe risk of having endometrial cancer or hyperplasia with atypia was significantly less in women with recurrent PMB (9%) as compared with those with a first episode of PMB (8%) (p = .002), but were significantly more likely to have benign endometrial polyps (28%) compared with women with a first episode of PMB (19%) (relative risk, 1.47; 95% confidence interval, 1.07–2.02; p = .02).ConclusionRecurrent PMB results in less likelihood of premalignant and malignant endometrial disease; however, in 1 of 4 women PMB is caused by endometrial polyps. First-line investigation in women with recurrent PMB should be tests that have high accuracy for enabling diagnosis of focal diseases, such as outpatient hysteroscopy or saline infusion sonography.     

Safety and Feasibility of a Single-port Laparoscopic Adnexal Surgery During Pregnancy

Study ObjectiveTo evaluate the safety and feasibility of single-port laparoscopic adnexal surgery during pregnancy.DesignA retrospective study (Canadian Task Force Classification III).SettingA university hospital.PatientsA total of 14 women with intrauterine pregnancy who underwent single-port laparoscopic surgery (SPLS).InterventionWe retrospectively reviewed the medical records of 14 women with intrauterine pregnancy who underwent SPLS between November 2009 and September 2012 for the treatment of an adnexal mass.Measurements and Main ResultsFactors investigated included the duration of surgery, differences between preoperative and postoperative hemoglobin, the size of the mass as measured by ultrasonography, major intraoperative or postoperative complications, conversion to multiport laparoscopy, and pregnancy outcomes. Single-port laparoscopic adnexal surgery was successfully performed in all 14 pregnant patients with an adnexal mass. The median gestational age at operation was 9 weeks (range, 4 weeks–17 weeks 4 days). Procedures included ovarian cystectomy with or without detorsion (n = 9), cyst aspiration with detorsion (n = 2), salpingectomy (n = 2), and salpingostomy (n = 1). The median duration of surgery was 59 minutes (range, 36–84 minutes). No major intraoperative or postoperative complications were encountered, and there was no need for conversion to multiport laparoscopic surgery. Five women had spontaneous vaginal delivery, and 5 women underwent cesarean delivery at term. One woman had preterm delivery at a gestational age of 24 weeks 5 days. In 1 case, abortion occurred 2 weeks after the operation.ConclusionBased on these initial findings, SPLS appears to be a safe and technically feasible treatment for an adnexal mass during pregnancy.     

Interdisciplinary Care and a Focus on Fertility Preservation When Multi-cystic Ovaries Cause Ovarian Torsion: A Case of a 9-year-old Girl with Severe,Undiagnosed Hypothyroidism

BackgroundOvarian torsion can occur in Van Wyk Grumbach syndrome, a disorder characterized by severe primary hypothyroidism and ovarian enlargement. To date, all documented cases of torsion in this setting describe oophorectomy, which has significant hormonal and fertility implications.CaseA 9-year-old pubertal girl presented to the emergency room with abdominal pain. Magnetic resonance imaging demonstrated bilateral, multi-cystic ovaries. Operative laparoscopy confirmed unilateral adnexal torsion, and detorsion without oophorectomy was accomplished. Postoperative laboratory tests revealed severe primary hypothyroidism. Ovarian size was reduced with hormone replacement therapy.Summary and ConclusionThis case demonstrates that prompt interdisciplinary intervention and awareness of severe hypothyroidism as a cause of ovarian torsion related to enlarged, multi-cystic ovaries may reduce the rate of oophorectomy, allowing preservation of pediatric patients’ future fertility, and reducing morbidity postoperatively through prompt, long-term thyroid supplementation.     

Are Too Many Imaging Tests Being Performed in Women With an Adnexal Mass?

ObjectiveTo evaluate the patterns of radiologic imaging requested by family physicians and gynaecologists in the work-up of women found to have an adnexal mass on pelvic ultrasound, and to evaluate whether advanced imaging tests are associated with more appropriate referral of women with a high-risk adnexal mass to gynaecologic oncologists.MethodsCentralized provincial databases of health care usage were used to identify women aged 45 and older who had a pelvic ultrasound examination between 2006 and 2008 Subsequent imaging tests ordered were identified according to physician specialty For women who proceeded to laparotomy, logistic regression was performed to determine which imaging tests enabled primary physicians to make appropriate referrals of women with high risk adnexal tumours to a gynaecologic oncologist.ResultsWe identified 193 261 women aged 45 and older who had a pelvic ultrasound Of these, 19 949 (10 3%) had a subsequent laparotomy; 2223 women were categorized as having a benign adnexal mass, 627 were categorized as having a malignant adnexal mass, and the remainder had another diagnosis such as uterine fibroid. Up to 12% of women had a pelvic MRI, and 58% of women had a CT scan after a pelvic ultrasound Family physicians referred 95% of women with a high-risk ovarian mass to a gynaecologic surgeon rather than to a gynaecologic oncologist, and gynaecologists referred 47% of such women to a gynaecologic oncologist after imaging. Gynaecologic oncologists operated on 55% of women with a malignant adnexal mass On multivariate analysis, a preoperative CT scan (OR 3.58; P < 0.001) and a CT scan and MRI (OR 7.78; P < 0.001) were associated with surgery performed by a gynaecologic oncologist, but a preoperative MRI alone was not significantly associated (OR 1. 86; P = 0.09). After ultrasound alone the mean time to surgery was 100 days; this increased significantly when further imaging tests were performed (with additional CT to 131 days, with MRI to 170 days, and with CT and MRI to 179 days; P = 0.002).ConclusionPerforming a pelvic MRI after a pelvic ultrasound does not increase the rate of referral of women with a high-risk adnexal mass to a gynaecologic oncologist. A consensus on appropriate imaging and triage is needed when an adnexal mass is identified on ultrasound.     

The value of ultrasound visualization of the ovaries during the routine 11-14 weeks nuchal translucency scan

OBJECTIVE: To investigate the feasibility and possible value of routine screening for ovarian pathology in asymptomatic pregnant women at 11-14 weeks' gestation. STUDY DESIGN: A policy of routine ovarian visualization was implemented in 2925 pregnant women attending for a nuchal translucency scan at 11-14 weeks' gestation. In all cases, an attempt was made to visualize the ovaries on transabdominal ultrasound scan. Simple cysts were defined as unilocular cysts with regular internal walls and no solid components, which contained clear anechoic fluid. All other cysts were classified as complex. Simple cysts<5 cm in diameter were all managed expectantly with no further follow-up. All women with large simple cysts>or=5 cm in diameter or complex cysts had further detailed follow-up scans. Surgical intervention during pregnancy was offered to women with clinical symptoms suggestive of cyst complications or those with ultrasound features suggestive of malignancy. All other women were managed expectantly until after delivery. RESULTS: Adnexal cysts were found in 728/2925 (24.9%) pregnant women. 400/728 (55%) women had simple cysts<5 cm in diameter, whilst 328/728 (45%) women had large simple or complex cysts requiring follow-up. On subsequent scans, cysts resolved spontaneously in 278/328 (84.8%) women. A total of 33/728 (4.5%) women with ultrasound evidence of adnexal cyst underwent surgery. In one woman the intervention was required because of pain, one woman had suspected cancer on ultrasound scan and the remaining 31/33 (94%) of operations were performed at patients' requests. All the cysts were found to be benign on histological examination. The overall intervention rate was 1.1/100 screened pregnant women or 4.5/100 cysts detected on ultrasound scan. CONCLUSION: Asymptomatic adnexal cysts detected in the first trimester of pregnancy are unlikely to be malignant or to cause clinical symptoms antenatally. The policy of routine ultrasound visualization of the ovaries in pregnancy cannot be justified.