The l/Jurnal /Jf Repr/Jdu(;tive Medif:inelJ!>

Robert D. Moore, D.O., and W. Gary Smith, M.D.

were in the third trimester without complications at this

writing. There was one intrauterine fetal death at 31

weeks; it was found to be secondary to an acute cord ac-

cident on autopsy remotefrom surgery.

CONCLUSION: Significant ovarian masses are diag-

nosed relatively frequently in

the pregnant woman. TheLaparosconic

suroery with dia g nosis risk of ma!ig~ancy is l~w,r 0 but complications resulting

and removal of adnexal masses from distention, rupture

during pregnancy appears to be and/or tor~io~ of the adnexa

~ .bl d . I can be a sIgnificant concern.

,eas, e an carries very ow As laparoscopic procedures

morbidity. improve and our experience

with laparoscopy in the preg-

nant uloman increases, most

of these patients can forego laparotomy and be managed

safely by laparoscopic removal of the mass. This series

outlines laparoscopic technique and outcomt,'s after re-

moval of significant adnexal masses in pregnancy. a Re-

prod Med 1999;44:97-100)

OBJECTIVE: To report on 14 cases of adnexal masses inthe srcond trimester of pregnancy that were managedwith laparoscopic surgery.STUDY DESIGN: A retrospective study. During theprriod brtwren January 1994 and January 1998, 14womrn prrsented with ad-nexalmassrs in pregnancy r

and wrrr surgically managed jCwith laparoscopy. A retro- I

sprctivr chart review of thesepatients was used to deter- ,Imine factQrs, including grs- ..

tationat agr, Qperating time,

length of hospital stay, !pathology rrsults, pregnancy I ---outcomes and complications.RESULTS: Fourtrm patimts had laparoscopic removalof adnexal masses in their second trimester of pregnancy.Average gestational age was 16 'lveeks (range, 11.5-21),average operating timr was 84 minutes (range, 32-145),and average hospital stay was 2.0 days (range, 1-5).Pathology revealed 4 srrous cystadenomas, 3 mucinouscystadenomas, 3 mature teratomas, 3 functional cystsand 1 bilateral endometrioma. There were no postopera-tive complications except for one case of mild peritonitis,which rrsolved with expectant management. There wereno casrs of preterm labor associated with the surgery. Tenpregnancies continued to term without complicationsand delivrred averagr-sizrd infants. Three prrgnancies

Keywords: adnexal diseases; laparoscopic surgical

procedures; pregnancy complications, neoplastic.

Intr()duct;()n

The incidence of surgical exploration for adnexalmasses in pregnancy ranges from 1 :442 to 1: 1,300.1In 1994, Kohler researched the literature and found

From the Department of Obstetrics and Gynecology, Maine Medical Center, Portland, Maine.

Dr. Moore was Chief Resident, Department of Obstetrics and Gynecology, Maine Medical Center, and currently is Advanced PelvicSurgery Fellow, Southeastern Gynecologic Oncology Associates and Northside Hospital, Atlanta, Georgia.

Dr. Smith is Assistam Director, Division of Gynecologic Oncology.

Address reprint requests to: Robert D. Moore, D.O., Southeastern Gynecologic Oncology, 980 Johnson Ferry Road, Suite 900, Atlanta, GA30342.

Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.

0024-7758/99/4402-0097/$15.00/0 @ The Journal of Reproductive MedicineCB>, Inc.Journal of Reproductive Medjcine@ 97

The Journal of Reproductive Medicine'"

in the dorsal supine position with a leftward tilt torelieve pressure on the inferior vena cava and max-imize venous return. General endotracheal anesthe-sia was used in all patients and end tidal CO2 close-ly monitored. Fetal viability was confirmed bydoptone prior to and immediately following sur-gery. A CO2 pneumoperitoneum was obtained byopen placement of the operating trocar with directvisualization of the peritoneal cavity. A standardlO-mm open laparoscopy port was used in mostcases. In pregnancies that were more advanced inthe second trimester or patients who had sizegreater than dates secondary to a large adnexalmass, all ports were placed in a more cephalad po-sition in relation to the umbilicus. Lateral operatingports were placed under direct visualization. Peri-toneal washings were collected and stored for pos-sible future analysis. In most cases, the adnexalmass was found in the posterior cul-de-sac behindthe uterus. The mass was lifted into the abdomen bylaparoscopic probes and graspers, and based uponthe location and characteristics of the mass, an ovar-ian cystectomy or oophorectomy and/ or salpingec-tomy was completed and the specimen sent forfrozen section. In all cases uterine manipulationwas kept to a minimum and avoided totally if pos-sible. In cases of torsion, the adnexa were unwound,checked for viability, and cystectomy or oophorec-tomy completed. Postoperatively patients were ob-served closely for increased uterine activity. Rou-tine postoperative prophylactic tocolysis was notused.

that approximately 1 in 600 pregnancies are compli-cated by the presence of an adnexal mass.2 This fig-ure is probably conservative as these studies re-ported mostly masses that had become symp-

There were no major complicationsin the mother or fetus.

ResultsPatients in the study group (Table I) had an averageage of 28.1 years (range, 22-37), and the averagegestational age was 16 weeks (range, 11.5-21). Sixpatients were diagnosed with masses (all> 8 cmwith various characteristics) in the first trimester.Three of these six were operated on early in the sec-ond trimester secondary to acute pain and persis-

tomatic or large enough to be detected by pelvic ex-amination. Most adnexal masses that are detectedare usually found by ultrasound dating studies, areasymptomatic and resolve spontaneously prior tothe second trimester. However, if the mass becomessymptomatic, persists into the second trimester orhas certain characteristics (Figure I), then operativeintervention is required. Traditionally these caseswere approached via laparotomy, with its potentialmorbidity and significant hospital stay. Since 1990laparoscopic diagnosis and management of symp-tomatic adnexal masses has had an emerging roleand in the near future may be the procedure ofchoice in the diagnosis and management of adnex-al disease in the pregnant woman. Parker et al re-cently reviewed laparoscopic management of 29pregnant women with adnexal masses who hadbeen reported on separately.3 In these cases surgery':Vas completed successfully laparoscopically withno reported maternal or fetal complications. Similarresults have been confirmed in several recent, smallcase reports.4-6 This paper reports on the manage-ment of 14 patients with adnexal masses who weresuccessfully treated by laparoscopic surgery during

pregnancy.Subjects and Methods

Between June 1994 and January 1998, 14 womenpresented with adnexal masses in pregnancy andwere surgically managed with laparoscopy at ourinstitution. A retrospective chart review of these pa-tients was used to determine the following factors:patient age, gestational age, presenting symptoms,ultrasound findings, operating time, hospital stay,pathology results, pregnancy outcomes and com-plications. Twelve of the 14 patients were managedand operated on by the same attending surgeon; allhad resident staff assistance.

Placement of the lapar6scope and operating tro-cars was modified according to the uterine size andgestational age. For surgery, all patients were set up

-

.Symptomatic and/or rupture (acute abdomen)

.Surface excrescences or internal papillae

.Evidence of ascites or carcinomatosis

.Rapidly growing

.Solid

.Complex cyst> 6 cm, persisting beyond 1 s! trimester

.Simple cyst> 8 cm, persisting beyond 1 st trjmester

.Future impeding of vaginal delivery

Figure 1 Adnexal masses in pregnancy: indications for surgery

Vol~me 44, N~mber 2/February 1999

Table I Laparoscopic Management of Adnexal Masses in

Pregnancy

Discussion

Th~ curr~nt study was th~ larg~st s~ri~s to dat~ d~-scribiJlg r~moval of adnexal masses by laparoscopyin the pregnant W°n:lan. Until 1990/ laparoscopywas considered absolutely contraindicat~d in preg-nancy. Rec~ntly / howev~r, with the advance int~ch-nology and skill in laparoscopic surg~ry,. the role oflaparoscopy in pregnancy seems to be undergoingr~definition. Diagnostic and th~rapeutic laparos-copy during pregnancy is being perform~d at an in-cr~asing rate. There have been at least 50 report~dcases of laparoscopic cholecystectomy.7 Spirtos etal8 r~ported th~ initial use of laparoscopy to aid inthe diagnosis of appendicitis in pregnancy / al-though laparotomy was used for removal of th~ ap-pendix. Since th~n, th~r~ have been reports of lapa-roscopic appendectomy in pr~gnant womenwithout maternal or f~tal complications.9

For many y~ars, gyn~cologic surgeons hav~ be~nroutin~ly p~rforming diagnostic laparoscopy forthe evaluation of adn~xal masse~ and potential ec-topic pregnan.ci~~.tO Diagnostic laparoscopy in thefirst trimester did not seem to have any adverse ef-fects upon the pregnancy if no ~ctopic pr~gnancy ordisea&e was found. More r~c~ntly th~ laparoscopehas b~en used for surgical treatment in pregnancyas well. Re~dy ~t al r~cently conduct~d a nationalsurvey that reported on 413 laparoscopic proce-dures perform~d iJl pr~gnancy for both general sur-gical and gY11~cologic dis~as~.lt No advers~ fetal ormaternal complications seem~d to occur above thebas~lin~ for th~ g~n~ral population or wer~ link~dto th~ laparoscopic procedur~. Cholecystectomywas the mo&t common proc~dur~ r~port~d. A re-cent &tudy U&ing the Swedi~h H~alth R~gistry com-pared laparoscopy and laparotomy in pregnancy.12It compar~d birth w~ight, gestational duration,growth r~striction, infant survival and fetal malfor-mation~. Th~r~ w~re no diff~r~nc~s in th~~e vari-able& for patient~ undergoing laparoscopy versuslaparotomy. However, as compared to the g~neral

tence of the mass, with one of these having torsionof the adnexa and mass. The other three were fol-lowed and then operated on in the second trimesterafter the mass failed to regress or grew larger.

Eight patients had pelvic masses that were diag-nosed and operated on during the second trimester..Two presented with simple cysts> 10 cm that grew.Three presented acutely with pain and an adnexalmass. All three patients had torsion of the adnexa.The remaining three patients presented withsolid I cystic complex masses> 7 cm in diameterwith characteristics consistent with teratomas. Allthree had pathologic confirmation of mature ter-atomas at the time of surgery.

Average operating time was 84 minutes (range,32-145). Htstologic diagnosis of the tumorsrevealed 4 ~erous cystadenomas, 3 mucinouscystad~nomas, 3 mature teratomas, 3 ful"Ictional/hemorrhagic corpus luteum cysts and 1 bil.at~ral en~dometrioma (Table II). There were no malignant tu-mors. Three patients required short-term (12-hour)tocolysis ~econdary to increased uterine activity;two of the three were> 20 weeks pregnant, and thethird was 16 weeks pregnant. None of these pa-tients had cervical dilatation or vaginal bleeding.One patient developed mild peritonitis after re-moval of a dermoid cyst; it resolved within 48 hourspostoperatively. Average ho~pital stay was 2.0 days(range, 1-5). There were no spontaneous abortionsor fetal losses following surg~ry. At this writing,three patients w~re in the third trimester, with nocomplications to date. Ten patients continued withuncomplicated pregnancies and delivered infantswho were average for gestational ag~ in size atterm. One patient had a fetal loss at 31 weeks. Au-topsy revealed a diamniotic/monochorioruc twinpregnancy with multiple vascular anastomoses be-twe~n a partial molar placenta that l~d to an acut~va~cular accid~nt and intrauterine death. The preg-nancy had proceeded in an uncomplicated manneruntil this event.

Table II Pathology Results

Histology No.433

3

S~ro~s cystildenomilMucinous cystildenomaMilture teriltomilF~nctional cystEndometrioma

Totill 14

The Tournai of Reproductive Medicine@

minimally invasive procedure, brief hospital stay,quick recovery and no impainnent of pregnancy.Although no definitive conclusions on fetal safetyduring the procedure can be made, the results ofthis study are encouraging and underscore the needfor future study.

population, there was an increased risk for in-fants in both groups of weighing < 2,500 g, of beingdelivered before 37 weeks and of having an in-creased risk of growth restriction. Previously, anoverall rate of fetal loss had been reported as10-25%, and thepreterm delivery rate was approx-imately 2Z% after adnexal surgery during pregnan-cy (emergency and nonemergency).i3,14 Thesenumbers, however, reflected the approach of la-parotomy.

Bordelon and Hunter5 identified three issuescentral to laparoscopy and pregnancy: (1) safe lapa-roscopic access with a gravid uterus, (2) modifica-tions of trocar sites to allow smooth conduct of theprocedure in the presence of an enlarged uterus,and (3) identification of the possible adverse effectsof a sustained CO2 pneumoperitoneum upon fetalphysiology and blood flow. The first two issues aretechnical and have been solved fairly easily by openlaparoscopy and a more caudad approach for sec-ondary trocar sites. The third issue is the major andmost important difference between proven opensurgical procedures in pregnancy and the laparo-scopic approach as these physiologic effects are notyet known. The pneumoperitoneum affects thefetus in two ways: (1) directly increasing the pres-sure on the uterus, and (2) altering maternal hemo-dynamics and acid-base balance.

Hunter et al,16 after studying pregnant ewes,gave some valuable information on these issues inthe maternal-fetal unit with laparoscopic surgery.In summary, he showed no adverse effect from in-creased pressure alone; however, there was fetalhypercarbia, acidosis, possible tachycardia and anincrease in fetal arterial pressure with the use of aCO2 pneumoperitoneum. Maternal respiratory aci-dosis is easily corrected by the anesthesiologist, butthe end tidal CO2 may not reflect true PCO2 andacid-base balance in the fetus. Again, the long-termeffects of these physiologic alterations on the fetusare unknown but should be avoided, if possible byclose monitoring of maternal indices.

CQnclusiQn

Laparoscopic surgery with diagnosis and removalof adnex~l m~sses during pregnancy appears to befe~sible and c~rri~s very low morbidity. In this se-ries of 14 pregnant women who had laparoscopicremoval of an adnexal mass during the s~condtrim~ster, there w~re no major complications in themother or f~tus. The p~ti~nts benefited from th~

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