A 32-year-old woman, gravida 2 para 0, comes to the office at 11 weeks gestation for a follow-up prenatal visit. The patient has no vaginal bleeding, abdominal cramping, or pelvic pain. At 6 weeks gestation, a transvaginal ultrasound revealed an intrauterine pregnancy consistent with gestational age and a 12-cm complex right adnexal mass with multiple septations. The patient has no chronic medical conditions. Previous surgeries include an appendectomy and suction curettage for a missed abortion. Menarche was at age 10 and she has regular menstrual cycles. Before attempting to conceive, the patient used a copper-containing intrauterine device for contraception, which was removed 8 months ago. She takes a prenatal vitamin and iron supplementation daily. The patient does not use tobacco, alcohol, or illicit drugs. Family history is significant for a grandmother who died from breast cancer at age 40. Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, and pulse is 80/min. She has gained 2 kg (4.4 lb) during this pregnancy. The abdomen is soft, nontender, and without rebound or guarding. A repeat ultrasound demonstrates a fetus measuring 11 weeks gestation with a heart rate of 160/min. The right adnexal mass has no change in appearance, but has increased to 13 cm in size. Which of the following is the best next step in management of this patient?

Question

A 32-year-old woman, gravida 2 para 0, comes to the office at 11 weeks gestation for a follow-up prenatal visit.  The patient has no vaginal bleeding, abdominal cramping, or pelvic pain.  At 6 weeks gestation, a transvaginal ultrasound revealed an intrauterine pregnancy consistent with gestational age and a 12-cm complex right adnexal mass with multiple septations.  The patient has no chronic medical conditions.  Previous surgeries include an appendectomy and suction curettage for a missed abortion.  Menarche was at age 10 and she has regular menstrual cycles.  Before attempting to conceive, the patient used a copper-containing intrauterine device for contraception, which was removed 8 months ago.  She takes a prenatal vitamin and iron supplementation daily.  The patient does not use tobacco, alcohol, or illicit drugs.  Family history is significant for a grandmother who died from breast cancer at age 40.  Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, and pulse is 80/min.  She has gained 2 kg (4.4 lb) during this pregnancy.  The abdomen is soft, nontender, and without rebound or guarding.  A repeat ultrasound demonstrates a fetus measuring 11 weeks gestation with a heart rate of 160/min.  The right adnexal mass has no change in appearance, but has increased to 13 cm in size.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c031_0131_8f63_4f329f17a1ec_MD0005_00 This patient has a large, complex adnexal mass during pregnancy; although she is asymptomatic, surgical intervention is indicated. The complex, persistent appearance (eg, septations) of the mass increases the likelihood of malignancy, and the large size (>10 cm) increases the risk of torsion, rupture, and labor obstruction. Early menarche, older age at menopause, and genetic mutations increase the risk of malignancy, whereas using combined oral contraception and breastfeeding decrease the risk. In this patient, surgical intervention should not be deferred due to pregnancy. The ideal time for surgery is in the early second trimester as the uterus is still contained within the pelvis, organogenesis is complete, and progesterone production has transferred from the corpus luteum to the placenta. If cancer is diagnosed, chemotherapy can be administered in the second and third trimesters, although recommendations vary depending on the tumor type. (Choice A) Tumor markers are unreliable in pregnancy and, therefore, not indicated. Several markers are antigens that have a role in fetal development at various gestational ages (eg, human chorionic gonadotropin), whereas other abnormal markers could be an indication of a fetal abnormality (eg, alpha-fetoprotein). (Choices C and E) Postponing surgery to the third trimester or postpartum could delay the diagnosis of ovarian cancer and allow continued disease progression. Even in the absence of malignant features, large masses are removed as treatment delay increases the risks of cyst rupture, acute abdomen, preterm delivery, or dysfunctional labor. Unlike a simple cyst, a large complex adnexal mass is unlikely to resolve spontaneously. (Choice D) Ultrasound-guided biopsy is not recommended when ovarian malignancy is suspected, as a biopsy increases the risk of spread of malignant cells and, therefore, upstaging of disease. Aspiration of a simple-appearing cyst is also not recommended as no tissue is obtained for pathology, cytology is not reliable for evaluation of malignancy, and reaccumulation of fluid is common. Educational objective: Pregnant women with a pelvic mass require surgical intervention when the mass is persistent, has complex features, and/or is >10 cm in diameter. Surgical removal is recommended during the early second trimester to avoid acute complications (eg, torsion, preterm delivery) and to prevent progression of potentially malignant disease. References: Adnexal mass during pregnancy: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26007316)

A 32-Year-Old Woman, Gravida 2 Para 0, Comes to the Office