The incidence of surgical nonobstetrical procedures during pregnancy is about 0.75 percent(1). Performing surgery during pregnancy can be challenging because both mother’s life and fetus viability should be considered, and both of them can be injured during these procedures. Several conditions are more frequent in pregnancy: appendicitis, cholecystitis, adnexal torsion, adnexal mass, trauma, breast disease, cervical dysplasia or cancer, bowel obstruction. Among all procedures, abdominal interventions have the most important impact, either considering laparotomy, or laparoscopy. In the last years, laparoscopy seems to be the treatment of choice in gynecologic pathology during pregnancy, and there is evidence that supports that it is a safe procedure to perform during pregnacy(2,3-6). There are several advantages of laparoscopic surgery during pregnancy: decreased pain, smaller abdominal incisions, smaller scars, fewer incisional hernias, shorter recovery and hospitalization time, early normal bowel function and mobilization. There are also possible some disadvantages, such as injuring the pregnant uterus, decreasing uterine blood flow by increased intraabdominal pressure or even carbon dioxide absorption by mother and fetus.
Because of the enlarged uterus, the placement of the trocars is important for a successful operation. The patient is placed in left side-down position. The access to the abdomen is made through an open technique. Usually, we use 5-mm laparoscopes for the sides and a 10-mm laparoscope superior to the umbilicus. In their study, Carter and Soper used 3-mm laparoscopes superior to the umbilicus on uteri that were at or above the umbilicus(7,8). Uterine manipulation must be minimal and intraperitoneal pressures must be kept below 12-mm Hg(6,9). Tocolytic drugs are recommended to be used in case of uterine manipulation(10).
Ultrasounds. Adnexal mass are usually discovered at routine ultrasound obstetrical examination. The IOTA (International Ovarian Tumor Analysis) criteria are used to characterize ovarian pathology. Although there is no evidence of the specific use of these criteria in pregnant women, ultrasounds as an examination with high sensitivity and specificity is also very useful during pregnancy (Kaijser et al., 2014(11)).
Magnetic resonance imaging. Magnetic Resonance Imaging (MRI) can be used when ultrasound examination is unclear and there is a high suspicion of malignancy. MRI is safely used during the second and third trimester, usually with no contrast because gadolinium doesn’t have enough safety data available.
Tumor markers. CA-125, AFP, b-hCG, Inhibine B and AMH are tumor markers that can be associated with ovarian tumor growth. Physiological decidual and amnion cells produce CA-125, so the CA-125 level is higher pregnancy. Still, CA-125 level may help making the difference between benign and malignant tumors. AFP (related to germ cell tumors), Inhibine B and AMH (related to granulosa cell tumors) levels are higher in pregnacy and are used for follow-up(12,13).
Ovarian torsion, also known as adnexal torsion or tubo-ovarian torsion, refers to an emergency condition where the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle can compromise the blood supply. The result can be arterial, venous and lymphatic stasis, leading to ovarian and fallopian tube necrosis. Either intermittent, or sustained stasis, early diagnostic and laparoscopy are important in order to preserve the adnexa. Approximately 20% of the cases occur during pregnancy(14). Hypermobility of the ovary and adnexal mass are the two main reason of adnexal torsion(15). Dermoid cysts and para ovarian cysts are frequently incriminated, and at most risk are masses between 5-10 cm(16). Adnexal torsion mainly occurs during the first trimester of pregnancy(17-21). In pregnacy, adnexal torsion can occur as a complication of ovarian hyperstimulation syndrome(22,23). Shalev et al.(24-26) have reported 41 patients with adnexal torsion, including 10 pregnant patients who had a favorable outcome. There is a common trend to consider laparoscopy the treatment of choice in adnexal torsion, being a safe procedure if special precautions are adhered to. Depending on the size of the cyst and the gestation age, aspiration, detorsion and subsequent cystectomy can be practiced.
The reported incidence of adnexal mass complicating pregnancy is about 0.2-2%, with a malignancy rate of 1-6%(27-29). Benign adnexal masses discovered during early pregnancy can be: functional cyst (corpus luteum, follicular cyst, haemorrhagic cyst), dermoid cyst, serous cystadenoma, mucinous cystadenoma, endometrioma, leiomyomas, and paraovarian cyst(27-32). Corpus luteum cysts and benign cystic teratomas has each one third(32,33). Cystic masses are conservative treated till the second trimester or even after delivery. Depending on evolution of the cyst, measures must be taken. Often, there is a spontaneous resolution of functional cysts(34,35). If masses persist or grow larger, they must be removed in order to prevent torsion or rupture. Non-functional cyst usually persists after 16 weeks of gestation(13,30,36,37). In cases where there is no need for surgical treatment during pregnancy, only survey is sufficient till delivery. Otherwise, laparoscopic procedure should optimally be done between 16 and 20 weeks of gestation(27,38). Suspicious features like vascularized septa, solid components, papillae or nodules require further investigation through Magnetic Resonance Imaging and tumour markers analyzes(39). Although ovarian cancer during pregnancy is rare, any sign of malignancy must be taken into consideration and appropriate treatment must be applied. The termination of pregnancy is indicated in early pregnancy, and chemotherapy can be safely used during second and third trimesters.
Gynecological disorders during pregnancy such as ovarian cysts and masses must first be thoroughly assessed by ultrasound examination and, if the situation requires, by MRI examination, safely done during the second and the third trimesters. Also, CA-125 level may be useful in distinguishing a benign from malignant disease. The moment of surgery is an important aspect. Small benign painless cysts should only be under surveillance as they may spontaneously remit, and large cysts or cysts that last over 16 weeks should be reassessed and undergo surgery. When a pregnant patient has to undergo surgery, the obstetrician, the general surgeon, or the orthopedist, the neurosurgeon as appropriate, together with the anesthetist and the neonatologist must consult each other and take a decision. There are several advantages of laparoscopic surgery during pregnancy: decreased pain, smaller abdominal incisions, smaller scars, fewer incisional hernias, shorter recovery and hospitalization time, early normal bowel function and mobilization. There are also possible some disadvantages, such as injuring the pregnant uterus, decreasing uterine blood flow by increased intraabdominal pressure or even carbon dioxide absorption by mother and fetus. Adnexal torsion and benign ovarian cysts and masses can be safely operated during first and second trimester. Although ovarian cancer during pregnancy is rare, any sign of malignancy must be taken into consideration and appropriate treatment must be applied. The termination of pregnancy is indicated in early pregnancy, and chemotherapy can be safely used during second and third trimesters. n