imaging of adenxal masses in pregnancy.pdf

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Imaging of Adnexal Masses in Pregnancy

Gloria Chiang, BA, Deborah Levine, MD

Objective. To illustrate the imaging appearances of a variety of adnexal masses in pregnancy.

Methods. Cases of adnexal masses in pregnancy were chosen to illustrate the appearance on ultra-

sonography and magnetic resonance imaging. Results. Adnexal masses in pregnancy have a wide

spectrum of imaging characteristics and clinical manifestations. Sonography is important in diag-

nosing, monitoring, and determining the malignant potential of these masses. Common adnexal

lesions seen in pregnancy include simple cysts, hemorrhagic cysts, leiomyomas, and hyperstimulat-

ed ovaries in patients who have undergone assisted fertility. Uncommon adnexal lesions specific to

pregnancy include hyperreactio luteinalis, theca lutein cysts with moles, and luteomas. Adnexal

masses associated with pain include ovarian torsion and heterotopic pregnancy. Adnexal lesions

that are found incidentally include teratomas, endometriomas, hydrosalpinx, cystadenomas, and

cystadenocarcinomas. When the diagnosis of the adnexal mass cannot be made on the basis of

sonographic appearance alone, magnetic resonance imaging may help. Conclusions. Familiarity

with the clinicopathologic and sonographic features of common and uncommon adnexal masses

in pregnancy is important for diagnosis and treatment. Key words: magnetic resonance imaging;

neoplasm; ovary; pregnancy; sonography.

Received December 28, 2003, from HarvardMedical School (G.C.) and Departments ofRadiology and Obstetrics and Gynecology, BethIsrael Deaconess Medical Center (D.L.), Boston,Massachusetts USA. Revision requested January 21,

2004. Revised manuscript accepted for publicationFebruary 10, 2004.

Address correspondence and reprint requests toDeborah Levine, MD, Department of Radiology,Beth Israel Deaconess Medical Center, 330Brookline Ave, Boston, MA 02215.

E-mail: [email protected].

AbbreviationshCG, human chorionic gonadotropin; MR, magneticresonance; T1, longitudinal relaxation time; T2, trans-verse relaxation time

dnexal masses in pregnancy have a wide spec-trum of imaging characteristics and clinicalmanifestations. Between 1% and 2% of preg-nant women will have an adnexal mass that is

sonographically detected and is persistent, and 1% to3% of these will be malignant.1,2 Sonography is impor-tant in diagnosing, monitoring, and determining themalignant potential of these masses.

Common adnexal lesions associated with pregnancyinclude simple cysts, hemorrhagic cysts, leiomyomas, andhyperstimulated ovaries in patients who have undergoneassisted fertility. Uncommon adnexal lesions specific topregnancy include hyperreactio luteinalis, theca luteincysts with moles, and luteomas. Adnexal masses associat-ed with pain include ovarian torsion and heterotopicpregnancy. Some adnexal entities are found incidentally,such as teratomas, endometriomas, hydrosalpinx, cys-tadenomas, and cystadenocarcinomas. Although thediagnosis of most adnexal pathologic conditions can bemade on the basis of sonographic appearance alone,magnetic resonance (MR) imaging may help when the

2004 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2004; 23:805819 0278-4297/04/$3.50

A

Image Presentation


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sonographic appearance is not specific.Familiarity with the clinicopathologic and sono-graphic features of common and uncommonadnexal masses in pregnancy is important fordiagnosis and treatment. In this image presenta-tion, we illustrate common and uncommontypes of adnexal masses in pregnancy.

Cysts and More Cysts

Simple CystsMost adnexal masses detected on sonographyduring pregnancy are simple cysts or hemor-rhagic corpus luteum cysts. Simple cysts areunilocular and anechoic and have a smooth, thinwall (Figures 1 and 2). Corpus luteum cystsenlarge during the first trimester, regress by the

12th week of gestation, and disappear later on inthe pregnancy.3 Size is the best indicator ofwhether the mass requires surgical intervention:90% to 100% of masses smaller than 5 cm indiameter will resolve spontaneously.4 Becauselarger cysts have an increased risk of torsion, rup-ture, and labor obstruction, close monitoringand sometimes surgery are necessary.4,5

Hemorrhagic CystsHemorrhagic corpus luteum cysts can have avariety of sonographic appearances due to the

changing appearance of the blood clot.Hemorrhagic cysts appear as predominantlyanechoic masses that contain hypoechoic

material within them (Figures 3 and 4). Theyexhibit increased sound through-transmissionbecause of their fluid nature. Most resolve by thesecond trimester.6Acutely hemorrhagic cysts canappear as echogenic masses with internal echoesmore hyperechoic than surrounding normalovarian parenchyma (Figure 5).

Hyperstimulated OvariesHyperstimulated ovaries are typically diagnosedin patients who have undergone ovulation induc-tion. The ovaries are enlarged with multiple cysts(Figures 68). More than 90% of patients whohave hyperstimulation will have spontaneousresolution of these benign cysts. Ovarian hyper-stimulation syndrome appears as markedlyenlarged ovaries containing multiple, large,

peripherally located, thin-walled cysts that some-times exude fluid from hemorrhage or ascites.7

The large ovaries are at risk of torsion (Figure 9)and hemorrhage, but usually they regress sponta-neously later in pregnancy or after delivery.7

Masses Unique to Pregnancy

Hyperreactio LuteinalisA similar appearance of hyperstimulated ovariescan be seen in patients who have not undergoneovulation induction. It is thought to result from

hypersensitivity of the ovary to circulatinghuman chorionic gonadotropin (hCG), whichmay or may not be high (Figures 10 and 11).5,8

806 J Ultrasound Med 23:805819, 2004


Figure 1. Corpus luteum cyst in a 29 year-old woman, 8 weekspregnant, with an 8-cm thin-walled anechoic cyst (calipers). The

cyst resolved after first-trimester therapeutic abortion.

Figure 2. Corpus luteum cyst in a 24 year-old woman at 19weeks gestation being scanned for fetal anomalies, with inci-

dental note of a 4.5-cm left adnexal cyst. On MR imaging, this

has the characteristics of a benign cyst, being thin walled, with

fluid signal intensity on a T2-weighted image, and having no

nodular elements. This cyst was present slightly later in gestation

than the typical corpus luteum cyst. However, it had resolved at

the time of postpartum imaging.


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Because this is commonly mistaken for an ovari-an neoplasm, MR imaging can be used to bettervisualize the predicted sites for peritonealimplants that are associated with ovarian malig-nancy and to decrease the likelihood of this pos-sibility.5 The lesions usually spontaneouslyinvolute after delivery.5

This condition can be seen in a normal preg-nancy but has also been associated with polycys-tic ovary disease and triplet pregnancies (due tohigh levels of hCG).5,810 Clinical manifestations

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Chiang and Levine

Figure 5. Acutely hemorrhagic cyst. Transvaginal scan from a35-year-old woman shows a 5.5-cm echogenic mass with

internal echoes more hyperechoic than surrounding ovarian

parenchyma and with echogenicity greater than that seen in

the typical hemorrhagic cyst, consistent with an acutely hem-

orrhagic cyst.

Figure 4. Hemorrhagic cyst, 38-year-old woman with a 5-cmmultiloculated cyst with thick septations in the right ovary

(calipers), consistent with the classic cobweb appearance of a

hemorrhagic cyst.

Figure 3. Ruptured hemorrhagic cyst in a 34 year-old woman, 7weeks pregnant, with sudden onset of lower abdominal pain,

nausea, and loss of consciousness. Hematocrit was 36% and

subsequently dropped to 28% after intravenous fluid resuscita-

tion. A, Transabdominal scan shows an intrauterine gestationalsac (g), with subchorionic hemorrhage (arrow) and a moderate

amount of free fluid (ff) in the pelvis compatible with hemor-

rhage. B, Sagittal view of the right upper quadrant shows fluid(arrowheads) with debris (D), consistent with a large amount of

blood around the liver. C, Transvaginal scan shows a 6-cm het-erogeneous right adnexal mass (M). This appearance was consis-

tent with either a ruptured hemorrhagic cyst or heterotopic preg-

nancy. A ruptured hemorrhagic cyst was found on laparoscopy.

A

B

C


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LuteomasLuteomas are rare solid ovarian lesions thatoccur in pregnancy. Fewer than 200 cases ofluteoma have been reported in the literature.14

Luteomas cause maternal virilization in 25% to30% of cases and carry a 50% risk of virilizing afemale fetus.15,16 Luteomas are usually asymp-tomatic and are found incidentally at cesarean

delivery.15,16

They are thought to result from ele-vated plasma androgens after stromal cell prolif-

eration during pregnancy and to involute post-partum with falling androgen levels.14,15

On sonography, they appear as heterogeneoussolid masses, predominantly hypoechoic com-pared with normal ovarian tissue, with thickwalls and irregular internal contours in anenlarged ovary (Figure 13).14,15 They are oftenhighly vascular and mimic ovarian neoplasms.14

The appearance of virilizing symptoms in thepregnant patient leads to this diagnosis. When aluteoma is suspected, laparotomy can be avoid-ed during pregnancy because the lesions regressafter delivery.

Masses Associated With Pain

Leiomyomas

Leiomyomas are the most common solid massesin pregnancy.3 They are seen on sonography in1.4% of pregnancies.17 Most are within the body ofthe uterus, but pedunculated and broad-ligamentmyomas can simulate an ovarian neoplasm.

They appear on sonography as hypoechoic,round, persistent masses (Figure 14). Leiomyo-mas may enlarge during pregnancy and maycause focal pain. When the leiomyoma outgrowsits blood supply, it may undergo red degenera-tion, which results in the development of cysticspaces, an echogenic rim, or a coarse heteroge-

neous pattern consisting of hyperechoic clusterswith focal areas of distal shadowing.3,18

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Chiang and Levine

Figure 9. Hyperstimulated ovary with torsion in a 31-year-old woman at11 weeks gestation with hyperstimulated ovaries and severe right lower

quadrant pain. A, Transabdominal scan shows an enlarged ovary, mea-suring up to 11 cm. B, Transvaginal scan shows an arterial waveform pre-sent in the solid portion of the ovary. Venous flow was present. Because

of extreme pain, the patient was taken to surgery, during which the ovary

was found to be twisted 3 times about its pedicle.

A

B

Figure 8. Hyperstimulated ovaries in a 36-year-old woman, 12weeks pregnant, with in vitro fertilization gestation. Transvaginal

scan shows 6-cm ovaries with multiple cysts, some of which con-tain debris, consistent with hemorrhagic corpus luteum cysts. LO

indicates left ovary; and RO, right ovary.


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Sonography is the mainstay of leiomyoma diag-nosis. However, MR imaging can be helpful inconfirming the diagnosis of a large degeneratingleiomyoma, which can simulate an ovarian neo-plasm on sonography (Figure 15). On longitudi-nal relaxation time (T1)-weighted images,degenerated leiomyomas appear heterogeneouswith central low intensity. When red degenera-tion has occurred, the T1-weighted images canshow high signal intensity. On transverse relax-ation time (T2)-weighted images, they canappear heterogeneously bright centrally, withpunctate areas of hyperintensity and a thin bandof myometrium around them.19,20 When bloodproducts are present, the T2-weighted appear-ance can be variable. Magnetic resonance imag-ing can clearly delineate the uterine origin of

leiomyomas, which can help differentiate themfrom solid ovarian tumors, thereby avoidingsurgery during pregnancy.21

Heterotopic PregnancyHeterotopic pregnancy occurs in 1 per 7000pregnancies and is increasing because of the ris-ing prevalence of ectopic pregnancies andincreased use of ovulation-inducing agents.22

The reference standard is being able to identifycardiac motion in intrauterine and extrauterinepregnancies, but this only occurs in about 14% of

cases.23

Heterotopic pregnancy should be con-sidered in patients who have undergone ovula-tion induction or in vitro fertilization but can alsooccur spontaneously (Figure 16).

Ovarian TorsionAbout 1% of large and complex masses havetorsion (Figures 1719).2,25 Torsion of an ovarianmass most frequently occurs in the mid to latefirst trimester, when the gravid uterus is enlarg-ing most rapidly.26 Lack of flow on 2-dimensionalDoppler sonography of the ovarian vessels onthe ipsilateral side of the clinical condition is theclassic finding of ovarian torsion.27 Care mustbe taken in making the diagnosis of torsionbecause blood flow may be present even in thepresence of torsion. This is due to the dualblood supply of the ovary, with the ovarianartery perfusing the ovary laterally and a branchof the uterine artery perfusing the ovary medial-ly. The presence of venous flow is predictive ofovarian viability.28 When an adnexal mass isseen and the patient has severe pain, torsionshould be considered.

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Figure 10. Hyperreactio luteinalis in a 34-year-old woman withdiamniotic dichorionic twins at 19 weeks. A, Transabdominalscan shows the twins. B and C, Transvaginal scans show bilater-al enlarged ovaries measuring up to 14 cm with multiple cysts.

Six weeks after vaginal delivery of twins, the ovaries had

decreased dramatically in size, but cysts were still present. The

woman was not taking hyperstimulating agents.

A

B

C


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Chiang and Levine

Figure 11. Hyperreactio luteinalis in a 38-year-old woman at 18weeks gestation with large adnexal cysts noted on routine

obstetric sonography. The patient had not taken any hyperstim-

ulating agents. A, Right upper quadrant scan shows a portionof the adnexal cyst (C). This was anechoic, measured 12 10

5 cm, and had thin septations versus adjacent cysts. B and C,Axial and coronal T2-weighted MR images show the enlarged

cysts (C) in bilateral ovaries crossing the midline. No other

abnormality was visualized. The cysts resolved after delivery.

A

B

C

Figure 12. Complete hydatidiform mole with theca lutein cystsin a 19-year-old woman, 11 weeks pregnant, with vaginal

bleeding and an hCG level of 400,000 U/L. A, Transabdominalscan shows an enlarged uterus (calipers) with a thickened

endometrium and multiple small cysts. B and C, Transvaginalscans show bilateral enlarged ovaries (calipers), the left up to

6 cm and the right up to 9 cm, with multiple cysts. The findings

are consistent with a complete hydatidiform molar pregnancy

with bilateral theca lutein cysts.

A

B

C


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Massive ovarian edema occurs when there isintermittent torsion of an ovary, which interfereswith venous and lymphatic drainage and causesovarian enlargement. It is usually unilateral andinvolves the right ovary in two thirds of cases. Onsonography, it appears as a solid mass with a cys-tic component and heterogeneous internal echotexture (Figure 19). Magnetic resonance imagingexhibits homogeneous low signal intensity onT1-weighted imaging and high signal intensity

on T2-weighted imaging that becomes brighteron more heavily T2-weighted images.29,30

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Figure 13. Luteoma in a 33-year-old woman, 28 weeks pregnant, with hirsutism and a 6-cm solid right adnexal mass. Serum androgen levels were ele-vated. The mass decreased in size to 2 cm after delivery (not shown). Hirsutism resolved 6 months after delivery. A, Transvaginal scan shows a 5-cm solidmass arising from normal-appearing ovarian tissue (arrowheads). B, Color Doppler image shows flow within the solid mass. Reproduced with permis-sion from theJournal of Ultrasound in Medicine.14

A B

Figure 14. Leiomyoma in a 33-year-old woman, 32 weeks preg-nant, with a 7-cm complex right adnexal mass (calipers) with a

broad base in the myometrium, consistent with exophytic

leiomyoma. At first glance, it may look like a hemorrhagic cyst,

but hemorrhagic corpus luteum cysts do not persist into the

third trimester.

Figure 15. Degenerated leiomyoma in a 39-year-old woman,16 weeks pregnant, with a 14-cm complex mass superior to the

uterus and separate from the ovaries on sonography. T2-weight-

ed MR image shows a broad base with the myometrium, low

signal intensity peripherally, and extensive high T2 signal areas

centrally, consistent with an exophytic degenerated leiomyoma.

This was of low signal intensity on T1-weighted imaging (not

shown), consistent with cystic degeneration.


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Incidental Findings

TeratomasTeratomas show a complex echo pattern due tothe presence of fat, solid components and calci-fied material (Figure 20).3,31Acoustic shadowingdue to the dense calcification is also seen.25

Most ovarian teratomas have a typical sono-graphic appearance and can be correctly diag-nosed by sonography. In the rare cases in which

the diagnosis is unclear, MR imaging is oftenhelpful in highlighting the fat within the mass.21

Magnetic resonance imaging can also helpdetermine the size of the mass if surgicalremoval is contemplated during pregnancy.Teratomas may be pedunculated and are proneto undergoing torsion and rupture, leading toperitonitis.3

HydrosalpinxHydrosalpinx appears as anechoic tubularfluid collections (Figure 21). They typically do

not change in size or appearance throughoutpregnancy.31

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Figure 16. Heterotopic pregnancy in a 32-year-old woman at 7 weeks gestation with abdominal pain. A, Transabdominal scan shows a live intrauter-ine pregnancy with surrounding fluid with debris, consistent with blood. B, Transvaginal scan shows a 6-cm complex heterogeneous left adnexal mass(arrowheads) that was separate from the ovary and a moderate amount of free fluid with debris. Histology showed ectopic pregnancy.

A B

Figure 17. Corpus luteum cyst with torsion in a 29-year-old woman, 9 weeks pregnant, with acute right lower quadrant pain. A, Transabdominalscan shows a 12-cm ovary (calipers) containing 2 cysts with debris. B, No flow was seen in the walls of the cysts or adjacent ovarian tissue. At surgery,torsion of 360 was noted. Histologic examination revealed corpus luteum cysts.

A B


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EndometriomasBecause endometriosis is a cause of infertility,it is uncommon to find an unsuspectedendometrioma at routine obstetric imaging.Endometriomas have a classic appearance of achocolate cyst with diffuse low-level internalechoes (Figure 22).

Cystadenomas and CystadenocarcinomasWhen an ovarian cyst is complex (and not hem-orrhagic), the likelihood of neoplasm isincreased. Cystadenomas may be simple cystsor have thin septations (Figures 2325). Serouscystadenomas tend to be anechoic, whereasmucinous tumors have low-level internalechoes. Irregular septations and mural nodulesincrease the likelihood of malignancy. When

malignancy is suspected in utero, a minilaparo-tomy is typically performed in the secondtrimester (to avoid spontaneous miscarriage inthe first trimester and the risk of precipitatingpreterm delivery in the third trimester; Figure26). If diagnosis is not made until late in gesta-tion, surgical removal of the ovary can be per-formed at the time of cesarean delivery.

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Figure 18. Teratoma with torsion in a 28-year-old woman, 30weeks pregnant, with acute right-sided pain. Sonography shows

a 9-cm cyst (calipers) with heterogeneous internal echoes and a

hyperechoic nodule, consistent with a teratoma. No Doppler

flow was seen around the cyst. At surgery, 2 complete twists of

the right adnexa were found. Histologic examination revealed a

teratoma. It is common to not visualize flow around a teratoma.

However, the amount of pain the patient has is the key to the

diagnosis.

Figure 19. Massive ovarian edema in a 33-year-old woman at 14 weeks

gestation with quadruplets spontaneously reduced to twins.Sonography (not shown) showed an enlarging left adnexal mass. A,Transverse T2-weighted MR image shows a 14-cm solid-appearing left

ovary (LO) with a high-signal-intensity stroma and peripheral cysts, some

of which are hemorrhagic. B, Transverse T2-weighted MR image showsan enlarged hyperstimulated right ovary (RO) in the cul-de-sac.

Histologic examination showed massive ovarian edema of the left ovary.

Reproduced with permission fromAbdominal Imaging.24

A

B


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Conclusions

Adnexal masses exhibit a wide range of imagingcharacteristics. Knowledge of the clinical

appearance and sonographic findings allows forcorrect diagnosis in most. Complex cystic mass-es include corpus luteum cysts, theca luteincysts, cystadenomas, and teratomas. Solid mass-es are commonly uterine leiomyomas. Magneticresonance imaging can be useful when the diag-nosis is not clear on sonography.

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Chiang and Levine

Figure 20. Teratoma in a 38-year-old woman, 12 weeks preg-nant, with incidental notation of a 4-cm echogenic left adnexal

mass (calipers) on a transverse view of gravid uterus. The cyst

was removed at the time of cesarean delivery, and histologic

examination revealed a teratoma.

Figure 21. Hydrosalpinx in a 19-year-old woman, 15 weekspregnant, with an oblong fluid collection (A, arrows) posterior tothe gravid uterus. B, Postpartum image showing a hydrosalpinx(H) and a normal ovary (O).

A

B

Figure 22. Endometrioma in a 29-year-old woman with a 7 3 4-cm bilobed left adnexal mass with diffuse low-level internal

echoes seen at 11 weeks (A) and again at 28 weeks (B) with nochange. The cyst was removed after delivery, and histologic

examination showed an endometrioma.

A

B


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Figure 23. Mucinous cystadenoma in a 41-year-old woman,7 weeks pregnant, with a 16-mm cyst containing a 6-cm

mural nodule. The cyst was removed laparoscopically after a

miscarriage, and histologic examination revealed a mucinous

cystadenoma.

Figure 24. Mucinous cystadenoma in a 40-year-old woman, 17weeks pregnant. A and B, Sonograms show an 8-cm predomi-nately anechoic cyst with septations and no nodularity (B,calipers). An MR examination was performed for further charac-

terization. C, Axial T2-weighted MR image shows the cyst (C)

with thin septations and no nodularity. Because both modalitiessuggested a benign neoplasm, the cyst was followed during

pregnancy and was not removed until cesarean delivery.

Histologic examination showed a mucinous cystadenoma.

A C

B


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Chiang and Levine

Figure 25. Serous cystadenoma in a 34-year-old woman with a cyst. A, Transabdominal scan at 19 weeks shows a 10-cm left adnexal cyst (calipers),anechoic, with a thin wall. B, At 31 weeks, the cyst (calipers) increased in size to 13 cm. After delivery (not shown), the cyst was 15 cm. It was removedand found to be a benign serous cystadenoma.

A B

Figure 26. Borderline mucinous tumor in a 33-year-old woman with a complex cyst. A and B, Transvaginal scans at 8 weeks shows a 3.7 2.6 3.1-cm complex right ovarian cyst (calipers) with relatively avascular septations and avascular echogenic nodules. Follow-up sonography at 11 weeks

(not shown) showed no change. C and D, Coronal (C) and Axial (D) T2-weighted MR images reveal the complex cyst (C) with several septations, nodu-lar components, and no fat (confirmed on T1-weighted images; not shown). Histologic examination revealed a borderline ovarian tumor.

A B

C D


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