International Journal of Gynecology and Obstetrics 85 (2004) 250254

Article

Elective vs. conservative management of ovarian tumors in

pregnancy
G.S.R. Lee, S.Y. Hur, J.C. Shin, S.P. Kim, S.J. Kim*
Department of Obstetrics and Gynecology, Holy Family Hospital, College of Medicine, The Catholic University of Korea, Seoul,
South Korea
Received 26 May 2003; received in revised form 16 December 2003; accepted 17 December 2003

Abstract
Objectives: To determine optimal management of the ovarian tumors in pregnancy. Methods: This study included
89 cases of the ovarian tumor in pregnancy that required surgery at Holy Family hospital of the Catholic University
from January, 1990 to December, 2001. Among 89 cases, 36 and 53 were emergency and elective surgery, respectively.
Students t-test and the x2-test were used for statistical analysis and a P-value of -0.05 was considered statistically
significant. Results: The most common size of torsion of ovarian tumors during pregnancy was 610 cm and the
incidence was the most frequent during the first trimester of pregnancy. The incidence of preterm delivery (-37
weeks) was higher in emergency surgery, but there was no difference in the gestational age at delivery, also no
difference in the birth weight or the method of delivery. Conclusions: Although surgery for ovarian tumors in
pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with
that after elective surgery. We propose that conservative management would be used in optimal management of
pregnant women with ovarian tumors.
2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Keywords: Ovarian tumor; Pregnancy; Elective management; Conservative management

1. Introduction
The reported incidence of ovarian tumor is 1 in
200 pregnancies w1x, or 1 in 13001312 live births
w2,3x. Koonings et al. w4x reported finding one
adnexal neoplasm for every 197 cesarean sections.
The ovarian tumors during pregnancy may result
in serious complications such as torsion and infarc*Corresponding author. Tel.: q82-32-340-2262; fax: q8232-340-2255.
E-mail address: ksajin@catholic.ac.kr (S.J. Kim).

tion, and the tumor can obstruct vaginal delivery

if it fills the pelvic cavity. Proper evaluation and
management of ovarian tumor during pregnancy is
important for the health of pregnant woman and
the continuance of pregnancy.
In the past, ovarian tumors in pregnancy were
managed by elective operation, preferably in the
second trimester, because of decreasing the risk of
complications as torsion, rupture, and ruling out
ovarian malignancy, but any abdominal surgery in
pregnancy causes significant physical and emotional stress to both the mother and fetus w5x.

0020-7292/04/$30.00 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights
reserved.
doi:10.1016/j.ijgo.2003.12.008

G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250254

Therefore, our purpose in this study is to compare emergency surgery followed by conservative
management to elective surgery performed due to
ovarian mass in pregnancy, and then it is to
determine optimal management of the ovarian
tumors in pregnancy.
2. Patients and method
This study includes 36 cases followed up among
48 pregnant women that underwent emergency
operation due to torsion of ovarian tumor during
pregnancy (Group A) (12 cases were failed to
follow up) and 53 cases that underwent elective
operation within the second trimester (Group B)
on the basis of the histologic finding and clinical
records retrospectively among 310 cases that
received the operation during pregnancy and delivery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001.
This study excluded the emergency operation of
ovarian tumor associated with hemorrhage, rupture, or appendicitis and the ovarian tumors that
resected incidentally by misdiagnosis or at the
time of cesarean section. Students t-test and the
x2-test were used for statistical analysis.
3. Results
3.1. Demographic characteristics
There was no significant difference in maternal
age (mean age; 27.8 years and 28.4 years, respectively) or parity between patients undergoing
emergency surgery (Group A) and those having
elective surgery (Group B). There was no significant difference in the gestational age at surgery
between the two groups. The median gestational
age at surgery was 12.6 weeks in Group A and
15.0 weeks in Group B, respectively. Emergency
surgery was performed in 22 cases (61.1%) during
the first trimester, in five cases (13.9%) during the
second trimester and in nine cases (25%) during
the third trimester. Elective surgery was done in
35 cases (66%) during second trimester and in 18
cases (34%) during the first trimester. There was
no difference in mean gestational age at delivery
(Group A: 38.82"1.76 weeks, Group B:

251

39.12"1.97 weeks) and mean birth weight (Group

A:3.08"0.36 kg, Group B: 3.17"0.52 kg). However, the incidence of preterm birth (-37 weeks)
was significantly higher in 22.2% of Group A than
3.77% of Group B (P-0.005), but there was no
difference in the gestational age at preterm delivery
(Group A: 35.78"0.85 weeks; Group B:
34.28"0.81 weeks) (Table 1).
3.2. Location and diameters of ovarian tumor
removed at surgery
There was no difference in location at operation
and the average size of the ovarian tumors between
the two groups. Three patients (8.3%) of Group
A and five patients (9.4%) of Group B had
bilateral ovarian tumors. The average size of the
ovarian tumors was 7.63"2.44 cm in Group A
and 9.14"3.23 cm in Group B. The most common
size of the ovarian tumor was 610 cm in both
groups (Table 2).
3.3. Histologic diagnosis of ovarian tumor
Dermoid cyst was the most common histologic
finding in both groups. The incidence of dermoid
cyst was 36.1% and 45.0%, respectively, in Group
A and Group B. No malignant tumor was found
in Group B, but two cases, an immature teratoma
and a mucinous adenocarcinoma, were diagnosed
at 9 weeks and 17q6 weeks, respectively, in Group
A (Table 3).
4. Discussion
The frequency of ovarian tumor found on ultrasonography during pregnancy is 1.14%, with most
of these tumors being either corpus luteum or
theca lutein cysts. Most, however, disappear spontaneously before the 16th week of pregnancy w6x.
It is difficult to determine a therapeutic plan for
those that persist or are large-sized ovarian tumors
with solid components and septa on ultrasonography.
The most common histological finding of ovarian tumors operated during pregnancy is that of a
benign cystic teratoma w7x. For this, Whitecar et

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Table 1
Demographic characteristics and outcome data of study groups

Maternal age (years)

Mean"S.D.
Range
Parity (no.)
Primipara
Multipara
Gestational age at surgery
Median (weeks)
1st trimester
No. (%)
Mean"S.D. (weeks)
2nd trimester
No. (%)
Mean"S.D. (weeks)
3rd trimester
No. (%)
Mean"S.D. (weeks)
Gestational age at delivery
Mean"S.D. (weeks)
Preterm delivery (-37weeks)
No. (%)
Mean"S.D. (weeks)
Term delivery (G37weeks)
No. (%)
Mean"S.D. (weeks)
Birth weight (kg)
Neonatal mortality (%)
Methods of delivery
NSD (No. (%))
CyS (No. (%))

Group A (ns36)

Group B (ns53)

27.81"3.07
2536

28.42"3.22
2137

21
15

14
39

12.6

15

22 (61.1%)
10.11"2.55

18 (34%)
13.02"1.52

5 (13.9%)
22.91"4.65

35 (66%)
16.45"1.32

9 (25%)
32.59"2.87

0
0

38.82"1.76

39.12"1.97

NS

8 (22.2%)
35.78"0.85

2 (3.77%)
34.28"0.81

P-0.005
NS

28 (77.8%)
39.68"0.93
3.08"0.36
0

51 (96.23%)
39.31"1.32
3.17"0.52
0

NS
NS
NS

12 (33.3%)
24 (66.7%)

27 (50.94%)
26 (49.06%)

NS
NS

NS
NS

NS, non-significant.

al. w2x have reported 30% of benign ovarian tumors

and Ueda et al. w8x have reported 45.3%.
The most frequent and most serious complication of benign ovarian tumors during pregnancy is

torsion, which frequently occurs in the first trimester of pregnancy, and may result in cyst rupture
with spillage into the peritoneal cavity. Whitecar
et al. w2x stated that torsion was responsible for

Table 2
Location and diameters of ovarian tumors removed operation

Location
Right
Left
Bilateral
Diameter of masses
Mean cystic size (cm)
-6 cm
610 cm
1115 cm
)15 cm

Group A (ns36)

Group B (ns53)

23
10
3

24
24
5

NS

7.63"2.44
3
26
6
1

9.14"3.23
5
30
16
2

NS

G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250254

253

Table 3
Histologic findings of ovarian tumors
Type

Group A (ns36)

Tumor-like lesion
Hemorrhagic corpus luteum
Simple cyst
Endometrial cyst
Parovarian cyst

4
10
0
0

Benign tumor
Dermoid cyst
Serous cystadenoma
Mucinous adenoma
Malignant tumor
Mucinous adenocarcinoma
Immature teratoma

(11.1%)
(27.9%)
(0%)
(0%)

13 (36.1%)
3 (8.4%)
4 (11.1%)

seven cases (43.8%) of 17 cases of emergency

surgery for adnexal tumors during pregnancy.
Novak et al. w9x recommended surgery for ovarian tumors that persist until the second trimester
of pregnancy to reduce fetal loss. Whitecar et al.
w2x reported a significant increase in preterm birth,
cesarean section, and perinatal mortality when
surgery was done after 23 weeks gestation. Hess
et al. w3x stated that the risk of abortion or preterm
birth was higher in the group that received emergency operation for ovarian tumor torsion than the
group that received elective operation. Ueda et al.
w8x reported ovarian surgery in the first trimester
for persistent or enlarging masses is important to
obtain a correct diagnosis and rule out malignancy.
However, operative intervention might have significant physical and emotional effects on the fetus
or the mother, increasing the risk of preterm
delivery w5,10,11x, and Platek et al. w12x evaluated
the outcomes of pregnancy complicated by a persistent adnexal mass that was managed conservatively or with surgical intervention and in
conclusion they reported that there are no differences in pregnancy outcomes, respectively.
Because complications of abdominal surgery are
increased in pregnancy, surgical management needs
to be reassessed. Thornton et al. w13x suggested a
policy of selective conservative management of
ovarian cysts during pregnancy on the basis of the
ultrasound appearance. Caspi et al. w14x suggested
that ovarian dermoid cysts -6 cm are not expected

1 (2.7%)
1 (2.7%)

Group B (ns53)
5
6
5
1

(9.1%)
(11.1%)
(9.1%)
(1.6%)

24 (45.0%)
7 (13.0%)
6 (11.1%)
0 (0%)
0 (0%)

to grow during pregnancy or to cause complications in pregnancy and labor.

In this study, women who had emergency surgery because of ovarian torsion showed a higher
frequency of preterm birth compared to those with
elective operation, but there was not different in
the gestational age at preterm delivery and there
was no perinatal mortality, nor there was any
difference in the vaginal delivery, cesarean section
and birth weight between both groups. What was
unique, was that although the emergency surgery
for torsion of ovarian tumor was done even in the
third trimester of pregnancy, there was no difference in the average gestational age at the emergency operation compared to the elective
operation. It is considered that torsion of ovarian
tumor frequently occur during the first trimester
of pregnancy, in this study also, 61.1% of torsion
of ovarian tumor occurred in the first trimester of
pregnancy. The most common size of ovarian
tumor during pregnancy ranged from 6 to 10 cm,
and there was no difference in the average size of
the tumor and its location between the two groups.
In the histological comparisons, there was no
malignant tumor in the group that received the
elective operation, but there were two cases including the immature teratoma and mucinous adenocarcinoma in the group that received the
emergency surgery. The former was managed with
a unilateral adnexectomy and delivered a health
baby at 38 weeks gestation, the latter had received

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G.S.R. Lee et al. / International Journal of Gynecology and Obstetrics 85 (2004) 250254

six cycles of chemotherapy after cesarean hysterectomy and left adnexectomy at 35.5 weeks
gestation.
In conclusion, it seems likely that the conservative management of the low risk level of malignancy is better than the operative intervention
during the second trimester of gestation, even
though there is a possibility of emergency surgery
later, and the emergency surgery during pregnancy
may not result in higher adverse pregnancy outcome compared with elective surgery. Although
surgery for ovarian tumor in pregnancy is delayed
until the onset of symptoms, adverse pregnancy
outcome is not worsened when compared with that
after elective surgery. We propose that conservative
management would be used in optimal management of pregnant women with ovarian tumors.
References
w1x Katz VL, Watson WJ, Hansen WF, Washington JL.
Massive ovarian tumor complicating pregnancy. A case
report. J Reprod Med 1993;38:907 909.
w2x Whitecar P, Turner S, Higby K. Adnexal masses in
pregnancy: a review of 130 cases undergoing surgical
management. Am J Obstet Gynecol 1999;181:19 24.
w3x Hess LW, Peaceman A, OBrien WF, Winkel GA,
Cruikshank Morison JC. Adnexal mass occurring with
intrauterine pregnancy: report of fifty four patients
requiring laparotomy for definitive management. Am J
Obstet Gynecol 1988;158:1029 1034.

w4x Koonings PP, Platt LD, Wallace R. Incidental adnexal

neoplasms at cesarean section. Obstet Gynecol
1988;73:767 769.
w5x Shnider SM, Webster GM. Maternal and fetal hazards
of surgery during pregnancy. Am J Obstet Gynecol
1965;92:891 900.
w6x Nesson MJ, Cavalieri R, Graham D, sanders RC. Cysts
in pregnancy discovered by sonography. J Clin Ultrasound 1986;14:509 512.
w7x Usui R, Minakmi H, Kosuge S, Iwasaki R, Ohwada M,
Sato I. A retrospective survey of clinical, pathologic,
and prognostic features of adnexal masses operated on
during pregnancy. J Obstet Gynecol Res 2000;26:89
93.
w8x Ueda M, Ueki M. Ovarian tumors associated with
pregnancy. Int J Gynecol Obstet 1996;55:59 65.
w9x Novak ER, Lambrou CD, Woodruff JD. Ovarian tumors
in pregnancy: an ovarian tumor registry review. Obstet
Gynecol 1975;46:401 406.
w10x Buttery BW, Beischier NA, Fortune DW, Macafee CA.
Ovarian tumors in pregnancy. Med J Aust 1973;1:345
349.
w11x Caverly CE. Ovarian cyst complicating pregnancy. Am
J Obstet Gynecol 1931;21:566 574.
w12x Platek DN, Henderson CE, Goldberg GL. The management of a persistent adnexal mass in pregnancy. Am J
Obstet Gynecol 1995;173:12361240.
w13x Thornton JG, Wells M. Ovarian cysts in pregnancy:
does ultrasound make traditional management inappropriate? Obstet Gynecol 1987;69:717 721.
w14x Caspi B, Levi R, Appleman Z, Rabinerson D, Goldman
G, Hagay Z. Conservative management of ovarian cystic
teratoma during pregnancy and labor. Am J Obstet
Gynecol 2000;182:503 505.