Question: Are there any management guidelines for a pregnant woman with an ovarian cyst? How to interpret CA 125 and other tumour markers in pregnant women?
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Answer: Three guidelines were identified:
A PatientPlus article "Ovarian Tumours and Fibroids in Pregnancy" says:
"Ovarian tumour markers are used mainly to monitor disease status during treatment, rather than as a diagnostic test, due to a lack of specificity. Several markers can be elevated due to pregnancy itself, e.g. CA-125, beta human chorionic gonadotrophin (beta-hCG)."
"Management.
Ovarian masses
- If the mass is thought to be benign and unlikely to cause complications, expectant management and follow-up scans are recommended.
- There is little evidence to support the routine laparoscopic excision of presumed benign ovarian tumours.
- Surgery after 15 weeks of gestation is indicated for large (greater than 5-10 cm in diameter) and/or symptomatic tumours and those that appear highly suspicious for malignancy (solid or mixed solid and cystic) on ultrasound.
- The extent of surgery is decided by the intraoperative findings showing whether the tumour is benign/malignant:
- Conservative surgery is indicated for benign masses/borderline ovarian tumours.
- More extensive surgery (including staging biopsies) for confirmed higher-grade malignancies.
- Rarely, chemotherapy may be given after delivery or at least after 20 weeks in order to minimise the potential fetal toxicity. The short- to medium-term fetal outcome appears to be relatively good."
A guideline from the Society of American Gastrointestinal and Endoscopic Surgeons published in 2011, makes the following recommendation:
"Laparoscopy is safe and effective treatment in gravid patients with symptomatic ovarian cystic masses. Observation is acceptable for all other cystic lesions provided ultrasound is not concerning for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions <6 cm in size (Low quality of evidence; Strong recommendation)."
The American College of Obstetricians and Gynaecologists Practice Bulletin "Management of Adnexal Masses" includes a section on the management of adnexal masses in pregnancy, which includes the recommendation:
"Most masses in pregnancy appear to have a low risk for both malignancy and acute complications and, thus, may be considered for expectant management"
(Evidence level IV)
One study of CA-125 levels in pregnant women with normal ovaries was identified (Aslam). This found that CA125 levels are increased at 11-14 weeks of gestation and cut off values which are used to assess the nature of ovarian cysts in nonpregnant women cannot be applied to pregnant women at this gestation.
(Evidence level III)
References:
- American College of Obstetricians and Gynaecologists Practice Bulletin 83. Management of Adnexal Masses. Obstet Gynecol 2007; 110: 201-14.
- Aslam N. Ong C. Woelfer B. Nicolaides K. Jurkovic D. Serum CA125 at 11-14 weeks of gestation in women with morphologically normal ovaries. BJOG: An International Journal of Obstetrics & Gynaecology. 107(5):689-90, 2000 May. Abstract Full text available to RCOG Fellows and Members
- PatientPlus. Ovarian Tumours and Fibroids in Pregnancy. 2011
- Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Los Angeles (CA): Society of American Gastrointestinal and Endoscopic Surgeons (SAGES); 2011
Search date: September 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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