Guideline for Management of Incidental Adnexal Masses Discovered During Cesarean Section

Indications for Intra‑operative Removal

Size‑Based Risk Assessment

Malignancy Considerations

Comparative Surgical Outcomes

Post‑partum Management of Small, Benign‑Appearing Masses

Recurrence Risk After Torsion

Treatment of Complex Cystic Adnexal Masses

Initial Risk Stratification

• The American College of Radiology recommends ultrasound features suggesting benign disease include: cysts <10 cm, distinct borders, no irregular solid components, thin septa, thin wall, absence of vegetations, and normal Doppler flow 5
• MRI with diffusion-weighted sequences can be added when ultrasound is indeterminate, achieving 95% accuracy in distinguishing benign from malignant lesions 5

Treatment Algorithm by Patient Category

Premenopausal Women

• For complex cysts <10 cm with benign features, laparoscopic cystectomy is preferred to preserve ovarian tissue and fertility, as recommended by the American College of Obstetricians and Gynecologists 6
• Surgical removal is mandatory for complex cysts ≥10 cm due to increased technical difficulty and torsion risk 6

Pregnant Women

• The American College of Obstetricians and Gynecologists indicates surgical intervention is necessary when symptoms develop, mass is ≥5 cm and persists beyond first trimester, or suspicion of malignancy exists 7, 8
• Laparoscopic approach is preferred over laparotomy, with benefits including shorter hospital stays, less pain, lower blood loss, and reduced risks of fetal loss and preterm birth 7, 8
• Critical technical considerations for pregnancy include left lateral decubitus positioning, insufflation pressure ≤12-15 mm Hg, port placement adjusted for fundal height, intraoperative capnography monitoring, and pre- and postoperative fetal heart rate monitoring 8, 9

Intraoperative Management

• The American College of Obstetricians and Gynecologists recommends against performing laparoscopy if ultrasound shows irregular solid components, thick septa, ascites, matted bowel, or CA-125 is elevated—these require laparotomy 5

Specific Histologic Subtypes

• Dermoid cysts are diagnosed by echogenic attenuating components with macroscopic fat and calcifications on ultrasound, and laparoscopic cystectomy is definitive treatment, as recommended by the American College of Radiology and the Society of Reproductive Surgeons 5, 6
• Endometriomas are identified by low-level internal echoes and nonvascular solid components, and cystectomy is preferred over drainage alone, according to the American College of Obstetricians and Gynecologists 5, 7
• Functional cysts and cystadenomas have a 70% resolution rate spontaneously, particularly in pregnancy, and observation is acceptable if <5 cm with benign features, as recommended by the American College of Radiology 5, 7

Intra‑operative and Peri‑operative Management of Concurrent Oophorocystectomy During Cesarean Section

Pre‑Operative Preparation

• In pregnant patients scheduled for cesarean delivery, involvement of an obstetrical anesthesiologist to review pregnancy‑specific physiologic changes and maternal comorbidities is recommended to optimize anesthesia safety. 10
• Cesarean‑based ovarian cyst removal should be performed at a facility that provides obstetric, neonatal, and pediatric services to ensure immediate care for both mother and newborn if complications arise. 10
• Informed consent must explicitly include the possibility that oophorectomy may be required if ovarian preservation is not technically feasible, allowing the patient to understand the potential loss of ovarian function. 11
• Positioning the mother in a left lateral tilt during the procedure is advised to maintain hemodynamic stability and placental perfusion; a right lateral tilt may be employed if it improves surgical exposure. 11

Surgical Access and Exposure

• The standard low‑transverse cesarean incision gives direct access to the adnexa, eliminating the need for additional laparoscopic ports when performing an ovarian cystectomy. 11
• After delivery of the infant and placenta, a systematic inspection of both adnexa is recommended to identify the target mass and assess the contralateral ovary. 11
• Mobilizing the uterus (e.g., gentle traction or uterine exteriorization) enhances visualization of the affected adnexa and facilitates safe cyst removal. 11

Hemostasis and Ovarian Bed Closure

• Meticulous hemostasis of the ovarian bed should be achieved using bipolar electrocautery to minimize postoperative bleeding and preserve ovarian tissue. 10

Intra‑Operative Maternal and Fetal Monitoring

• Maternal normocapnia must be maintained throughout the operation via standard anesthetic monitoring to avoid fetal acidosis. 10
• Continuous monitoring for maternal hypotension is essential because reduced maternal blood pressure can decrease placental perfusion and lead to fetal hypoxia. 11
• Anesthesiologists should recognize that fetal distress may manifest before any overt maternal hemodynamic changes, prompting immediate fetal assessment. 11

Post‑Operative Management

• Prophylactic antibiotics, administered according to standard cesarean‑section protocols, are recommended to reduce the risk of postoperative infection after concurrent cystectomy. 11