1. ADNEXAL MASSES İN PREGNANCY
DR.EREN AKBABA
School of Medicine, Muğla
Sıtkı Koçman University

2. ADNEXAL MASSES İN PREGNANCY
Since the introduction of routine obstetric ultrasound examination adnexal masses are diagnosed more frequently than before.
The incidence of adnexal masses during pregnancy : 0,2-2%
With a 1-6% malignancy rate, the vast majority of these masses are benign (Hoover and Jenkins, 2011; Leiserowitz, 2006; Runowicz and Brewer, 2014; Telischak et al., 2008)
Of all malignant tumours of the ovary: %10 are metastases of other organs, mainly gastrointestinal or breast tumours.(Amant et al., 2010).
GEBELİKTE ADNEXİAL KİTLE İNSİDANSI YÜZDE İKİ İLE BİNDE İKİ ARASINDA
BUNLARIN %1-6 SI MALİGN
ÇALIŞMALAR GÖSTERİYORKİ GEBELİKTE TESPİT EDİLEN ADNEXAL KİTLE ORANI ARTARKEN MALİLGNİTE ORANI ARTMAMAKTADIR.

3. ADNEXAL MASSES İN PREGNANCY
Malignancy is not the only risk associated with adnexal mass.Masses that persist into the second trimester are at risk for torsion,rupture,or labor obstruction.
Torsion:%1-22
Rupture: %0-9
Obstruction of labor:%2-17
Leiserowitz G. 2006,Schmeler K.2005

4. ÇEŞİTLİ PREVALANS ÇALIŞMALARI VAR SONUÇLAR GEBELİKTE TESPİT EDİLEN ADNEXAL KİTLELERİN %6 CİVARINDA MALİGN OLDUĞU GÖRÜLÜYOR.

5. Clinical Obstetrics & Gynecology., March 2015.
GEBELİKTE ADNEXAL KİTLELERİN ÇOK BÜYÜK BİR KISMI BENİGN ,BENİGN GRUBTAN ENSIK DERMOİD KİSTE RASTLANIYOR.MALİGN GRUPTA YAŞ GENÇ GEBE GRUBUNDA GERM HÜCRELİ TÜMÖR OLAN DİSGERMİNOM DAHA İLERİ YAŞTA EPİTELYAL MALİGN OVER TÜMÖRLERİNE DAHA SIK RASTLIYORUZ.
Histopathology of adnexal masses removed in pregnancy. Benign ovarian masses account for the majority of masses diagnosed in pregnancy, most of which are mature cystic teratomas, corpus luteum cysts, and cystadenomas.
Clinical Obstetrics & Gynecology., March 2015.

6. ADNEXAL MASSES IN PREGNANCY: BASKENT UNIVERSITY EXPERIENCE Polat DURSUN, Filiz F. YANIK, Esra CABUK, Hulusi B. ZEYNELOGLU, Berk BILDACI, Esra KUSCU, Ali AYHAN Turk Soc Obstet Gynecol 2011
Histopathologic type, %
Dermoid cyst
%22,2
Serous cystadenom
%14.8
Mucinosis cyst
Endometrioma
%11.1
Morgagni cyst
Follicle cyst
Siderophagic cyst
Fibroma
Thecomata
%7.4
%3.7
POLAT DURSUN VE ARKADAŞLARININ YAPTIĞI BİR ÇALIŞMADA ENSIK DERMOİD KİSTE RASTLAMIŞLAR.

7. Ovarian cancer insidance :0.75 per 1000 deliveries.
Ovarian cancer during pregnancy Kazım Gezginç, Rengin Karataylı, Fatma Yazıcı, Ali Acar, Çetin Çelik, Metin Çapar Department of Obstetrics and Gynecology, Meram Medical School, Selçuk University, Konya, Turkey March 17 , Int J Gynaecol Obstet. 2011 
Ovarian cancer insidance :0.75 per 1000 deliveries.
Median age of diagnosis:26.5
Kazım gezginç ve arkadaşları DOĞUM İÇEREN KONYADAN YAPTIKLARI ÇALIŞMALARINDA gebelikte malign over tümörü sıklığını doğumda 75 olarak prevalans bildirmişlerdir.

8. Frequency of malignant and benign ovarian masses during pregnancy Archives of Gynecology and Obstetrics 2014(Ahmed Nazer ,Canada)
Ovarian mass
Per 10,000 deliveries
Total malignant ovarian masses
0.12
 Malignant neoplasm of ovary
0.11
 Fallopian tube
0.001
 Uterine adnexa
 Other specified sites of uterine adnexa
Neoplasm of uncertain behavior of ovary (LMP)
Benign adnexal mass 25
Ovarian mass in pregnancy
YAKLAŞIK 8 MİLYON DOĞUMU İNCELEYEN ÇOK MERKEZLİ ÇALIŞMADA OVER KANSERİ PREVALANSINI DOĞUMDA YAKLAŞIK 1.1 OLARAK VERMİŞLERDİR.

9. ADNEXAL MASSES İN PREGNANCY
Ovarian cancer is the second most common gynecological malignancy complicating pregnancy after cervical cancer.
In the premenopausal population adnexal masses found on examination are often incidentally, mostly benign and of little clinical significance.
One has to make a distinction between an ovarian mass and a non-ovarian mass
An adnexal mass in pregnancy can be complicated by torsion, rupture, or bleeding/infection, or labor obstruction.
Arch Gynecol Obstet Al-Halal H, Kezouh A, Abenhaim HA (2013)
OVER KANSERİ SERVİKSDEN SONRA GEBELİĞİ KOMPLİKE EDEN 2. ENSIK JİNEKOLOJİK KANSERDİR.ADNEXAL KİTLE OVARİANMI DEĞİLMİ,BENİGN Mİ MALİGNMİ,OPERE EDELİMMİ ETMEYELİMMİ,LAPARASKOPİ Mİ LAPARATOMİMİ YAPALIM OPERE ETMEZSEK TESPİT EDLEN KİTLE TORSİON RÜPTÜR KANAMA ENFEKSİYON DOĞUM OBSTRÜKSİYONU OLURMU SORULARINA YANIT BULMAYA ÇALIŞCAZ.

10. Imaging
Ultrasound is the most common diagnostic tool it is safe to use . Morphology is the most important determinant in distinguishing benign masses from malignancies.
Color Doppler imaging has been shown to significantly improve the ability to distinguish benign from malignant masses. The Doppler criteria show that malignant tumors will generally have lower blood flow impedance and higher blood flow velocity; these findings can also be seen in inflammatory lesions (Usui et al., 2000; Leiserowitz, ,Telischak et al., 2008; Hoover and Jenkins, Cohen-Herriou et al., 2013; Levine, 2014).
GEBEDE ADNEXAL KİTLENİN TANISINDA BENİGN MALİGN AYIRIMINDA EN ÖNEMLİ GÖRÜNTÜLEME ARACI ULTRASON,COLOR DOPPLER BENİGN MALİGN AYIRIMINDA MALİGN OVER TÜMÖRÜ SANTRALİNDEKİ DÜŞÜK DİRENÇLİ AKIMINI GÖSTERMEDE YARDIMCI.

11. Imaging
MRI Magnetic resonance imaging (MRI) can be safely used during the second and third trimester, although the use of gadolinium-based contrast material should be avoided because fetal safety has not been established .
MRI is particularly useful in making 3-dimensional images, distinguishing between different morphologic characteristics like bone of muscular tissue, e.g. leiomyomas,endometriomas and complex masses with solid compounds. (Runowicz and Brewer, 2004;Leiserowitz, 2006; Telischak et al., 2008).
MR GEBELİKTE GÜVENLİ BİR GÖRÜNTÜLEME ARACIDIR.ADNEXAL KİTLENİN OVARİANMMI PARAOVARİANMI OLDUĞUNU ANLAMADA KOMPLEX ÇOK BÜYÜK KİTLELERİN SINIRLARINI ANLAMADA DİĞER BATIN BÖLGELERİNİN DEĞERLENDİRİLMESİ ULTRASONDA BENZER GÖRÜNÜMLER VEREN OLUŞUMLARIN BİRBİRİNDEN AYIRIMINDA FAYDALI.

12. ADNEXAL MASSES İN PREGNANCY
Potential non-ovarian masses include pedunculated fibroids, hydrosalpinx or paraovarian cysts.
Fibroids appear as heterogeneous,solid masses
Hydrosalpinx present more as a tubular shaped structure. A hydrosalpinx can be difficult to distinguish from a malignant neoplasm due to the presence of nodules and thick endosalpingeal
folds.
Para-ovarian cysts are a common incidental finding and do not have any clinical significance.
(Chiang and Levine, 2004; Glanc et al.,2008; Levine, 2014)
HİDROSALPİNGSİN ZAMAN ZAMAN MALİGN KİTLELERDEN AYIRIMI ZOR OLABİLİR.

13. – Widespread appearance; ‘Ring of fire’ with Doppler.
Benign adnexal masses discovered during early pregnancy sonography with their morphologic appearance on ultrasound. (Giuntoli et al., 2006; Glanc et al., 2008; Hoover et al., 2011; Leiserowitz, 2006; Parsons, 2001; Telischak et al.,2008; Whitecar et al., 1999).
Type of mass
Sonographic features
1. Functional cyst
– Corpus luteum
– Widespread appearance; ‘Ring of fire’ with Doppler.
– Follicular cyst
– Mainly simple cyst < 10 cm, sometimes with debris.
– Haemorrhagic cyst
– Fine interdigitating lines (fishnet); solid compounds with concave outer lining. No flow with Doppler
2. Dermoid cyst
– Rokitansky nodule; a hyperechoic nodule with acoustic shadowing in a background of low-level echoes.
– ‘Tip of the iceberg’ phenomenon, where a highly echogenic cyst, contents of sebum and hair, causes posterior attenuation of sound.
– ‘Dermoid mesh’, multiple interdigitating lines and dots which are seen when hair is floting in sebum.
HEMORAJİK KİSTLERDE BALIK AĞI TARZINDA İNCE BAĞLANTILAR VE KAN AKIMI OLAMAMASI ANLAMLIDIR.

14. Type of mass
Sonographic features
3. Serous cystadenoma –
Large simple cyst > 5 cm.
– Thin septations or papillary formations.
4. Mucinous cystadenoma
– > 5 cm in diameter.
– Multiple septae.
– Heterogenic aspect
5. Endometrioma
– Round thick regular wall; diffuse homogenous low-level internal echoes (chocolate cyst).
– Calcifications with acoustic shadowing.
6. Leiomyomas
– Not attached to the ovary.
– Round regular wall.
– When outgrowing the blood supply central necrosis may be seen.
7. Paraovarian cyst
– 1-2 cm simple cysts.

15. Ultrasound/diagnostic features of adnexal mass
                                                                                                                                                                                                                                                                                                                                                            
Ultrasound/diagnostic features of adnexal mass

16. KORPUS LUTEUM BAZEN KİST İÇİ KANAMA VE PIHTILAŞMA SÜREÇLERİNE BAĞLI OLARAK DEĞİŞİG GÖRÜNÜMLER VEREBİLİRLER
KORPUS LUTEUM

17. WHİTE BALL GÖRÜNÜM.DERMOİD KİST VEYA DİSGERMİNOMDA KAN AKIMI İZLENMEMESİ TORSİYONU DÜŞÜNDÜRMELİDİR.

18. Sırasıyla müsinöz kistadenom, LMP(Low malignant potantial) müsinöz tm(USG), seröz kistadenokarsinom.

19. DİFFUZ HOMOJEN İNTERNAL EKO İZLENİR,NADİREN KALSİFİYE ODAKLAR VARDIR.
Endometriomada ayrı bir not düşmek gerekir çünkü progesteron nedeni ile nadiren duvarında kanlanma artışı ve desudializasyon olur buda malignensiyi takit edebilir.MR YARARLI OLABİLİR.
ENDOMETRİOMA

20. Pregnancy-associated changes of ovarian masses
Endometriomas can have a strongly changed appearance during pregnancy because of decidualized walls due to high levels of progesterone in pregnancy. A previous history of symptoms of endometriosis can be indicative. Glanc etal., 2008; Patel et al., 1999
ENDOMETRİOMALAR GEBELİKTEKİ YOĞUN PROGESTERON NEDENİ İLE ULTRASONOGRAFİK BAZI ÖZELLİKLERİNİN DEĞİŞTİĞNİ TEKRAR VURGULAMAK İSTERİM BU VAKALARDA AYIRICI TANIDA HASTA GEÇMİŞİ ENDOMETRİOZİS YÖNÜNDEN ÖNEMLİ.

21. ENDOMETRİOMA DUVARINDAKİ DECUDİALİZAYON VE TERATOM DAHİ WHİTE BALL GÖRÜNÜMÜ DİKKAT ÇEKİCİ.
Benign adnexal masses. Ultrasound images of an ovarian endometrioma (A) with characteristic homogenous echogenicity in a cystic mass, and a mature cystic teratoma (B) with heterogenous echogenicity and calcifications, both diagnosed in pregnancy. Images courtesy of Dr Bryann Bromley.

22. BU ULTRASON GÖRÜNTÜSÜNDE MALİGN ENDOMETRİOİD OVER KARSİNOMUNDAKİ PAPİLLER PROJEKSİYON.
Malignancy. Ultrasound image of an endometrioid ovarian adenocarcinoma with papillary projections diagnosed during pregnancy. Image courtesy of Dr. Bryann Bromley. .

23. Seröz kistadenom(USG)
İNCE SAPTASYONLARI OLAN SERÖZ KİSTADENOM GEBELİĞİN 16 HAFTASINA KADAR ÇOĞUKEZ GERİLER KAYBOLURLAR.
Seröz kistadenomlar müsinöz tümörlerden daha sıktır, fakat kural olarak musinöz tümörler kadar büyük boyutlara ulaşmazlar.
Seröz kistadenom(USG)

24. SERÖZ KİSTADENOMLARA GÖRE DAHA AZ SIKLIKLA BİLATERALDİRLER
SERÖZ KİSTADENOMLARA GÖRE DAHA AZ SIKLIKLA BİLATERALDİRLER.ÇOK BÜYÜK BOYUTLRA ULAŞABİLİRLER HORMON AKTİF DEĞİLLERDİR.
ÇOĞU ZAMAN GEBELİĞİN 16. HAFTASINA KADAR KAYBOLMAZLAR.
MÜSİNÖZ KİSTADENOM

25. GEBELİĞE EŞLİK EDEN ADENOMYOZİSDE ADNEKSİYAL KİTLELERİN AYIRICI TANISINDA AKILDA BULUNDURULMALDIR,OVERLE İLİŞKİSİ OLMAMASI YOĞUN KAN AKIMI VE İÇİNDEKİ LAKÜNER ALANLAR AYIRIMDA YARDIMCI OLABİLİR,MR AYIRICI TANIDA YARDIMCIDIR.

26. BALIK AĞI TARZINDA İNCE BANTLARIN OLDUĞU HEMORAJİK KİST
BALIK AĞI TARZINDA İNCE BANTLARIN OLDUĞU HEMORAJİK KİST.color dopplerde kan akımı izlenmez.
HEMORAJİK KİST

27. MULTİLOKULE THECA LUTEİN KİSTİ
ÖZELLİKLE GESTASYONEL TROFOBLASTİK HASTALIKLARDA İZLENEN TEKA LUTEİN KİSTLERİNİN CERRAHİYE İHTİYACI YOKTUR.
MULTİLOKULE THECA LUTEİN KİSTİ

28. For predicting a malignant tumor (M features)
IOTA (International Ovarian Tumor Analysis) simple rules. Adjusted from Timmerman et al., 2010.
Ultrasonic features
For predicting a malignant tumor (M features)
M1 – Irregular solid tumor
M2 – Presence of ascites
M3 – At least four papillary structures
M4 – Irregular multilocular solid tumor with largest diameter ≥ 100 mm
M5 – Very strong blood flow (colour score 4)
For predicting a benign tumor (B features)
B1 – Unilocular
B2 – Presence of solid components, of which largest solid component has largest diameter < 7 mm
B3 – Presence of acoustic shadows
B4 – Smooth multilocular tumor with largest diameter < 100 mm
B5 – No blood flow (colour score 1)
Rule 1: If one or more M features are present in absence of B feature, mass is classified as malignant.
Rule 2: If one or more B features are present in absence of M feature, mass is classified as benign.
Rule 3: If both M features and B features are present, or if no B or M features are present, result is inconclusive and second stage test is recommended.
ULTRASON ÖZELLİKLERİNE GÖRE BENİGN MALİGN AYIRIMINDA İNTERNATİONAL TÜMÖR ANALİS GRUBUNUN 2010 YILINDAKİ ÇALIŞMASI.

29. Pregnancy-associated changes of ovarian masses
When a pregnant patient presents with a symptomatic adnexal mass early in pregnancy, an ectopic pregnancy must always be ruled out since an undiagnosed ectopic pregnancy may have a potentially lethal outcome(.Runowicz and Brewer, 2014).
Other pregnancy associated masses are benign and typically present as bilateral cysts, except for luteomas who present as unilocular solid masses .(Leiserowitz, 2006;Hoover and Jenkins, 2011; Hoffman, 2014).
SEMPTOMATİK BİR GEBEDE EKTOPİK GEBELİK ilk olarak akla gelmeli MUTLAKA EKARTE EDİLMELİDİR.

30. Pregnancy-associated changes of ovarian masses
The most common pregnancy-associated ovarian masses are functional cysts like the corpus luteum of pregnancy and theca-lutein cysts. Most of these cysts will resolve after the first weeks of gestation but some, like the theca lutein cysts, can persist until after delivery. Masses still present after 16 weeks of gestation are predominantly nonfunctional.
(Chiang and Levine, 2004; Leiserowitz,2006; Glanc et al., 2008; Hoffman, 2014).
GEBELİĞN İLK HAFTASINDA TESPİT EDİLEN ULTRASONOGRAFİK ÖZELLİKLERİ BENİGN OLAN ADNEXİAL KİTLE GEBELİĞİN 16 . HAFTASINA KADAR KAYBOLMUYORSA ÇOĞUZAMAN NON FONKSİYONEL BİR ADNEXİAL KİTLEDİR.

31. Tumour markers
The reliability of tumour markers in the diagnosis and characterization of tumours during pregnancy is often debated. During pregnancy elevations of tumour markers are mostly associated with the normal physiologic changes of pregnancy and presence of obstetric complications(miscarriage,preeclampsia,HELLP)
(Han et al., 2012)
GEBELİKTE TM MARKERLARI YÜKSELDİĞİNDEN KULLANIMI OLDUKÇA SINIRLIDIR.

32. Ca 125 in ilk tremesterde ve gebeliğin son haftalarında fizyolojik yüksektir 2 trimesterde ve gebelik sonrası anlamlı olabilir.

33. Tumour markers
When an ovarian mass is diagnosed in pregnancy, CA-125 levels may help to distinguish between a benign or malign lesion and can be used to evaluate treatment(Giuntoli et al., 2006; Leiserowitz, 2006).
However,decidua- and amnion cells also produce CA-125 resulting in higher CA-125 levels during pregnancyespecially in the first and third trimester (respectively because of trophoblast invasion and detachment of the placenta). Tumour markers associated with germ cell tumours (e.g. AFP and b-hCG) and granulosa cell tumours
(Inhibine B and AMH) can also be elevated in normal pregnancy and can therefore only be used as follow-up .(Leiserowitz, 2006).
Diğer tümör markerlarıda gebelikte yükselir

34. Gebelikte tespit edilen adnexial kitlelere yaklaşım konusunda birçok araştırmacı çalışmalar yapmıştır.

36. Surgery during pregnancy (open vs laparoscopy)
The clinician needs to make a careful decision when to operate,
1.Too early (risk of miscarriage and loss of luteal function before the fourth month of pregnancy)
2.Too late (complications as torsion, rupture or bleeding, progression in case of malignancy, premature labour) can affect the patient and fetus.
Çok erken cerrahi uygularsak luteal fonksiyonu bozup abortusa neden olabiliriz,fakat çok geç kalıp dahada ilerlemiş bir over kanseri yada torsiyon rüptür ,kanama ,preterm doğum ile komplike olmuş bir olgu ilede karşılaşabiliriz.

37. Surgery should be considered in 3 general groups
1.Acut symtomatic with signs and symptoms of ovarian torsion or hemodynamically unstable due to cyst rupture.
2.Suspicious for malignancy
3.Larger adnexal masses that are at higher risk of the above complications.
AJOG 2011
AKUT TORSİON YADA KİST RÜPTÜRNE BAĞLI HEMODİNAMİC OLARAK UNSTABİL HASTALAR
MALİGNENSİ ŞÜPHESİ YÜKSEK HASTALAR
VE BU KOMPLİKASYONLARIN YAŞANMASI İHTİMALİ YÜKSEK OLAN HASTALARDA YAKLAŞIM CERRAHİDİR.

38. Surgery during pregnancy (open vs laparoscopy)
A midline laparotomy with minimal uterine manipulation is preferred in case of an open approach.
Laparoscopy :A guideline from the The Society of American Gastrointestinal and Endoscopic Surgeons, published in 2008, the following recommendations specific to performing laparoscopy during pregnancy.
Yumi H. Surg Endosc 2008
Laparatomide uterusun mümkün olduğunca az manüplasyonu önemlidir.

39. Surgery during pregnancy (open vs laparoscopy)
Laparoscopy is safe and feasible when specific guidelines are followed. 1.Laparoscopic management nonemergent cases should be optimally scheduled between 16 and 20 weeks of gestation, based on the time allowed for spontaneous resolution, the optimized visualisation of the mass in contrast with the enlarged uterus, and the decreased ratio of premature labour.
Adnexial kitle nedeni ile laparaskopi gebelik haftaları arasında yapılması önerilir,bu bize adnexial kitlenin spontan gerilemesi için bir şans verilmesi,adnexlerin rahatça görülebildiği bir dönem olması ve preterm doğum ihtimalinin daha ileri haftalara göre düşük olması avantajlarını sunar.

40. Surgery during pregnancy (open vs laparoscopy)
2.Important to consider is the position of the patient to avoid hypovolemia, hypotension and hypoxemia by the slowly change to Trendelenburg allowing only mild inclination, and from 20 weeks of gestation onwards, using the left lateral tilt position. 3.The preferred method for primary trocar insertion should be the open laparoscopy and supra-umbilical port placement to limit the possibility of uterine perforation by insertion of a Veress needle. (Hassan technique). Veress needle is not contraindicated.The surgeon may consider using the veress needle in conjunction with ultrasound guidance.
Özellikle 20. gebelik haftasından sonraki vakalarda uterusun vena kavaya basısı nedeni ile oluşabilecek hipotansiyon ve hipoksiden kaçınmak amacı ile hafif trendelenburg sağa ya da sola yatık pozisyon tercih edilmelidir.

41. Surgery during pregnancy (open vs laparoscopy)
4. Trochars should be placed at least 6cm above the fundus or in the left upper quadrant.
5. Intraoperativ CO2 monitoring by capnography should be used.
6. Intraoperative abdominal pressure should be maintained less than 15mm/hg while in trendelenburg position to ensure adequate venous return and uteroplacental sufficiency.

42. Surgery during pregnancy (open vs laparoscopy)
7. The CO2 pneumo-peritoneum and CO production during electrocoagulation do not seem to be detrimental to the fetus when a maximum pressure of mmHg, an experienced surgeon and limited operation time is considered (Han et al., 2014; Ko et al., 2009). 8. At this time there is no indication for prophylactic tocolysis for antenatal surgery.

43. Surgery during pregnancy (open vs laparoscopy)
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``

44. Guidelines for Diagnosis, Treatment, and Use of Laparoscopy for Surgical Problems During Pregnancy Prepared by the Society of American Gastrointestinal and Endoscopic Surgeons Guidelines Committee .

45. Early stage ovarian cancer (borderline and invasive)
For early stage ovarian cancer, stage I and II according to the International Federation of Gynecologyand Obstetrics (FIGO), standard surgical procedure consisting of hysterectomy, bilateral adnexectomy, omentectomy, cytology, biopsies and lymphadenectomy should be aimed for. (Prat J and FIGO Committee on Gynecologic Oncology, 2014) For early stage disease, fertility- and pregnancy preserving treatment may be considered. In these selected cases surgery includes removal of the adnex and surgical staging (cytology, peritoneal biopsies, omentectomy and appendectomy in mucinous tumours). (Prat J and FIGO Committee on Gynecologic Oncology, 2014).
ERKEN EVRE STAGE 1-2 OVER KANSERLİ GEBE VAKALARDA SİTOREDÜKTİF CERRAHİ ÖNERİLİR.
BU HASTALAR GEBELİĞİN YADA FERTİLİTENİN DEVAMINI İSTİYORSA ADNEX ÇIKARILIR SİTOLOJİ PERİTONEAL BİOPSİ OMENTEKTOMİ LENFADENKTOMİ MÜSİNÖZ TÜMÖRLERDE APENDEKTOMİ EKLENİR.

46. Early stage ovarian cancer (borderline and invasive)
For invasive epithelial ovarian carcinoma, grade I and diagnosed at FIGO stage Ia, fertility- and pregnancy preserving management can also be performed(Prat J and FIGO Committee on Gynecologic Oncology, 2014) Restaging after delivery may be considered because of occult extra-ovarian disease, which may not be assessed adequately during pregnancy (Amant et al., 2010; Morice et al., 2012).
Non-epithelial tumours (germ-cell and sex-cord stromal tumours), which frequently present as bulky masses, are over 90% diagnosed at FIGO stage Ia and therefore are also treated by a resection and surgical staging (Mancari et al., 2014).
For high grade stage I and any stage II disease, standard adjuvant chemotherapy (carboplatin-paclitaxel) can be considered.
İNVAZİV GRADE 1 STAGE 1A TÜMÖRLEDE FERTİLİTE VE GEBELİĞİN DEVAMI YÖNÜNDE İSTEĞİ VARSA ORGAN VE GEBELİĞİ KORUYUCU CERRAHİ YAPILIP DOĞUM SONRASI RESTAGİNG CERRAHİ ÖNERİLİR.
NON EPİTELYAL TÜMÖRLER ÇOĞU KEZ KİTLE BÜYÜK OLDUĞUNDAN VE ÇOĞU KEZ STAGE 1 A OLDUKLARINDAN KİTLE EKSİZYONU CERRAHİ STAGİNG ÖNERİLİR.
YÜKSEK GRADELİ STAGE 1-2 HASTALARA ADJUVAN KEMOTERAPİ UYGULANMALIDIR.

47. Advanced stage ovarian cancer (borderline and invasive)
In unilateral borderline tumours, a laparoscopic procedure without spilling is possible
In case of higher stage disease in borderline tumours,adnexectomy/biopsy during pregnancy is aimed for, followed by completion of surgery after delivery.
Since chemotherapy is not effective for borderline disease and given the indolent nature, an otherwise conservative approach during pregnancy is advised.
YÜKSEK GRADE Lİ BORDERLİNE OVER TÜMÖRLÜ GEBELERE ADNEKSOTOMİ /BİOPSİ DOĞUM SONRASI TAMAMLAYICI CERRAHİ ÖNERİLİR.
KEMOTERAPİ BU HASTALARA ÖNERİLMEZ.

48. Advanced stage ovarian cancer (borderline and invasive)
Similar, the performance of complete cytoreductive surgery for advanced stage invasive (FIGO stage III) ovarian cancer is not possible during pregnancy. In most reported cases of advanced invasive disease, patients chose to terminate pregnancy when diagnosis has been made early in the first trimester of pregnancy (Mancari et al., 2014).
İLERİ EVRE OLGULARDA GEBEYKEN TAM BİR SİTOREDÜKTİF CERRAHİ YAPILAMIYACAĞINDAN GEBELİĞİN TERMİNASYONU SONRASINDA CERRAHİ DÜŞÜNÜLMELİDİR.

49. Advanced stage ovarian cancer (borderline and invasive)
When the patient wants to proceed the
pregnancy, neoadjuvant chemotherapy (carboplatin and paclitaxel) until fetal maturity and complete cytoreductive surgery after delivery is recommended from midpregnancy onwards (Amant et al., 2014).
İLERİ EVRE OVER KANSERLİ GEBELER GEBELİĞN DEVAMINI İSTİYORLARSA KEMOTERAPİ FETAL MATÜRASYONUN TAMAMLANMASINDAN SONRA DOĞUM VE SİTOREDÜKTİF CERRAHİ ÖNERİLİR.
BU HASTALARDA TERCİHAN VAJİNAL DOĞUM ÖNERİLEBİLİR.

50. İncidental adnexal masses at caesarean section
İncidence 1/200-1/400
Mostly benign
Prefered cyst excision
Frozen section
The incidence of malignant tumors: 0,21/1000 C/S
%15,38(2/13)MGHOT
%23,08(3/13)MEOT
%61,54(8/13)BOT
All in stage I
Lixiao et al ,2011
Schortz et al,2009
SEZERYAN ESNASINDA İNCİDENTAL RASTLANAN ADNEXİAL KİTLE ORANI YAKLAŞIK SEZERYAN DOĞUMDA 1 DİR .BUNLARINDA ÇOĞU BENİGNDİR .
SEZERYAN ESNASINDA İNCİDENTAL RASTLANAN ADNEXİAL KİTLELERDE KİST EKSİZYONU VE FROZEN ÖNERİLMEKTEDİR.

51. İncidental adnexal masses at caesarean section.
ÜLKEMİZDENDE OLAN ÇEŞİTLİ ÇALIŞMALAR VARDIR.SEZERYAN ESNASINDA RASTLANAN ADNEXİAL KİTLE ORANLARINI BENZER SUNMUŞLARDIR.

52. Surgical risk in pregnancy
The traditional management of an adnexal mass in pregnancy has been surgical.However , surgery includes the add risks of fetal loss,preterm contractions,and an increased risk of embolic events.
AJOG 2011
GEBELİKTE ADNEXİAL KİTLE TESPİT EDİLEN OLGULARDA SEZERYAN,HİSTEREKTOMİ,VENÖZ TROMBO EMBOLİ,PRETERM DOĞUM ,SPONTAN ABORTUS ORANLARI ARTMIŞTIR.
ÇEŞİTLİ YAYINLARDA BUNU DESTEKLEMEKTEDİR.

53. Hysterectomy VTE Cesarean section
Comparison of obstetrical outcomes in delivering women with benign and malignant adnexal masses.Archives of Gynecology and Obstetrics 2014
Outcomes
Controls
Benign ovarian masses
Malignant adnexal masses %
Adjusted ORa (95 % CI)
P value
Abruptio placentae
1.09
1.46
0.84 (0.75–0.95)
0.004
2.79
1.15 (0.46–2.86)
0.76
Postpartum hemorrhage
2.67
2.10
0.96 (0.87–1.07)
0.5
0.26 (0.09–0.75)
0.012
Infection of amniotic cavity
2.02
2.97
1.02 (0.94–1.11)
0.60
3.35
1.06 (0.47–2.41)
0.88
Eclampsia
0.08
0.10
0.75 (0.48–1.16)
0.20
0.56
3.10 (0.43–22.31)
0.26
Preeclampsia
3.90
6.38
1.12 (1.05–1.19)
<0.001
0.40 (0.16–0.98)
0.04
Blood transfusion
0.90
1.62
1.09 (0.97–1.22)
0.17
5.03
1.20 (0.51–2.85)
0.67
Hysterectomy
0.28
1.65 (1.25–2.19)
0.005
6.70
60.90 (27.38–135.53)
VTE
0.22
0.36
1.27 (1.00–1.61)
0.05
2.23
5.52 (1.96–15.53)
0.001
DIC
0.03
0.06
0.87 (0.48–1.61)
0.66 –
Maternal death
0.01
0.02
1.16 (0.43–3.13)
0.50
6.78 (0.84–54.45)
0.072
Cesarean section
31.26
77.50
7.36 (7.11–7.62)
76.5
5.92 (4.17–8.41)
Forceps delivery
1.00
0.77 (0.58–1.01)
0.061
Vacuum delivery
4.68
1.10
0.70 (0.61–0.81)
GEBELİKTE ADNEXİAL KİTLE TESPİT EDİLEN OLGULARDA ÖZELLİKLEDE MALİGN GRUBTA SEZERYAN,HİSTEREKTOMİ,VENÖZ TROMBO EMBOLİ,PRETERM DOĞUM ORANLARI ARTMIŞTIR.

54. Comparison of fetal outcomes in delivering women with benign and malignant adnexal masses
Controls
Benign ovarian mass
Malignant adnexal mass %
Adjusted ORa 95 % CI
P value
IUGR
1.95
2.37
0.93 (0.84–1.02)
0.11
0.56
0.20 (0.03–1.42)
IUFD (intrauterine fetal demise)
0.67
0.44
0.92 (0.75–1.14)
0.50
0.75 (0.10–5.42)
0.78
Preterm birth (<37 weeks)
7.39
9.24
0.99 (0.94–1.05)
0.79
18.4
2.24 (1.48–3.42)
<0.001
Preterm rupture of membrane
1.13
1.17
0.95 (0.82–1.09)
0.43
2.23
0.83 (0.29–2.38)
0.74
GEBELİKTE ADNEXİAL KİTLE TESPİT EDİLEN OLGULARDA SEZERYAN,HİSTEREKTOMİ,VENÖZ TROMBO EMBOLİ,PRETERM DOĞUM ORANLARI ARTMIŞTIR.

55. CHEMOTHERAPY İN PREGNANCY
First trimester :Should be avoided secondary to tetratogenic effects on the fetus;
Second and Third trimesters :Safe.
Growth and functional impairment are of greater concern than fetal malformation. Doll, D.C., Q.S. Ringenberg, and J.W. Yarbro, Antineoplastic agents and pregnancy.
(Paclitaxel and cisplatin chemotherapy)
Nevertheless, there should be some side effects in mind(Neutropenia and thrombocytopenia ,Spontaneous abortion)
Aviles, A., et al., Growth and development of children of mothers treated with chemotherapy during pregnancy:. Am J Hematol, ,Marret H et al ,2010
KEMOTERAPİ İLK TRİMESTERDE TERATOJENİK ETKİLERİ VARDIR.
2-3.TRİMESTERDE GÜVENLİDİR YİNEDE NÖTROPENİ TROMBSİTOPENİK ETKİLERİ DOĞUMU GÜÇLEŞTİRBİLİR.

56. Conclusion
Ovarian cysts or masses during pregnancy should be accurately evaluated to decide the most appropriate treatment option.
Ultrasound and MRI are safe and allow distinguishing between benign and malignant lesions.
A wait-and-see strategy is advised for an ovarian cyst with benign features.
Masses with septa, solid components, papillary or nodules, or when persisting after 16 weeks of pregnancy should be further investigated.
GEBELİĞE EŞLİK EDEN ADNEXİAL KİTLELERİN ÇOĞU BENİGN OLMAKLA BERABER DOĞRU YAKLAŞIM SUNMAK İÇİN DİKKATLİ DEĞERLENDİRİLMELİDİR.
ULTRASON VE MR BENİGN MALİGN AYIRIMINDA GÜVENLİ ENSTÜRMANLARDIR.
16 .GEBELİK HAFTASININ SONRASINDA DEVAM EDEN SEPTALI KİSTLER,SOLİD ALAN -PAPİLLER YAPI İÇEREN OVARİAN KİTLELER DAHA FAZLA İNCELEMEYE İHTİYAÇ DUYAR.

57. Conclusion
Laparoscopy is safe and feasible, and both maternal and perinatal outcomes are favorable.
If corpus luteum is removed before 8 weeks, then progesterone supplement should be given.
LAPARASKOPİ BELİRLENMİŞ KOŞULLARA UYMAK KAYDIYLA ANNE VE BEBEK İÇİN TERCİH EDİLEBİLİR.
LAPARASKOPİNİN BU HASTALARDA BELKİDE EN BÜYÜK AVANTAJİ VENÖZ EMBOLİ RİSKİNİN LAPARATOMİYE GÖRE DÜŞÜK OLUŞUDUR.
8 HAFTANIN ALTINDA OVARİAN CERRAHİ GEÇİRENLERE PROGESTERON DESTEĞİ VERİLMELİDİR.

58. Conclusion
When advanced stage invasive ovarian cancer is diagnosed, termination of pregnancy may be considered in early pregnancy, otherwise chemotherapy can be administered during second and third trimester.
Treatment options should be discussed for each patient individually.
When there is high suspicion of malignancy, a multidisciplinary approach is necessary, and preferably patients should be referred to centres with specialized experience.
İLERİ EVRE OVER KANSERLİ ERKEN GEBELİK DÖNEMİNDEKİ HASTALARA GEBELİĞİN SONLANDIRILMASI ÖNERİLMELİ,
2-3. TRİMESTERDE KEMOTERAPİ GÜVENLİDİR.
YİNEDE TEDAVİ SEÇENEKLERİ HASTALAR İÇİN BİREYSELLEŞTİRLİMELİDİR.

59. DİNLEDİĞİNİZ İÇİN TEŞEKKÜRLER