Conservative management of a symptom-free adnexal mass with a benign aspect on ultrasound examination can be justified until the 16th week of gestation for two reasons. First, it is stated that an adnexal mass before the 16th week of gestation is often a functional cyst and the incidence of these cysts after 16 weeks is minimal [1, 3]. However, in our series one patient still had a persistent functional cyst after this period (case no. 9). Second, we have to consider the direct risk of surgery to the foetus early in pregnancy. Surgery is thought to be related to an increased risk of spontaneous abortion. Although laparoscopy in the third trimester has been described by some authors, it causes technical difficulties due to the enlarged uterus (Table 2) [17, 18]. Therefore, in our opinion, if laparoscopy is necessary, the second trimester seems to be the optimum period for surgery to be performed.
In our opinion, even in cases with suspicion of a malignant adnexal mass without additional features of malignancy on ultrasound (e.g. ascites, omental cake), a primary diagnostic laparoscopy is mandatory (Fig. 1) . The peritoneal cavity and pelvic mass can be inspected for macroscopic malignant features. The advantage of this sequence is that origin, location and size of the pelvic mass can be determined. If the surgeon decides to convert to laparotomy, the location and size of the incision can be adjusted to the laparoscopic findings (case no. 7) . However, in this context, we have to consider that, even in experienced hands, for macroscopic qualification of an adnexal mass the false-positive findings for malignancy were as high as 53% . Additional to ultrasound, in case of uncertainty of the origin of the mass, pre-operative MRI can give additional information .
Determination of CA-125 as a predictor of ovarian malignancy is shown not to be useful in pregnancy , since its level is frequently elevated in normal pregnancy. CA-125 has a low specificity (69%), which leads to many false positive findings (22%) .
A major concern with regard to laparoscopic procedures during pregnancy is the initial insertion of the Veress needle and the first trocar. In contrast to general surgery , in gynaecology no official guidelines are available concerning the laparoscopic approach during pregnancy. General surgeons’ published data suggest that the open laparoscopic entry technique is preferred in pregnancy so that entry-related complications may be avoided . Although the closed entry technique in gynaecology should not be abandoned , in the case of pregnancy we advocate the use of the open entry technique. Although our series do not give enough evidence to support the abandoning of the closed entry technique in pregnancy, we have to bear in mind that an ovarian cyst, when located in the pouch of Douglas, can lift the uterus and increase the chance of injury by the sharp instruments. In addition, the risk of penetration of the adnexal mass during the closed entry technique is possible, with the adverse effect of spillage of cystic content . However, a closed entry technique can be considered when the size of the pelvic mass is less than 12 weeks of gestation. In our series no entry-related complications for either entry technique was experienced.
When feasible, if the patient is of reproductive age we recommend ovarian cystectomy, both in pregnant and non-pregnant women, to preserve ovarian tissue. Unfortunately, in case no. 6 cystectomy was not feasible, due to adhesions, and ovarian tissue could not be spared.
In this study the mean duration of laparoscopic cystectomy was 76 min and that of laparoscopic adnexectomy was 70 min. Neither procedure is more time consuming. Performing cystectomy in pregnant patients, we encountered no difficulties or excessive blood loss.
Four patients received prophylactic tocolytic agents. Nowadays, the routine use of prophylactic tocolysis is shown to be ineffective [1, 16], thus, in our clinic, tocolysis is given only to patients who are suffering from postoperative uterine irritability, in contrast to the practice by Mathevet et al. .
An adnexal mass during pregnancy that requires surgery is a relatively rare phenomenon and is still a dilemma for clinicians. Although reports of small series on this subject are published (approximately 210 cases) it is still important for more data and evidence to be collected in order for this problem to be treated optimally. We have to consider that, for many reasons, e.g. surgeons’ experience and preferences, it is difficult for one to carry out randomised prospective studies for surgical evaluation .
Our algorithm in Fig. 1 shows how we support the guidelines of general surgeons in performing open laparoscopy in pregnant women in order to avoid entry-related complications to the uterus and adnexal mass.