Adnexal Masses in Pregnancy: A single centre prospective observational cohort study

Adnexal Masses in Pregnancy: A single centre prospective observational cohort study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 20 July 2024 V1 Latest version Share on Adnexal Masses in Pregnancy: A single centre prospective observational cohort study Authors : Jonathan Gaughran 0000-0002-4469-429X [email protected] , Catherine Magee , Caroline Knight , Sian Mitchell , and Ahmad Sayasneh Authors Info & Affiliations https://doi.org/10.22541/au.172144630.07716457/v1 Published Diagnostics Version of record Peer review timeline 274 views 116 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective To prospectively determine the nature of adnexal masses diagnosed during pregnancy, and investigate whether ultrasound was a reliable means of assessing these. Design A single centre prospective observational cohort study. Setting A large tertiary referral London Hospital. Population Pregnant women with an adnexal mass detected at or prior to the 12-week routine antenatal ultrasound. Methods A detailed ultrasound by a level II ultrasound practitioner at the time of detection; at 12 weeks; 20 weeks and 6 weeks postpartum. Main outcome measures Subjective impression of mass; International Ovarian Tumour Analysis simple rules classification; resolution and intervention rate; incidence of complications related to the mass. Results The incidence was 1%. 274 participants were included. Subjective impression was: simple 75.9%; dermoid 29.1%; endometrioma 6.6%; haemorrhagic 3.3%; para-ovarian 2.6%; torted simple 0.7%; decidualized endometrioma 0.4%; fibroma 0.4%; theca luteal 0.4% and borderline ovarian tumour: 0.7%. There was a significant reduction in the volume at each scan (P <0.0001). 74.2% of masses resolved spontaneously. Surgery was performed in 14/274: 2 antenatally, 6 at Caesarean Section and 6 post-partum. In 5/247 (2%) there was complication due to the mass. Using IOTA simple rules, 272/274 (99.3%) (p<0.0001) were classifiable. Only 1/274 (0.4%) had malignant features as per IOTA (p=0.05). As there was no confirmed malignancy, the accuracy of IOTA simple rules could not be calculated. Conclusion Adnexal masses in pregnancy are uncommon and the majority spontaneously resolve. Malignancy is rare, as are complications. In the absence of concerns regarding malignancy or cyst accident, there is no need for additional monitoring of these masses during pregnancy. Title Page Title: Adnexal Masses in Pregnancy: A single centre prospective observational cohort study Running Title: Adnexal Masses in Pregnancy Authors: Jonathan Gaughran *1,2 , Catherine Magee 1 , Judith Hamilton 1 , Caroline Knight 2,3 , Sian Mitchell 1, 2 , Ahmad Sayasneh 2,4 . * Corresponding author: [email protected] . T: +447825162136 1 Guy’s & St Thomas’ Hospitals, Women’s Health, London, UK. 2 King’s College London, School of Life Sciences, London, UK 3 Guy’s and St Thomas’ Hospitals NHS Trust, Fetal Medicine, London UK 4 Guy’s and St Thomas’ Hospitals, Gynaecological Oncology, London, UK Objective To prospectively determine the nature of adnexal masses diagnosed during pregnancy, and investigate whether ultrasound was a reliable means of assessing these. Design A single centre prospective observational cohort study. Setting A large tertiary referral London Hospital. Population Pregnant women with an adnexal mass detected at or prior to the 12-week routine antenatal ultrasound. Methods A detailed ultrasound by a level II ultrasound practitioner at the time of detection; at 12 weeks; 20 weeks and 6 weeks postpartum. Main outcome measures Subjective impression of mass; International Ovarian Tumour Analysis simple rules classification; resolution and intervention rate; incidence of complications related to the mass. Results The incidence was 1%. 274 participants were included. Subjective impression was: simple 75.9%; dermoid 29.1%; endometrioma 6.6%; haemorrhagic 3.3%; para-ovarian 2.6%; torted simple 0.7%; decidualized endometrioma 0.4%; fibroma 0.4%; theca luteal 0.4% and borderline ovarian tumour: 0.7%. There was a significant reduction in the volume at each scan (P Conclusion Adnexal masses in pregnancy are uncommon and the majority spontaneously resolve. Malignancy is rare, as are complications. In the absence of concerns regarding malignancy or cyst accident, there is no need for additional monitoring of these masses during pregnancy. Key words: ultrasound, cyst, ovary, mass, IOTA, pregnancy, adnexa. No Funding was awarded to conduct this research. Introduction Adnexal masses in pregnancy are uncommon, with the incidence ranging from 1 in 76 to 1 in 2328. (1) The incidence appears to be rising which is likely to be multifactorial. (2) As ultrasound technology and its availability improve, detection is likely to increase. (3) Additionally, due a steady rise in the age at which women are having their first child, matched with the fact that both benign and malignant adnexal masses are more common with advancing age, the prevalence of adnexal masses in pregnancy is likely to increase. (4), (5) The majority are asymptomatic and detected during routine antenatal care. (6, 7) Malignancy in this cohort is rare, and the risk of adnexal torsion is 1-6% lower than in non-pregnant women. (8-10) As operating during pregnancy is associated with risk of adverse fetal and maternal outcomes, conservative management is favoured when safe. (11) The assessment of the adnexa during routine antenatal ultrasound is a form of opportunistic screening, for which there is no evidence basis. Ultrasound may be less reliable in pregnancy for a number of reasons. As the uterus expands, the adnexa may not be visible trans-vaginally, meaning the trans-abdominal approach must be employed which is believed to be less accurate. (12) Additionally, alterations in utero-ovarian blood flow may alter Doppler findings. (13) Endometriomas may undergo alterations driven by hormonal changes known as decidualization which mimic malignancy on ultrasound, and rarer masses specific to pregnancy such as luteomas may be detected. (14-16) While guidelines exist on the management of adnexal mass in pre – and post-menopausal women, currently none exist for pregnancy, and ultrasound tools such as International Ovarian Tumour Analysis (IOTA) have not been validated. (4, 17) With a poor evidence base and a potential growing incidence, the need to offer evidence based guidance is paramount. (18) The primary aim of this study was to determine the nature of adnexal masses diagnosed in pregnancy; to monitor their spontaneous resolution, complication and intervention rate. The secondary aims were to determine if ultrasound by a level II practitioner is a reliable means of assessing this pathology; to assess whether IOTA simple rules are accurate in pregnancy, and when available, to compare histology to ultrasound findings. Methods This was a single centre prospective observational cohort study run between January 2019 and August 2021, with approval from the South London Research & Ethics Committee (8/LO/1033). Potential participants were identified either whilst attending the Early Pregnancy Unit (EPU) for an emergency ultrasound scan in early pregnancy, or by staff performing routine antenatal dating scans. Any pregnant woman (confirmed on ultrasound or by positive urinary or serum human chorionic gonadotropin) over the age of 16 years with at least one adnexal mass (excluding corpora lutea of <30mm) were eligible . (7) Anyone with a personal history of ovarian malignancy or a Borderline Ovarian Tumour (BOT) was excluded. Patient demographics and medical history were recorded. All participants received study specific ultrasound assessment of their adnexal mass at the time of detection, at the time of the routine dating scan (11-14 weeks), at the anomaly scan (18-22 weeks) and approximately 6 weeks post-partum. Scans were performed by level II ultrasound practitioners with appropriate expertise and certification in gynaecology ultrasound. (19, 20) All images were subsequently reviewed by level III ultrasound practitioners from the research group (JG or AS) and if any disagreement or uncertainty, the patient was asked to return for a further scan by a level III practitioner. All ultrasound scans were performed using a Voluson ® E8 or E10 (GE Healthcare Ultrasound, Milwaukee, Wisconsin, USA) and findings documented on Astraia© (Ismaning, Germany). Early pregnancy, 12-week and postpartum scans were performed trans-vaginally as the default with conversion to trans-abdominal as required, using the machine’s ‘Gynaecology’ pre-setting. The default for all 20-week scans was a trans-abdominal approach due to displacement of the adnexa by the expanded uterus and the machine’s ‘obstetric first trimester’ pre-setting was used. The adnexal mass volume (ml) was calculated using the prolate ellipsoid formula (L x H x W x 0.52). A subjective impression based on pattern recognition was assigned and IOTA simple rules features were recorded using a pre-populated proforma on Astraia© and the resultant impression of ‘benign’, ‘malignant’ or ‘unclassifiable’ documented. (21) The hospital electronic records were accessed for operative notes as well as MRI and histology results. As per the consent form, any incomplete data from patients who withdrew or were lost to follow up were included in the analysis. Statistical Analysis: Statistical analysis was performed using MedCalc  (MedCalc version 20.010, Belgium, 2018). (22) A power calculation was based on the likelihood of a diagnosis of the least common complication of adnexal masses in pre-menopausal women: malignancy, and was determined to be a sample size of 26,616. Statical significance was determined as a P value of <0.05. A 95% confidence interval was calculated for incidence rates, Paired T-Tests were used to assess changes in the adnexal mass volume, and a 2-way Chi-squared test was used to check for correlation between variables. (23, 24) Results During this 31-month period, 13,956 pregnant patients were scanned in the EPU as an emergency, and 14,727 routine 12-week antenatal scans were performed giving a total of 28,683. Adnexal masses were detected in 277 patients, yielding an incidence of 1% (277/28,683). Two patients declined to participate in the study and one was not eligible due to a recent diagnosis of a serous BOT. As such, 274 patients were included in the analysis. The mean age at diagnosis was 32.03 years (range: 19-45 years) . Ethnicity was documented as: White in 165/274 (60.2%); Black in 80/274 (29.2%); Asian in 22/274 (8.0%); Arabic in 6/274 (2.2%) and Mixed Race in 1/274 (0.4%). The mean gravida and parity were 1.94 (median: 1.00) and 0.53 (median: 0.00) respectively. The pregnancy was conceived using Assisted Reproductive Techniques in 15/274 (5.5%) of participants. Pregnancy loss (6 miscarriages and 1 termination) occurred in 7/274 (2.6%; incidence rate: 0.26 [95% CI: 0.01 – 0.05]) of participants, all of which were prior to 12 weeks’ gestation – this data was included in the analysis. Symptoms of lower abdominal/pelvic pain or discomfort were reported in 24/274 (8.8%); incidence rate 0.09 (95% CI 0.06 – 0.13) Of the 274 women who participated in this study, a unilateral mass was detected in 266/274 (97%) and a bilateral mass in 8/274 (3%). The total adnexal mass count was 282. A total of 21/274 (7.7%; incidence rate 0.77 [95% CI 0.05 – 0.12]) of participants were lost to follow up, all of whom had a single mass. An adnexal mass was detected in 114/274 (41.6%) of participants during an emergency presentation to the EPU prior to 12-weeks’ gestation. In 24/114 (21.1%) of these participants, abdominal pain was the reason for presentation, while in 90/114 (78.9%) it was due to vaginal bleeding or hyperemesis. By the time of the 12-week scan, in 17/114 (14.9%) of participants the mass had spontaneously resolved. At the routine 12-week scan, a mass was detected in 250/274 (91.2%) of participants. This was a new mass, detected in asymptomatic participants in 153/250 (61%), while in 97/250 (39%) of participants this was persistence of the mass detected during an emergency scan earlier in pregnancy. By the time of the 20-week scan, in 73/250 (29.2%) of participants the mass had resolved, and 7 participants were lost to follow up, reducing the denominator to 243. At the 20-week scan, a mass was detected in 170/243 (70%) of participants, all of which were believed to be persistence of masses detected during the 12-week scan. By the time of the 6-week post-partum scan, in 104/170 (61%) of participants the mass had resolved and 14 were lost to follow up, further decreasing the denominator to 156. At the 6-week post-partum scan, as mass was detected in 66/156 (42%) of participants. None of these were believed to be new masses, but rather persistence of masses detected at the 20-week scan. Overall, in 74% of participants the mass spontaneously resolved by the post-partum scan. This is shown in Figure 1. The mean volume of the adnexal masses decreased significantly over the course of the study. Prior to the 12 weeks the mean volume was 47.24cm 3 (95% CI: 44.09 – 50.39cm 3 ). At the 12 week’s scan the mean volume was 32.09cm 3 (95% CI: 28.29 – 35.88cm 3 ); a reduction of -15.15cm 3 (95% CI: -18.47 to -11.83; P <0.0001). At the 20 weeks scan the mean volume was 22.82 (95% CI: 19.96 – 26.69 cm 3 ); a reduction of -15.56cm 3 (95% CI: -17.79 to -13.33; P < 0.0001). At the 6-week post-partum scan the mean volume was 9.94cm 3 (95% CI: 7.68 – 12.20cm3); a further reduction of -12.36cm 3 (95% CI: -14.89 to -9.84; P =0.0001). This is represented in Figure 2. Subjective impression was as follows: simple 208/274 (75.9%); dermoid 25/274 (9.1%); endometrioma 18/274 (6.6%); haemorrhagic 9/274 (3.3%); para-ovarian 7/274 (2.6%); torted simple 2/274 (0.7%); decidualized endometrioma 1/274 (0.4%); fibroma 1/274 (0.4%); theca luteal 1/274 (0.4%) and mucinous BOT 2/274 (0.7%). In the 8 patients who had bilateral masses, the subjective impression was the same for both sides. In the 14 cases where histology was available, the subjective impression was correct in 11/14 (79%) and incorrect in 3/14 (21%). During follow up, there was a change in subjective impression in 14/274 (5.1%) which was not statistically significant (Chi squared test P = 0.31). The changes were as follows: simple changed to endometrioma (4); simple changed to haemorrhagic (3); haemorrhagic changed to simple (3); endometrioma to haemorrhagic (1); simple to dermoid (1) ovarian changed to para ovarian (1) and para ovarian changed to ovarian (1). There was a statistically significant correlation between the subjective impression and resolution rate (Chi Squared test P <0.0001), with simple cysts being by far the most common to resolve. This is demonstrated in Table S1. A Level III gynaecology ultrasound practitioner was asked to review and confirm all the aforementioned cases in which there was a change in subjective impression, the two suspected BOT and one other case. As such, their input was deemed necessary in 18/274 (6.6%) of patients. In all cases the level III practitioner agreed with the level II practitioner, bar one where the subjective impression was changed from endometrioma to fibroma. MRI was used in 1/274 (0.4%) of participants. Due to this low number an agreement rate between MRI and ultrasound and MRI and histology could not be calculated. In this one case both ultrasound and MRI gave an impression of mucinous BOT. Subsequent histological diagnosis was a dermoid cyst. Surgery to remove the adnexal mass was performed in 14/274 (5.1%) of participants. There was no statistically significant difference in the timing of surgery (Chi squared test, P = 0.32): antenatally in 2/14 (14.3%), at the time of Caesarean Section in 6/14 (42.9%) and post-partum in 6/14 (42.9%). Of the two surgeries performed in the antenatal period, one was a confirmed torsion of a simple cyst and the second was a case with a subjective impression of mucinous BOT but a histological diagnosis of a dermoid cyst. There was no malignancy or BOT diagnosed in the surgical group. A summary of the histological diagnosis is shown in Table S2. After excluding the 7 participants who experienced first trimester pregnancy losses and the 21 participants lost to follow up, complications due to the adnexal mass occurred in 5/246 (2%) of participants. In one case a simple cyst ruptured and bled leading to significant hemoperitoneum, subsequent intra-abdominal infection and premature delivery of a live infant at 26 weeks’ gestation. The participants underwent antenatal surgery as described above, and another two presented with suspected torsion of simple cysts, underwent trans-abdominal drainage with resolution of symptoms and had an uncomplicated pregnancy thereafter. Using IOTA simple rules, 272/274 (99.3%) were classifiable and 2/274 (0.7% were unclassifiable ( P <0.0001). Only 1/274 (0.4%) had malignant features ( P = 0.05). As there was no malignancy in this cohort, the diagnostic performance of IOTA simple rules could not be calculated. Discussion Main Findings This study shows that adnexal masses in pregnancy are uncommon, the majority are incidental findings that will spontaneously resolve; complications are uncommon and malignancy is rare. While the accuracy of IOTA in pregnancy is yet to be established, this study suggests it is likely to be applicable. Strengths & Limitations There are a number of strengths to this study. At the time of writing, this was the largest prospective study assessing adnexal masses in pregnancy and the second to assess IOTA simple rules in this cohort. (25) The inclusion of women of all ages and ethnic backgrounds as well as those who had conceived as a result of ART should increase the generalizability. The fact that all scans were performed by level II ultrasound practitioners from medical, nursing and sonography backgrounds, as part of emergency and routine antenatal care, should further increase the generalizability of this paper as it reflects the geographical variations in practitioners performing these scans. (26) Each patient was not followed up by a single operator which is again reflective of standard practice and may reduce bias. As evidence suggests that pattern recognition has a higher accuracy when performed by more experienced ultrasound practitioners, this study benefited from the involvement of level III gynaecological ultrasound practitioners for masses deemed to be malignant, unclassifiable or where there was any form of uncertainty. (27) Limitations of this study include it being single centred and conducted in a unit with experienced level II and level III gynaecological ultrasound practitioners which may not be the case in other settings. Our sample was heterogenous in that it included both symptomatic and asymptomatic women, however this does mimic clinical practice. Due to the absence of malignancy in this cohort the performance of IOTA simple rules could not be assessed. Finally, because of the relatively small numbers of women requiring surgical intervention, the gold standard of histological diagnosis was only available for a few participants, meaning proxy markers of mass resolution/reduction in size had to be used. To overcome these limitations, a prospective multicentre study is required. Ideally this would examine unselected, asymptomatic women at fixed points such as 8-, 12- and 20-weeks’ gestation and 6 weeks and 3 months postpartum. Interpretation The incidence rate in this study of 1% was comparable to the results of a large retrospective review. (28) Based on the Royal College of Obstetricians and Gynaecologists (RCOG) nomenclature for discussing risk, patients should be advised that adnexal masses in pregnancy are ‘uncommon’. (29) The mean age at diagnosis in this study (32.02 years) mirrored that of two recent systematic reviews and also the mean age in the UK for women to have their first child. (5, 14, 16) The expectation was that in this cohort, a large proportion of the masses detected would be physiological cysts that would self-resolve throughout the pregnancy. (10) This was shown to be the case, as the subjective impression was a ‘simple cyst’ in 76% of participants, and of these, 80% resolved. Additionally, when assessing all subjective impressions, in 74% of participants the mass had resolved by the time of the post-partum scan and there was a statistically significant decrease in the mean volume of masses over the course of the study. This information should assist in guiding clinicians when formulating follow up plans, and also offer reassurance when counselling patients. The distribution of subjective impressions mimicked that of large previous studies, with simple cysts being by far the most common, followed by dermoid cysts, endometriomas and para-ovarian cysts. (30) The fact that a subjective impression was given for all masses in this study is likely a reflection of scans being performed by experienced level II ultrasound practitioners, with support from level III practitioners. Subjective impression of adnexal masses is based on pattern recognition and has a quoted accuracy of 92% in non-pregnant women in deciphering benign from malignant masses. (31) There is no data to date comparing this with pregnancy. In this study histology was available in 14/274 of participants. While this number is small, in 11/14 (79%) of cases the subjective impression was correct. Additionally, the high-resolution rate of simple cysts and perseverance of endometriomas and dermoid cysts in this study, suggests subjective impression is reliable in pregnancy. While the change in subjective impression over the course of the study was not clinically significant, it is of interest as to date there appears to be no data regarding how commonly this occurs either when the same practitioner assesses a mass serially, or when different practitioners assess the same mass. Other than the aforementioned changes in the morphology of endometriomas, no other studies have assessed changes in other histological subtypes during pregnancy. In this study the most common change was from either a simple to a haemorrhagic cyst or vice versa. This can be explained by spontaneous haemorrhage and resolution within a simple cyst and is commonly seen in clinical practice. A Level III ultrasound practitioner was asked to review and confirm all these cases, as well as the two suspected BOTs. As such, their input was deemed necessary in 18/ 274 (6.6%) of patients. In all cases there was agreement except for one, where the diagnosis of a fibroma was made. In this study 99.3% of mases were classifiable based on IOTA simple rules which was higher when compared to studies in the non-pregnant cohort with quoted rates of 76%. (21) The reason for this may be multifactorial. Firstly, in this cohort, simple cysts, endometriomas and dermoid cysts were most commonly diagnosed and have been shown to be largely classifiable, while malignancy and rarer benign tumors such as luteomas which were not detected in this study are more likely to be unclassifiable. (21) Secondly, all practitioners performing the ultrasounds had considerable experience both in gynaecological ultrasound and also in the use of IOTA simple rules, which has been shown to improves rates. (31) Thirdly, as most large studies assessing IOTA simple rules were conducted soon after its release in 2008, it would seem likely that with time, clinicians would have become more familiar with it, which would increase the rates of classification. Supporting this is the fact that smaller, more recent studies assessing IOTA simple rules found 89% to 93% of masses in non-pregnant women were classifiable. (32, 33) While it was not a primary aim of this study, it was not possible to determine the sensitivity, positive likelihood ration, negative likelihood ration, positive predicative value, or accuracy of IOTA simple rules due to the absence of malignancy in our cohort. As expected, the role of surgical intervention in this cohort was limited, with only two patients undergoing surgery in the antenatal period. (7, 10) While one benefited from de-torsion of an ovary and subsequent uncomplicated pregnancy, the second underwent unnecessary intervention for a presumed BOT which was a dermoid on histological examination. The pregnancy continued without complication. In this latter case, MRI had agreed with the ultrasound impression of BOT. Due to the fact that MRI was only utilized in one case, no conclusions can be drawn about its accuracy. Of note, two recent systematic reviews failed to demonstrate superiority of MRI over ultrasound, but instead suggested a propensity for over diagnosis of malignancy. (14, 16) Conclusion We suggest that in the absence of concerns regarding malignancy, torsion, or haemorrhagic rupture, there is no need for further monitoring of adnexal masses during the pregnancy, but rather a transvaginal ultrasound can be offered at least 6 weeks post-partum to give time for resolution, and avoid unnecessary intervention. Further work is required to determine the benefit of screening the adnexa during routine antenatal ultrasound and the accuracy of ultrasound tools such as IOTA. Ethics Statement Approval for this study was granted from the South London Research & Ethics Committee (8/LO/1033). Informed, written consent was taken from all participants. Acknowledgements: Alison Smith, Superintendent Sonographer, Guy’s & St Thomas’ Hospitals, London UK. The Nurses and Sonographers working in the Early Pregnancy & Acute Gynaecology Unit Women’s Health, Guy’s & St Thomas’s Hospitals, London UK Author Contributions All authors contributed to the design, data collection, analysis and editing of drafts of this manuscript. Conflict of Interest None Funding No Funding was awarded to conduct this research. Bibliography www.medcalc.org 1. Aggarwal P, Kehoe S. Ovarian tumours in pregnancy: a literature review. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2011;155(2):119-24.2. Martone S, Troìa L, Luisi S. Adnexal masses during pregnancy: management for a better approach. Gynecological Surgery. 2021;18(1):3.3. Lentz B, Fong T, Rhyne R, Risko N. A systematic review of the cost-effectiveness of ultrasound in emergency care settings. The Ultrasound Journal. 2021;13(1):16.4. RCOG. 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IOTA Simple Ultrasound Rules for Triage of Adnexal Mass: Experience from South India. J Obstet Gynaecol India. 2019;69(4):356-62.33. Landolfo C, Saso S, Del Forno S, Ranaei-Zamani N, Grewal K, Fourie H, et al. OC04.06: Management of adnexal masses during pregnancy: a prospective study. Ultrasound in Obstetrics & Gynecology. 2019;54(S1):10-1. Figure 1: Masses detected, masses resolved and loss to follow up numbers at each study contact. Figure 2: Mean volume change in adnexal masses over study time. Table S1: Resolution rate during follow up based on subjective impression.*BOT = Borderline Ovarian Tumour. Table S2: Histological diagnoses, timing of surgery, and ultrasound and MRI impression. *BOT = Borderline Ovarian Tumour Supplementary Material File (figure 1.docx) Download 23.14 KB File (table 1.docx) Download 13.78 KB File (table2.docx) Download 13.89 KB Information & Authors Information Version history V1 Version 1 20 July 2024 Peer review timeline Published Diagnostics Version of Record 30 Sep 2024 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords antenatal care carcinoma of the ovary: diagnosis imaging medical disorders in pregnancy radiological imaging: ultrasound Authors Affiliations Jonathan Gaughran 0000-0002-4469-429X [email protected] Guy's and St Thomas' NHS Foundation Trust View all articles by this author Catherine Magee Guy's and St Thomas' NHS Foundation Trust View all articles by this author Caroline Knight Guy's and St Thomas' NHS Foundation Trust View all articles by this author Sian Mitchell Guy's and St Thomas' NHS Foundation Trust View all articles by this author Ahmad Sayasneh Guy's and St Thomas' NHS Foundation Trust View all articles by this author Metrics & Citations Metrics Article Usage 274 views 116 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Jonathan Gaughran, Catherine Magee, Caroline Knight, et al. Adnexal Masses in Pregnancy: A single centre prospective observational cohort study. Authorea . 20 July 2024. 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