Massive theca-lutein cysts, virilization, and hypothyroidism associated with normal pregnancy

Testosterone serum levels are not predictive of maternal virilization in hyperreactio luteinalis

Background

Elevated concentrations of circulating testosterone are present in hyperreactio luteinalis (HL), a pregnancy-specific, self-limited condition. HL is associated with maternal virilization in about 30% of cases. The correlation between testosterone levels and maternal virilization has not yet been quantified. Our aim was to identify a testosterone cut-off level which may allow to predict maternal virilization.

Methods

A literature research was performed. Publications were chosen if serum testosterone concentrations and presence or absence of maternal virilization was mentioned. Additionally, we report serial levels of steroids analyzed by Liquid chromatography–tandem mass spectrometry (LC–MS/MS) in one case of HL managed at our institution.

Results

In all, 31 cases fulfilled the search criteria. We found significant overlap between testosterone levels in asymptomatic women and women with signs of virilization (range 6.2–37.3 nmol/l and 13.7–197.5 nmol/l, respectively). The method applied for testosterone analysis was mentioned in three reports only. Peak serum testosterone concentration in our case was 120.3 nmol/l.

Conclusion

From the available data, maternal virilization in HL cannot be predicted by the level of circulating testosterone. However, comparability of results is hampered by the analytical methods applied. LC–MS/MS should preferably be used for reporting concentrations of circulating testosterone.

Delayed Lactogenesis II: A Comparison of Four Cases

Lactogenesis II is the onset of copious milk production (i.e., the milk "coming in"), which usually occurs between 30 to 40 hours postpartum. When lactogenesis II fails to occur or is delayed, it may be due to a number of underlying hormonal or non-hormonal conditions. Of the various hormonal etiologies, many can be identified with the aid of a few standard blood tests. Gestational ovarian theca lutein cysts may cause delayed lactogenesis II and are fairly easily detected by ordering testosterone levels. Although this condition can delay lactogenesis II for as long as 31 days, with proper management women affected by these cysts have established breastfeeding. Three of the four women reviewed in this article were eventually able to produce 100% of their infants' caloric requirements.

Delayed lactogenesis II secondary to gestational ovarian theca lutein cysts in two normal singleton pregnancies

Hyperreactio luteinalis is an unusual condition in which, during pregnancy, both ovaries are enlarged by multiple theca lutein cysts that produce a high level of testosterone. Several weeks postpartum, the cysts resolve and testosterone level returns to normal. Two case studies are presented in which mothers with gestational ovarian theca lutein cysts experienced delayed lactogenesis II. The elevated testosterone at the time of birth suppressed milk production. Once the testosterone level dropped to approximately 300 ng/dL, milk production began. After the initial delay, both mothers breastfed their infants without supplementation.

Early prenatal sonographic diagnosis of twin triploid gestation presenting with fetal hydrops and theca-lutein ovarian cysts

The presence of theca-lutein ovarian cysts in the early second trimester of pregnancy is highly suspicious for a complete hydatidiform molar pregnancy but can be seen in association with a partial mole. Theca-lutein cysts may occur following hormonal stimulation for assisted reproductive techniques or in association with multiple gestations. Rare causes include immune and nonimmune fetal hydrops, maternal hypothyroidism, and triploid gestations. We report a case of a monochorionic twin gestation in which prenatal sonography demonstrated multiple anomalies and hydrops in each twin and bilateral theca-lutein ovarian cysts. Triploidy in both twins and a partial hydatidiform mole were confirmed at pathologic examination.