Theca lutein cyst

Last updated

Theca lutein cyst is a type of bilateral functional ovarian cyst filled with clear, straw-colored fluid. These cysts result from exaggerated physiological stimulation (hyperreactio luteinalis) due to elevated levels of beta-human chorionic gonadotropin (beta-hCG) or hypersensitivity to beta-hCG. [1] [2] On ultrasound and MRI, theca lutein cysts appear in multiples on ovaries that are enlarged. [3]

Contents

Theca lutein cysts are associated with gestational trophoblastic disease (molar pregnancy), choriocarcinomas, and multiple gestations. [4] [5] In some cases, these cysts may also be associated with diabetes mellitus and alloimmunisation to Rh-D. They have rarely been associated with chronic kidney disease and hyperthyroidism. [6]

Usually, these cysts spontaneously resolve after the molar pregnancy is terminated. Rarely, when the theca lutein cysts are stimulated by hormones called gonadotropins, massive ascites can result. In most cases, however, abdominal symptoms are minimal and restricted to peritoneal irritation from cyst hemorrhage. [7] Due to the enlargement of the ovaries, there is an increased risk for torsion. [3] Surgical intervention may be required to remove ruptured or infarcted tissue. [7]

Etiology

Main causes

Theca lutein cysts commonly form due to an elevated level of chorionic gonadotropin, a luteinizing hormone otherwise known as beta human chorionic gonadotropin (beta-hCG). Theca lutein cysts occur almost exclusively in pregnancy and have an increased incidence in pregnancies complicated by gestational trophoblastic disease. [8] But additionally, theca lutein cysts may develop in conditions such as placentomegaly that may accompany diabetes, anti-D alloimmunization, mutifetal gestation, and individuals undergoing fertility treatment including chorionic gonadotropin or clomiphene therapy. Theca lutein cysts are also often notably seen in patients with choriocarcinoma or hydatidiform mole. [7] Rarely these type of cysts are present in normal pregnancy. In the event they do occur in otherwise uncomplicated pregnancies they are most likely associated with elevated levels of beta-hCG. [9]

Secondary health conditions

There are some cases of chronic kidney disease (CKD) being a secondary cause of the formation of theca lutein cysts. Although not common, some case studies have shown that people with CKD have reduced clearance of human chorionic gonadotropin (hCG) . [10] [11] As a result, theca lutein cysts may form since there is in an increase of hCG levels in the body.

Additionally, it is reported that 10% of people with hyperreactio luteinalis can develop hyperthyroidism. [12] Although the exact mechanism is still unclear, it is suspected that hCG and thyroid stimulating hormone (TSH) are closely related. [13] As a result, hCG can weakly bind to TSH receptors in the thyroid gland causing production of thyroid hormones T3 and T4. [13] Since hyperreactio luteinalis causes increased levels of hCG, hCG can thus cause overproduction of T3 and T4. Most people do not experience symptoms and to not require antithyroid treatment. [12] Overall, 0.2% of pregnant people develop clinical hyperthyroidism requiring treatment. [14]

Signs and symptoms

Characteristics

Theca lutein cysts are an uncommon type of follicular cysts that reflect a benign ovarian lesion of a physiological exaggeration of follicle stimulation often termed as hyperreactio lutealis. Theca lutein cysts are lined by theca cells that may or may not be luteinized or have granulosa cells. They are usually bilateral and are filled with clear, straw-colored fluid. [7] Overall theca lutein cysts can be characterized by the luteniziation and hypertrophy of the theca interna layer. The resulting bilateral cystic ovaries are variably enlarged that have multiple smooth-walled cysts formation and ranging in size with a diameter from 1 to 4 cm. [15]

Symptoms

Symptoms are usually asymptomatic and minimal, but hemorrhage of the cysts can cause acute abdominal pain. Additionally, a sense of pelvic heaviness or aching may be described. [7]

Maternal virilization may also occur. Signs of maternal virilization include deepening of the voice, facial hirsutism and scalp hair loss seen during the onset of pregnancy (usually towards the end of the first trimester) followed by regression several months post-partum. [16] Maternal virilization can be seen in up to 30 percent of people with this condition, however, virilization of the fetus has only rarely been reported and if so is dependent on the timing of hyperandrogenism. [17] Overall, maternal findings including temporal balding, hirsutism, and clitoromegaly are associated with massively elevated levels of androstenedione and testosterone. [9] Additionally, continued signs and symptoms of pregnancy, especially hyperemesis and breast paresthesias, are also reported in cases of histologically proven theca lutein cysts. [7]

An occurrence of a ruptured cysts may result in intraperitoneal bleeding. In this case, symptoms may mimic the signs of a hemorrhagic corpus luteum cyst. [7]

Diagnosis

Physical examination

Theca lutein cysts are detected and diagnosed during a pelvic examination followed by a thorough evaluation. The evaluation includes a collection of the person's age, family history, and previous histories of ovarian or breast cancers. A full physical examination is performed to check for tenderness, peritoneal signs, and a frozen pelvis. [7]

Imaging

CT Ovarian Cyst CT Ovarian Cyst.jpg
CT Ovarian Cyst

Further work up involves imaging, such as a pelvic ultrasound or CT scan. [7] Theca lutein cysts with diameters over 6 cm in size can be seen through these imaging modalities. [18] Benign ovarian cysts and complex cysts that are potentially malignant are distinguishable via ultrasounds. [19] Labs are also collected to evaluate leukocytes and tumor markers, such as beta-hCG and cancer antigen 125 (CA125). [20]

Ultrasonography Hemorrhagic Ovarian Cyst Hemorrhagic ovarian cyst.jpg
Ultrasonography Hemorrhagic Ovarian Cyst

During pregnancy, ultrasonography is the first-line method for evaluating ovarian cysts. Both transabdominal and transvaginal route of ultrasonography are used with either two-dimensional or three-dimensional modalities. [3] Two-dimensional is more common, but three-dimensional can offer more results. [3] Doppler ultrasonography can also be used and is helpful at analyzing the characteristics of the cyst. [3] It can identify the presence of color flow within a septum as well as the presence of a solid component of the mass. [3] Ultrasonography is an effective tool for observing the progression or regression of the cyst. [3] Magnetic resonance imaging (MRI) is the second-line method used when ultrasonography cannot detect the cyst. [3] Cysts that are too large to be accurately analyzed by ultrasonography are typically when MRI would be used. [3] The advantages of MRI are its larger field of view and multiplanar capabilities. [21] In addition, pathologies such as infarctions and placental invasive disorders can be seen more clearly. [3] MRI is especially beneficial in gestational age and obese people. [3] MRI is also beneficial at preventing the exposure of ionizing radiation to the fetus during pregnancy. [22] Both ultrasonography and MRI show enlarged ovaries with multiple theca lutein cysts. [3]

Risks

Risk factors

Oral contraceptives containing only progestin can increase the occurrence of follicular cysts. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) or progestin implants are also associated with the occurrence of follicular cysts. [20]

People who are of pre- and postmenopausal age with breast cancer and are being treated with tamoxifen are at increased risk for the development of benign ovarian cysts. However, many of these cysts are functional and can resolve with time. [20] Tamoxifen treatment can be continued unless the cyst is found to be malignant. [20]

People with hyperandrogenism, which can occur in polycystic ovarian syndrome (PCOS), are at risk for developing hyperreactio luteinalis. [3]

Smoking can also cause an increased risk for functional cysts. [20]

Treatments

Theca lutein cysts usually spontaneously resolve on their own after the source of hormonal stimulation is removed such as the removal of the molar pregnancy, removal of the choriocarcinoma, stopping fertility therapy or after delivery. [7] [20] It may take months for the cysts to resolve on their own. [7] Treatment for theca lutein cysts is very conservative due to their benign nature and ability to disappear after the removal of hormonal stimulation. [17] Individual patient characteristics must be taken into consideration when deciding whether or not to treat the cyst. These patient factors include: (1) size of cyst and whether or not it is benign or malignant, (2) patient symptoms, (3) patient age, and (4) impact of cyst on the pregnancy. [23] Benign cysts less than 6 cm are more likely to spontaneously resolve over time.

Surgical treatments may be needed for serious complications due to theca lutein cysts. Surgery is considered when the cyst is considered malignant or when signs of torsion and hemorrhage are present. [7] [23] Removal of the ovaries may also be performed if large areas of tissue continue to infarct despite resolving the torsion. [24]

Surgery due to ovarian torsion

Ovarian cysts such as theca lutein cysts can cause ovarian torsion. Torsion occurs when the cysts enlarge the ovaries, causing an imbalance resulting in the twisting of the fallopian tubes. [25] As a result, blood flow to the ovaries is restricted which can cause infarction of the tissue. This requires prompt surgical treatment. [25] Detorsion surgery is done laparoscopically, often trying to keep the ovaries functional. [25] Laparoscopic surgery is minimally invasive procedure where only a small incision is made and a small camera is inserted at the site of procedure. Laparoscopic surgery is safe to do during the first half of pregnancy, but risk of uterus and fetus injury increases after 20 weeks of pregnancy. [23] Laparotomy is considered if the cyst is malignant and too large to remove laparoscopically. [26] A laparotomy is preferred during the third trimester of pregnancy. [23] This procedure is more invasive than a laparoscopic surgery and involves a larger incision.

Surgery due to hemorrhage

Theca lutein cysts have the potential to rupture and hemorrhage resulting in acute abdominal pain as well as intraperitoneal bleeding. [7] [24] Laparoscopic surgery is performed to control bleeding and remove unwanted blood clots and fluid. [27] The cyst is then removed surgically. A laparotomy may need to be performed if the cyst is large or more complicated. [26]

Cyst aspiration

In some cases, the cyst can be reduced of its volume through aspiration. This procedure aims to drain the fluid from the cyst, as a result decreasing the size of the cyst preventing risk of torsion or as a method of detorsion. This method of treatment is considered when there are reasons to not treat conservatively or if there are high risks associated with surgery. [23] This treatment is done with the guidance of radiology and is done for symptomatically large cysts. [23]

Other considerations

Misdiagnosis

Despite classification of a benign condition, hyperreactio lutealis can potentially mimic a malignancy in pregnancy leading to a misdiagnosis amongst physicians. The fear of missing a cancer diagnosis often leads to often unnecessary surgical intervention. As a result these interventions may lead to impaired future fertility. Not much literature evidence is fully discussed and still needs to go under further investigation. Despite current knowledge, treatments for conditions still remain the same. [17]

As previously mentioned, an occurrence of a ruptured cysts that result in intraperitoneal bleeding share symptoms may mimic signs and symptoms of hemorrhagic corpus luteum cyst. [7]

Effects on fetus

Despite its notable presentation, ovarian enlargement and increased androgen presence, hyperreacto lutenilais is a self-limiting condition with resolution at postpartum. As a result, the condition presents itself without much after-effect on both mother and fetus [17] Fetal virilization is rare, and more dependent on the timing of increased androgen presence. Therefore most of the effects are present to the mother through maternal viralization. [17]

Most associated adverse pregnancy outcomes are due to an abnormally high observed beta-hCG levels during gestation. As a result, the subset of pregnant people in these abnormal values should be considered for enhanced surveillance. Discussion on vaginal delivery is preferred in addition to potential breastfeeding strategies to be introduced while maternal androgen levels fall in order to sustain breastfeeding and lactation for this condition. [17]

Post-complications

Some possible post-complications that have been associated with abnormally raised levels of hCG can be seen in the potential development of pre-eclampsia, [28] [29] HELLP syndrome, [30] eclampsia [31] and hypothyroidism. [13] In most cases, most case reports discuss the prevalence of preeclampsia and preterm contractions and delivery [32] [28] in association with high hCG levels. It is hypothesized that these elevated levels are possibly contribute to incomplete placental invasion and inadequate angiogenesis. [28]

Related Research Articles

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<span class="mw-page-title-main">Pregnancy test</span> A test based on scientific data to determine if a female is pregnant

A pregnancy test is used to determine whether a female is pregnant or not. The two primary methods are testing for the female pregnancy hormone in blood or urine using a pregnancy test kit, and scanning with ultrasonography. Testing blood for hCG results in the earliest detection of pregnancy. Almost all pregnant women will have a positive urine pregnancy test one week after the first day of a missed menstrual period.

<span class="mw-page-title-main">Ovarian cyst</span> Fluid-filled sac in the ovary

An ovarian cyst is a fluid-filled sac within the ovary. Often they cause no symptoms. Occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either breaks open or causes twisting of the ovary, it may cause severe pain. This may result in vomiting or feeling faint, and even cause head aches.

<span class="mw-page-title-main">Corpus luteum</span> Temporary endocrine structure in female ovaries

The corpus luteum is a temporary endocrine structure in female ovaries involved in the production of relatively high levels of progesterone, and moderate levels of estradiol, and inhibin A. It is the remains of the ovarian follicle that has released a mature ovum during a previous ovulation.

<span class="mw-page-title-main">Molar pregnancy</span> Abnormal form of pregnancy (human disorder)

A molar pregnancy, also known as a hydatidiform mole, is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus. It falls under the category of gestational trophoblastic diseases. During a molar pregnancy, the uterus contains a growing mass characterized by swollen chorionic villi, resembling clusters of grapes. The occurrence of a molar pregnancy can be attributed to the fertilized egg lacking an original maternal nucleus. As a result, the products of conception may or may not contain fetal tissue. These molar pregnancies are categorized into two types: partial moles and complete moles, where the term 'mole' simply denotes a clump of growing tissue or a ‘growth'.

<span class="mw-page-title-main">Choriocarcinoma</span> Malignant, trophoblastic cancer, usually of the placenta

Choriocarcinoma is a malignant, trophoblastic cancer, usually of the placenta. It is characterized by early hematogenous spread to the lungs. It belongs to the malignant end of the spectrum in gestational trophoblastic disease (GTD). It is also classified as a germ cell tumor and may arise in the testis or ovary.

<span class="mw-page-title-main">Gestational trophoblastic disease</span> Pregnancy-related tumours

Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumours. These tumours are rare, and they appear when cells in the womb start to proliferate uncontrollably. The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy.

Gestational choriocarcinoma is a form of gestational trophoblastic neoplasia, which is a type of gestational trophoblastic disease (GTD), that can occur during pregnancy. It is a rare disease where the trophoblast, a layer of cells surrounding the blastocyst, undergoes abnormal developments, leading to trophoblastic tumors. The choriocarcinoma can metastasize to other organs, including the lungs, kidney, and liver. The amount and degree of choriocarcinoma spread to other parts of the body can vary greatly from person to person.

<span class="mw-page-title-main">Hyperandrogenism</span> Medical condition

Hyperandrogenism is a medical condition characterized by high levels of androgens. It is more common in women than men. Symptoms of hyperandrogenism may include acne, seborrhea, hair loss on the scalp, increased body or facial hair, and infrequent or absent menstruation. Complications may include high blood cholesterol and diabetes. It occurs in approximately 5% of women of reproductive age.

Ovarian hyperstimulation syndrome (OHSS) is a medical condition that can occur in some women who take fertility medication to stimulate egg growth, and in other women in very rare cases. Most cases are mild, but rarely the condition is severe and can lead to serious illness or death.

<span class="mw-page-title-main">Trophoblastic neoplasm</span> Medical condition

Gestational trophoblastic neoplasia (GTN) is group of rare diseases related to pregnancy and included in gestational trophoblastic disease (GTD) in which abnormal trophoblast cells grow in the uterus. GTN can be classified into benign and malignant lesions. Benign lesions include placental site nodule and hydatidiform moles while malignant lesions have four subtypes including invasive mole, gestational choriocarcinoma, placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT). The choriocarcinoma has 2 significant subtypes including gestational and non-gestational and they are differentiated by their different biological feature and prognosis. Signs and symptoms of GTN will appear vary from person to person and depending upon the type of the disease. They may include uterine bleeding not related to menstruation, pain or pressure in pelvis, large uterus and high blood pressure during pregnancy. The cause of this disease is unknown but the identification of the tumor based on total beta-human chorionic gonadotropin (β-hCG) in the serum.

Poor ovarian reserve is a condition of low fertility characterized by 1): low numbers of remaining oocytes in the ovaries or 2) possibly impaired preantral oocyte development or recruitment. Recent research suggests that premature ovarian aging and premature ovarian failure may represent a continuum of premature ovarian senescence. It is usually accompanied by high FSH levels.

<span class="mw-page-title-main">Ovarian torsion</span> Medical condition

Ovarian torsion (OT) or adnexal torsion is an abnormal condition where an ovary twists on its attachment to other structures, such that blood flow is decreased. Symptoms typically include pelvic pain on one side. While classically the pain is sudden in onset, this is not always the case. Other symptoms may include nausea. Complications may include infection, bleeding, or infertility.

<span class="mw-page-title-main">Corpus luteum cyst</span> Medical condition

A corpus luteum cyst is a type of ovarian cyst which may rupture about the time of menstruation, and take up to three months to disappear entirely. A corpus luteum cyst rarely occurs in women over the age of 50, because eggs are no longer being released after menopause. Corpus luteum cysts may contain blood and other fluids. The physical shape of a corpus luteum cyst may appear as an enlargement of the ovary itself, rather than a distinct mass -like growth on the surface of the ovary.

<span class="mw-page-title-main">Interstitial pregnancy</span> Medical condition

An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.

Hyperthecosis, or ovarian hyperthecosis, is hyperplasia of the theca interna of the ovary. Hyperthecosis occurs when an area of luteinization occurs along with stromal hyperplasia. The luteinized cells produce androgens, which may lead to hirsutism and virilization in affected women.

Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proceed past the first four weeks of pregnancy. An untreated ovarian pregnancy causes potentially fatal intra-abdominal bleeding and thus may become a medical emergency.

Ovarian drilling, also known as multiperforation or laparoscopic ovarian diathermy, is a surgical technique of puncturing the membranes surrounding the ovary with a laser beam or a surgical needle using minimally invasive laparoscopic procedures. It differs from ovarian wedge resection, which involves the cutting of tissue. Minimally invasive ovarian drilling procedures have replaced wedge resections. Ovarian drilling is preferred to wedge resection because cutting into the ovary can cause adhesions which may complicate postoperative outcomes. Ovarian drilling and ovarian wedge resection are treatment options to reduce the amount of androgen producing tissue in women with polycystic ovarian syndrome (PCOS). PCOS is the primary cause of anovulation, which results in female infertility. The induction of mono-ovulatory cycles can restore fertility.

Early pregnancy bleeding refers to vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.

<span class="mw-page-title-main">Tubo-ovarian abscess</span> One of the late complications of pelvic inflammatory disease

A tubo-ovarian abscess (TOA) is one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis. It consists of an encapsulated or confined pocket of pus with defined boundaries that forms during an infection of a fallopian tube and ovary. These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. It is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs. A TOA can also develop as a complication of a hysterectomy.

References

  1. ↑ Kaňová N, Bičíková M (2011). "Hyperandrogenic states in pregnancy". Physiological Research. 60 (2): 243–252. doi: 10.33549/physiolres.932078 . PMID   21114372.
  2. ↑ Rukundo J, Magriples U, Ntasumbumuyange D, Small M, Rulisa S, Bazzett-Matabele L (2017). "EP25.13: Theca lutein cysts in the setting of primary hypothyroidism". Ultrasound in Obstetrics & Gynecology. 50: 378. doi: 10.1002/uog.18732 .
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 Yacobozzi M, Nguyen D, Rakita D (February 2012). "Adnexal masses in pregnancy". Seminars in Ultrasound, CT, and MR. Multimodality Imaging of the Pregnant Patient. 33 (1): 55–64. doi:10.1053/j.sult.2011.10.004. PMID   22264903.
  4. ↑ Lauren N, DeCherney AH, Pernoll ML (2003). Current obstetric & gynecologic diagnosis & treatment. New York: Lange Medical Books/McGraw-Hill. p. 708. ISBN   0-8385-1401-4.
  5. ↑ William's Obstetrics (24th ed.). McGraw Hill. 2014. p. 50. ISBN   978-0-07-179893-8.
  6. ↑ Coccia ME, Pasquini L, Comparetto C, Scarselli G (February 2003). et al. "Hyperreactio luteinalis in a woman with high-risk factors. A case report". The Journal of Reproductive Medicine. 48 (2): 127–129. PMID   12621799.
  7. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Lavie O (2019). "Benign Disorders of the Ovaries & Oviducts". In DeCherney AH, Nathan L, Laufer N, Roman AS (eds.). CURRENT Diagnosis & Treatment: Obstetrics & Gynecology (12th ed.). New York, NY: McGraw-Hill Education.
  8. ↑ Elami-Suzin M, Freeman MD, Porat N, Rojansky N, Laufer N, Ben-Meir A (October 2013). "Mifepristone followed by misoprostol or oxytocin for second-trimester abortion: a randomized controlled trial". Obstetrics and Gynecology. 122 (4): 815–820. doi: 10.1097/aog.0b013e3182a2dcb7 . PMID   24084539. S2CID   39473570.
  9. 1 2 Casey BM, Dashe JS, Spong CY, McIntire DD, Leveno KJ, Cunningham GF (May 2007). "Perinatal significance of isolated maternal hypothyroxinemia identified in the first half of pregnancy". Obstetrics and Gynecology. 109 (5): 1129–1135. doi:10.1097/01.aog.0000262054.03531.24. PMID   17470594. S2CID   9486153.
  10. ↑ Chen EM, Breiman RS, Sollitto RA, Coakley FV (December 2007). "Pregnancy in chronic renal failure: a novel cause of theca lutein cysts at MRI". Journal of Magnetic Resonance Imaging. 26 (6): 1663–1665. doi: 10.1002/jmri.21168 . PMID   18059008. S2CID   22160271.
  11. ↑ al-Ramahi M, Leader A (February 1999). "Hyperreactio luteinalis associated with chronic renal failure". Human Reproduction. 14 (2): 416–418. doi: 10.1093/humrep/14.2.416 . PMID   10099989.
  12. 1 2 Aghajanian P, Rimel BJ (2019). "Gestational Trophoblastic Diseases". In DeCherney AH, Nathan L, Laufer N, Roman AS (eds.). CURRENT Diagnosis & Treatment: Obstetrics & Gynecology (12th ed.). New York, NY: McGraw-Hill Education.
  13. 1 2 3 Braunstein G (October 2009). "Thyroid function in pregnancy". Clinical Thyroidology for the Public. American Thyroid Association. 2 (6): 5–6.
  14. ↑ Fitzgerald PA (2022). Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR (eds.). Hyperthyroidism (Thyrotoxicosis). New York, NY: McGraw-Hill Education.{{cite book}}: |work= ignored (help)
  15. ↑ Schorge J, Schaffer J, Halvorson L, Hoffman B, Bradshaw K, Cunningham F (2010-07-08). "Williams Gynecology". Journal of Midwifery & Women's Health. 55 (4). doi:10.1016/j.jmwh.2010.05.004. ISSN   1526-9523.
  16. ↑ "Maternal virilization in pregnancy (Concept Id: C4024735) - MedGen - NCBI". www.ncbi.nlm.nih.gov.
  17. 1 2 3 4 5 6 Malinowski AK, Sen J, Sermer M (August 2015). "Hyperreactio Luteinalis: Maternal and Fetal Effects". Journal of Obstetrics and Gynaecology Canada. 37 (8): 715–723. doi:10.1016/s1701-2163(15)30176-6. PMID   26474228.
  18. ↑ Lima LL, Parente RC, Maestá I, Amim Junior J, de Rezende Filho JF, Montenegro CA, Braga A (2016). "Clinical and radiological correlations in patients with gestational trophoblastic disease". Radiologia Brasileira. 49 (4): 241–250. doi:10.1590/0100-3984.2015.0073. PMC   5073391 . PMID   27777478.
  19. ↑ Montes de Oca MK, Dotters-Katz SK, Kuller JA, Previs RA (July 2021). "Adnexal Masses in Pregnancy". Obstetrical & Gynecological Survey. 76 (7): 437–450. doi:10.1097/OGX.0000000000000909. PMID   34324696. S2CID   236324402.
  20. 1 2 3 4 5 6 Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, Corton MM, Schaffer JI (2020). "Benign Adnexal Mass". Williams Gynecology (4 ed.). New York, NY: McGraw-Hill Education.
  21. ↑ Dekan S, Linduska N, Kasprian G, Prayer D (May 2012). "MRI of the placenta - a short review". Wiener Medizinische Wochenschrift. 162 (9–10): 225–228. doi:10.1007/s10354-012-0073-4. PMID   22717878. S2CID   19768549.
  22. ↑ Oto A, Ernst R, Jesse MK, Saade G (2008-07-01). "Magnetic resonance imaging of cystic adnexal lesions during pregnancy". Current Problems in Diagnostic Radiology. 37 (4): 139–144. doi:10.1067/j.cpradiol.2007.08.002. PMID   18502322.
  23. 1 2 3 4 5 6 Bhagat N, Gajjar K (2022). "Management of ovarian cysts during pregnancy". Obstetrics, Gynaecology & Reproductive Medicine. 32 (9): 205–210. doi:10.1016/j.ogrm.2022.06.002. ISSN   1751-7214. S2CID   250326018.
  24. 1 2 Cunningham FG, Leveno KJ, Dashe JS, Hoffman BL, Spong CY, Casey BM (2022). "Gestational Trophoblastic Disease". Williams Obstetrics (26th ed.). New York, NY: McGraw Hill.
  25. 1 2 3 Guile SL, Mathai JK (2022). "Ovarian Torsion". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   32809510.
  26. 1 2 "Ovarian cyst - Treatment". United Kingdom National Health Service. 2018.
  27. ↑ "Management of Ruptured Ovarian Cyst". Johns Hopkins Medicine. 2021.
  28. 1 2 3 Atis A, Cifci F, Aydin Y, Ozdemir G, Goker N (July 2010). "Hyperreactio luteinalis with preeclampsia". Journal of Emergencies, Trauma, and Shock. 3 (3): 298. doi: 10.4103/0974-2700.66545 . PMC   2938501 . PMID   20930978.
  29. ↑ Masuyama H, Tateishi Y, Matsuda M, Hiramatrsu Y (July 2009). "Hyperreactio luteinalis with both markedly elevated human chorionic gonadotropin levels and an imbalance of angiogenic factors subsequently developed severe early-onset preeclampsia". Fertility and Sterility. 92 (1): 393.e1–393.e3. doi: 10.1016/j.fertnstert.2009.04.002 . PMID   19446290.
  30. ↑ Grgic O, Radakovic B, Barisic D (November 2008). "Hyperreactio luteinalis could be a risk factor for development of HELLP syndrome: case report" (PDF). Fertility and Sterility. 90 (5): 2008.e13–2008.e16. doi:10.1016/j.fertnstert.2008.06.053. PMID   18829007.
  31. ↑ Gatongi DK, Madhvi G, Tydeman G, Hasan A (July 2006). "A case of hyperreactio luteinalis presenting with eclampsia". Journal of Obstetrics and Gynaecology. 26 (5): 465–467. doi:10.1080/01443610600759244. PMID   16846881. S2CID   32235924.
  32. ↑ Lynn KN, Steinkeler JA, Wilkins-Haug LE, Benson CB (July 2013). "Hyperreactio luteinalis (enlarged ovaries) during the second and third trimesters of pregnancy: common clinical associations". Journal of Ultrasound in Medicine. 32 (7): 1285–1289. doi:10.7863/ultra.32.7.1285. PMID   23804351. S2CID   20652763.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.