Luteoma-induced fetal virilization

Imaging features, clinical characteristics and neonatal outcomes of pregnancy luteoma: A case series and literature review

INTRODUCTION

This study aimed to investigate the imaging features, clinical characteristics and neonatal outcomes of pregnancy luteoma.

MATERIAL AND METHODS

We retrospectively analyzed patients with pregnancy luteoma admitted to the First Affiliated Hospital of Sun Yat-sen University between January 2003 and December 2022. We recorded their imaging features, clinical characteristics and neonatal outcomes. Additionally, we reviewed relevant studies in the field.

RESULTS

In total, 127 cases were identified, including eight from our hospital and 119 from the literature. Most patients (93/127, 73.23%) were of reproductive age, 20-40 years old, and 66% were parous. Maternal hirsutism or virilization (such as deepening voice, acne, facial hair growth and clitoromegaly) was observed in 29.92% (38/127), whereas 59.06% of patients (75/127) were asymptomatic. Abdominal pain was reported in 13 patients due to compression, torsion or combined ectopic pregnancy. The pregnancy luteomas, primarily discovered during the third trimester (79/106, 74.53%), varied in size ranging from 10 mm to 20 cm in diameter. Seventy-five cases were incidentally detected during cesarean section or postpartum tubal ligation, and 39 were identified through imaging or physical examination during pregnancy. Approximately 26.61% of patients had bilateral lesions. The majority of pregnancy luteomas were solid and well-defined (94/107, 87.85%), with 43.06% (31/72) displaying multiple solid and well-circumscribed nodules. Elevated serum androgen levels (reaching values between 1.24 and 1529 times greater than normal values for term gestation) were observed in patients with hirsutism or virilization, with a larger lesion diameter (P < 0.001) and a higher prevalence of bilateral lesions (P < 0.001). Among the female infants born to masculinized mothers, 68.18% (15/22) were virilized. Information of imaging features was complete in 22 cases. Ultrasonography revealed well-demarcated hypoechoic solid masses with rich blood supply in 12 of 19 cases (63.16%). Nine patients underwent magnetic resonance imaging (MRI) or computed tomography (CT), and six exhibited solid masses, including three with multi-nodular solid masses.

CONCLUSIONS

Pregnancy luteomas mainly manifest as well-defined, hypoechoic and hypervascular solid masses. MRI and CT are superior to ultrasonography in displaying the imaging features of multiple nodules. Maternal masculinization and solid masses with multiple nodules on imaging may help diagnose this rare disease.

A case of excision of ovarian torsion necrosis due to luteoma in a female who conceived a twin pregnancy through in vitro fertilization misdiagnosed with acute appendicitis

The aim of this study was to describe a case of ovarian torsion necrosis due to delayed treatment of luteoma in a woman with IVF twin pregnancy who was misdiagnosed with acute appendicitis. We summarized the clinical manifestations and diagnosis of luteoma in a woman with IVF twin pregnancy and reviewed the relevant literature. We report the case of a 34-year-old Asian female who became pregnant through in vitro fertilization (IVF) and had acute right underbelly pain at 26 weeks and 6 days of gestation, which was misdiagnosed as acute appendicitis. Written consent was obtained from the patient. After fasting for a short duration and receiving anti-inflammatory and intravenous fluid replacement treatment after admission, the woman experienced increased right lower abdominal pain without relief and decreased fetal movement. B-ultrasound and CT examination showed that luteoma torsion was possible, and we performed emergency surgical laparotomy. During the operation, it was found that the right ovary was enlarged, the fallopian tube was twisted 720 degrees, and there was no lesion in the appendix. The right necrotic ovary was removed, and pathological results showed a hemorrhagic corpus luteum in the right ovary. The patient's abdominal pain was relieved after the operation and the pregnancy was continued. This is a typical case of ovariectomy associated with a luteoma of pregnancy. Whether in vitro fertilization and related procedures increase the risk of luteoma and whether they increase the risk of ovarian torsion necrosis in the case of luteoma formation are questions that need further study.

Hirsutism Caused by Pregnancy Luteoma in a Low-Resource Setting: A Case Report and Literature Review

BACKGROUND

Pregnancy luteomas are rare, benign, ovarian neoplasms resulting from increased androgenic activity during pregnancy. Often, they occur asymptomatically and are only diagnosed incidentally during imaging or surgery: cesarean section or postpartum tubal ligation. Most common symptoms associated with pregnancy luteoma include acne, deepening of voice, hirsutism, and clitoromegaly. Most pregnancy luteomas regress spontaneously postpartum. Thus, the management of pregnancy luteomas depends on the clinical situation.

CASE

We report a case of 28-year-old gravida 2, para 1 who presented at 39 + 1 weeks of gestation with prolonged labor and delivered by emergency cesarean. Intraoperatively, a huge left ovarian mass was identified and resected, and tissue was sent for histopathology and a diagnosis of pregnancy luteoma was made after the pathological report.

CONCLUSION

The present report emphasizes that pregnancy luteoma is a benign neoplasm and imprudent surgical intervention should be reserved. Proper imaging techniques, preferably MRI or ultrasonography that visualize the size of the ovary and reproductive hormonal profiles, would suffice for the diagnosis and management of pregnancy luteoma.

Gynecologic cancer in pregnancy

Cancer complicates 1 in 1000 pregnancies. Multidisciplinary consensus comprised of Gynecologic Oncology, Pathology, Neonatology, Radiology, Anesthesiology, Maternal Fetal Medicine, and Social Work should be convened. Pregnancy provides an opportunity for cervical cancer screening, with deliberate delays in treatment permissible for early stage carcinoma. Vaginal delivery is contraindicated in the presence of gross lesion(s) and radical hysterectomy with lymphadenectomy at cesarean delivery is recommended. Women with locally advanced and metastatic/recurrent disease should commence treatment at diagnosis with chemoradiation and systemic therapy, respectively; neoadjuvant chemotherapy to permit gestational advancement may be considered in select cases. Most adnexal masses are benign and resolve by the second trimester. Persistent, asymptomatic, benign-appearing masses can be managed conservatively; surgery, if indicated, is best deferred to 15-20 weeks, with laparoscopy preferable over laparotomy whenever possible. Benign and malignant germ cell tumors and borderline tumors are occasionally encountered, with unilateral adnexectomy and preservation of the uterus and contralateral ovary being the rule. Epithelial ovarian cancer is exceedingly rare. Ultrasonography and magnetic resonance imaging lack ionizing radiation and can be employed to evaluate disease extent. Tumor markers, including CA-125, AFP, LDH, inhibin-B, and even CEA and ßhCG may be informative. If required, chemotherapy can be administered following organogenesis during the second and third trimesters. Because platinum and other anti-neoplastic agents cross the placenta, chemotherapy should be withheld after 34 weeks to avoid neonatal myelosuppression. Bevacizumab, immune checkpoint inhibitors, and PARP inhibitors should be avoided throughout pregnancy. Although antenatal glucocorticoids to facilitate fetal pulmonary maturation and amniotic fluid index assessment can be considered, there is no demonstrable benefit of tocolytics, antepartum fetal heart rate monitoring, and/or amniocentesis. Endometrial, vulvar, and vaginal cancer in pregnancy are curiosities, although leiomyosarcoma and the dreaded twin fetus/hydatidiform mole have been reported. For gynecologic malignancies, pregnancy does not impart aggressive clinical behavior and/or worse prognosis.

Bilateral pregnancy luteoma: a case report

Pregnancy luteoma is a non-neoplastic lesion of the ovary occurring during pregnancy and is usually discovered incidentally at the time of a cesarean section or during postpartum tubal ligation. An accurate diagnosis is important for the mother and the fetus as it can be confused with ovarian malignancy leading to unnecessary surgery. We report a case of a pregnant female who was discovered to have bilateral enlarged ovaries at the time of emergency cesarean section.

Late presentation of hyperandrogenism in pregnancy: clinical features and differential diagnosis

Background

Hyperandrogenic states in pregnancy are rare but arise most commonly due to new-onset ovarian pathology in pregnancy. We describe the case of a young woman who presented in the latter half of her pregnancy with features of hyperandrogenism. We review the biochemical and imaging findings and discuss the differential diagnosis.

Case presentation

A 26-year-old woman presented in the later part of her pregnancy with widespread hirsutism. Biochemical testing confirmed hyperandrogenism (testosterone, 13.7 nmol/l and second-trimester pregnancy range, 0.9–4.9 nmol/l), although she had no history of menstrual disturbance, hirsutism or acne prior to conception. Radiological evaluation (ultrasound and magnetic resonance imaging) revealed multiple cystic lesions in both ovaries, leading to a presumptive diagnosis of hyperreactio luteinalis (HL). The implications of maternal hyperandrogenism on foetal virilisation were considered and the patient was counselled appropriately. She delivered a healthy baby boy uneventfully. Androgen levels, hirsutism and acne normalised within a few weeks of delivery.

Conclusion

HL can occur at any stage of pregnancy and is an important differential diagnosis in pregnant patients with features of androgen excess. Most cases regress spontaneously after delivery and major interventions are usually not needed.

Learning points

Hyperandrogenism in pregnancy is rare.

Clinical features are similar to the non-pregnant state in the mother but virilisation in the foetus can have profound consequences.

HL and pregnancy luteoma are the most common ovarian pathologies leading to hyperandrogenism in pregnancy.

Spontaneous regression occurs in the post-partum period in the vast majority of cases and surgery is only required for local complications.

Management of ovarian disease in pregnancy

The ovary is a complex structure that is responsible for maintaining the endocrine support for a pregnancy during the first trimester until the placenta is sufficiently developed to assume this role. Most ovarian disorders of pregnancy actually relate to pre-existing ovarian conditions such as polycystic ovary syndrome and premature ovarian insufficiency. Both of these are associated with increased complications in pregnancy and require careful monitoring. Ovarian disorders that are a particular consequence of the hormonal milieu of pregnancy such as pregnancy luteoma (PL) and hyperreactio luteinalis (HL) are rare. However, they have important implications for both the mother and the foetus since they can be confused with ovarian malignancy leading to unnecessary surgery. This review focuses on the salient aspects of management of these ovarian conditions during pregnancy.

A case of hypertension with virilisation during pregnancy

This case report describes the onset of hypertension and virilisation during pregnancy due to a Brenner tumour.

Prenatal virilization associated with paternal testosterone gel therapy

Transdermal testosterone gels are used in the treatment of hypoandrogenism of males. Virilization due to exposure to testosterone gels has been reported in children resulting in a US Food and Drug Administration (FDA) warning about secondary exposure to these products. At present, we are unaware of prenatal virilization associated with unintentional testosterone gel exposure. We report prenatal virilization in a female infant due to secondary maternal exposure to the father's testosterone gel. We also describe postnatal virilization of the child's twin sister.