• aspiration
• cyst
• ovarian torsion
• treatment
• ultrasound

The coexistence of a heterotopic pregnancy with a giant ovarian cyst is an incredibly rare abnormal pregnancy in cases of natural conception. The incidence of this condition has increased significantly as a result of the continuous development of assisted reproductive technologies. When this type of pregnancy occurs, both the continuation of intrauterine pregnancy and the life of the pregnant woman are severely threatened. Early diagnosis and treatment using safe and effective methods are paramount in this situation.

A 30-year-old primigravida at a gestation age determined as 8 wk 4 d by scan was admitted to the hospital with heterotopic pregnancy and a right ovarian cyst. Laparoscopic resection of the ectopic pregnancy was performed, but the intrauterine pregnancy and ovarian cyst were preserved.

The approach to a patient with heterotopic pregnancy and a giant ovarian cyst is individualized base on the fertility requirements. We recommend the following: (1) If the patient satisfies parity and has no fertility requirement, a laparoscopic salpingectomy should be performed and the giant ovarian cyst and intrauterine pregnancy removed; (2) If the patient has fertility requirements wishes to have more children in the future, laparoscopic salpingectomy or salpingostomy should be performed and the intrauterine pregnancy preserved. Serial ovarian cyst aspiration can be performed under ultrasound and resection can be done after delivery; and (3) Heterotopic pregnancy should be diagnosed early by active surveillance during antenatal visits using ultra sound as this is important for the avoidance of catastrophic complications.

• Heterotopic pregnancy
• Ectopic pregnancy
• Giant ovarian cyst
• Case report

Hyperreactio luteinalis (HRL) is characterised by benign enlargement of ovaries in pregnancy associated with hyperandrogenism. A 19-year-old primigravida presented with breathlessness, abdominal distension and vomiting in the thirteenth week of gestation. Abdominal examination revealed distension of abdomen disproportionate to the gestational age. Ultrasound was suggestive of bilaterally enlarged multicystic ovaries with a characteristic “spoke-wheel” pattern and a diagnosis of HRL was made. Laboratory investigations revealed primary hypothyroidism and elevated testosterone. She was initiated on levothyroxine therapy. Her respiratory distress worsened on the third day of admission for which she underwent emergency laparotomy with cyst aspiration. Thyroid function tests normalized within six weeks after the initiation of therapy and remained normal for the remainder of pregnancy. Serum testosterone levels returned to normal six weeks postpartum. The elevated thyroid-stimulating hormone levels could have contributed to development of HRL by cross-reacting with human chorionic gonadotropin and follicle-stimulating hormone receptors. Hyperandrogenism and ovarian enlargement regresses with levothyroxine therapy.

• fsh
• hcg
• hyperreactio luteinalis
• hypothyroidism
• pregnancy
• spoke-wheel
• tsh

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.

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.

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.

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.

• Electrochemiluminescence immunoassay
• Hyperandrogenism
• Hyperreactio luteinalis
• Liquid chromatography–tandem mass spectrometry
• Maternal virilization
• Pregnancy-associated virilization