Gestational hyperandrogenism arises from either maternal (eg, ovarian masses) or fetal (eg, placental aromatase deficiency) sources that result in maternal and possible fetal virilization.

Diagnosis Clinical features
Placental aromatase deficiency • No ovarian mass
• High maternal & fetal virilization risk
• Resolution of maternal symptoms after delivery
Luteoma
• Solid, unilateral/bilateral ovarian masses
• Moderate maternal virilization risk; high fetal virilization risk
• Spontaneous regression of masses after delivery
Theca lutein cyst • Cystic, bilateral ovarian masses
• Moderate maternal virilization risk; low fetal virilization risk
• Spontaneous regression of masses after delivery
Sertoli-Leydigt umor • Solid unilateral ovarian mass
• High maternal & fetal virilization risk
• Surgery required (2nd trimester or postpartum)

The most common benign ovarian tumors resulting in gestational hyperandrogenism are luteomas of pregnancy and theca lutein cysts.

  1. Luteomas of pregnancy, as seen in this patient, often appear as solid, bilateral ovarian masses on ultrasound. Elevated β-hCG levels stimulate the luteoma (composed of large lutein cells) to release androgens, which may cause maternal virilization; some patients are asymptomatic. Women who develop virilization symptoms are at high risk of delivering a female fetus with virilization.
  2. Theca lutein cysts are cystic, bilateral ovarian masses that occur from ovarian hyperstimulation secondary to markedly elevated β-hCG levels (eg, hydatidiform mole, multiple gestation). Theca lutein cysts may cause maternal virilization; however, there is a low risk of female fetal virilization.

Management of bilateral, benign ovarian masses is observation and expectant management, as the masses and symptoms resolve spontaneously after delivery due to falling β-hCG levels. the Q mentions “bilateral 7-cm solid masses in the ovaries”

(Choices B and C)  Surgery with either an ovarian biopsy or oophorectomy may be indicated if a malignant ovarian tumor is suspected.  Sertoli-Leydig tumors secrete testosterone, which can result in virilization.  In contrast to the masses in this patient, these tumors often appear as unilateral, solid, complex masses on ultrasound.

(Choice E)  Suction curettage is indicated if a complete hydatidiform mole is seen on ultrasound (eg, "snowstorm" appearance).  This patient has a normal intrauterine gestation.

2415→Hyperandrogenism in pregnancy is commonly due to benign, bilateral ovarian masses such as luteomas and theca lutein cysts. Patients with virilization during pregnancy and bilateral ovarian masses are observed and managed expectantly, as the symptoms and masses spontaneously regress after delivery.