A 40-year-old woman comes to the emergency department due to nausea, vomiting, and dizziness. The patient has been unable to tolerate any oral intake over the last 2 days. She has had no fevers, chills, diarrhea, or constipation. She reports no sick contacts. The patient has a history of migraines for which she takes daily preventive treatment, but she has been unable to take her medications for the past several days due to nausea. Her last menstrual period was approximately 8 weeks ago, and she has a history of irregular menses. Temperature is 36.7 C (98 F), blood pressure is 90/60 mm Hg, and pulse is 112/min. BMI is 32 kg/m². Physical examination shows dry mucous membranes, decreased skin turgor, and prolonged capillary refill. The abdomen is soft and nontender. Pelvic examination shows a 12-week-size uterus and bilateral adnexal masses. Pelvic ultrasound shows a uterus filled with multiple small cysts but no embryo. The ovaries are 10 cm bilaterally with a multilocular cystic appearance. Urine pregnancy test is positive. Which of the following is the most likely mechanism of this patient's adnexal pathology?

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11ec25c8_da36_4781_bc81_19d3c581718b_MD0003_00 This patient presents with hyperemesis gravidarum, an enlarged uterus (12-week size at 8 weeks gestation), and bilaterally enlarged ovaries, a presentation concerning for a complete hydatidiform mole, a type of gestational trophoblastic disease. A complete hydatidiform mole results from abnormal fertilization of an empty ovum by either 2 sperm or by 1 that subsequently duplicates its genome. The resultant gestation is composed of proliferative trophoblastic tissue that secretes high levels of β-hCG. The markedly elevated β-hCG level causes hyperstimulation of the ovaries and formation of theca lutein cysts, which are large, bilateral, multilocular ovarian cysts. Theca lutein cysts are expectantly managed as they resolve after treatment of the hydatidiform mole by suction curettage or hysterectomy when the β-hCG level decreases. complete hydatidiform mole (Choice A) Polycystic ovarian syndrome is associated with excessive intra-ovarian androgen conversion and presents with anovulatory oligomenorrhea, hyperandrogenism (eg, hirsutism), and multiple small ovarian cysts. (Choice B) An ectopic pregnancy is a pregnancy (eg, blastocyst) that implants outside of the uterus, typically in the fallopian tube. Ectopic pregnancies typically present as a unilateral adnexal mass. (Choice C) A simple cyst occurs when a follicle fails to rupture during ovulation. Simple cysts are unilateral and unilocular on ultrasound. (Choice E) A benign cystic teratoma (eg, dermoid cyst) is a tumor composed of differentiated germ cells. Teratomas can be bilateral but have both solid and cystic components. Teratomas are usually asymptomatic and are not associated with an hydatidiform mole. Educational objective: Hydatidiform mole, a type of gestational trophoblastic disease, can present with theca lutein cysts, bilateral multiloculated ovarian cysts that are associated with ovarian hyperstimulation from markedly elevated β-hCG levels. The theca lutein cysts resolve after treatment of the hydatidiform mole when the β-hCG level decreases. References: Gestational trophoblastic disease. (http://www.ncbi.nlm.nih.gov/pubmed/17304028)

A 40-Year-Old Woman Comes to the Emergency Department Due to Nausea