Twin Pregnancy with Theca Lutein Cysts: Causes, Risks & Management

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Twin pregnancies present unique physiological and clinical challenges, particularly when they involve a monochorionic diamniotic (MCDA) placentation and maternal ovarian changes such as bilateral theca lutein cysts (TLCs). MCDA twins share a single placenta but have two separate amniotic sacs. This type of twinning arises due to a single fertilized egg splitting between 4–8 days post-fertilization. When coupled with the development of theca lutein cysts, it raises concerns about maternal and fetal well-being.

Understanding Monochorionic Diamniotic Twin Pregnancy

MCDA twin pregnancies account for approximately 70% of all monozygotic (identical) twin pregnancies. The shared placenta predisposes these pregnancies to several complications, including:

  • Twin-Twin Transfusion Syndrome (TTTS) – An imbalance in blood flow between the twins.
  • Twin Anemia-Polycythemia Sequence (TAPS) – Chronic, slow transfusion from one twin to the other.
  • Selective Intrauterine Growth Restriction (sIUGR) – Unequal placental sharing leading to impaired growth of one twin.
  • Twin Reversed Arterial Perfusion (TRAP) Sequence – A rare condition where one twin is acardiac and relies on the other for circulation.

Theca Lutein Cysts in Pregnancy

Theca lutein cysts are benign, functional ovarian cysts caused by excessive stimulation of luteinizing hormone (LH) and human chorionic gonadotropin (hCG). These cysts often develop in high-hCG states, such as:

  • Multiple gestations (e.g., MCDA twins, triplets, etc.)
  • Gestational trophoblastic disease (e.g., molar pregnancy)
  • Ovarian hyperstimulation syndrome (OHSS) in ART cycles

Bilateral theca lutein cysts are often asymptomatic but can cause pelvic discomfort, ovarian torsion, hemorrhage, or rupture in severe cases.

Occurrence in Natural Conception vs. ART (Assisted Reproductive Technology)

1. Natural Conception

  • MCDA twin pregnancies with bilateral theca lutein cysts can occur naturally, although it is rare. This happens when:
  • Spontaneous splitting of the zygote occurs in early development.
  • hCG levels are unusually high, stimulating ovarian follicular response beyond normal.

2. Assisted Reproductive Technology (ART)

  • The incidence is higher in ART pregnancies, especially with controlled ovarian hyperstimulation (COH) and in-vitro fertilization (IVF). Factors contributing include:
  • Gonadotropin use (FSH, LH, hCG) leading to exaggerated ovarian response.
  • Multiple embryo transfers, increasing the chance of MCDA twinning.
  • hCG-triggered ovarian stimulation, which enhances the likelihood of theca lutein cyst development.

Diagnosis

1. Ultrasound Imaging

  • MCDA twins are confirmed via ultrasound by identifying:
  • Thin intertwin membrane (<2mm) with the "T-sign".
  • Single placenta with two amniotic sacs.

Theca lutein cysts appear as bilateral, multilocular ovarian cysts on ultrasound, typically without solid components or internal vascularity.

2. Laboratory Investigations

  • Elevated beta-hCG levels (sometimes exceeding 100,000 mIU/mL).
  • Hormonal panel to rule out other ovarian pathologies (e.g., androgen-secreting tumors).

Management and Prognosis

1. Conservative Management

  • Most theca lutein cysts resolve spontaneously postpartum as hCG levels decline.
  • Pain management with acetaminophen or NSAIDs (if not contraindicated in pregnancy).
  • Frequent ultrasound monitoring to assess for complications (e.g., torsion, hemorrhage).

2. Management of MCDA Twin Pregnancy

  • Frequent antenatal visits (every 2 weeks from 16 weeks gestation) to monitor for TTTS, TAPS, or IUGR.
  • Doppler studies and serial fetal growth scans to assess placental function.
  • Early delivery planning if complications arise (usually around 34–36 weeks gestation in uncomplicated cases).

3. Surgical Intervention (If Necessary)

  • Ovarian torsion or rupture may require emergency laparoscopic or open surgery.
  • Severe TTTS may require laser ablation of placental anastomoses or amnioreduction.

MCDA twin pregnancy with bilateral theca lutein cysts is a unique clinical scenario that requires careful monitoring. While the condition may occur in both natural and ART pregnancies, it is more commonly seen in ART due to ovarian hyperstimulation. Regular ultrasound surveillance, hormonal assessment, and multidisciplinary care can help optimize maternal and fetal outcomes.

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