Thecalutein cysts are large ovarian cysts that are usually seen in early
pregnancy due to overstimulation with human chorionic gonadotopin (hcg - the
hormone measured in pregnancy tests).  Although they can be associated with
"normal" pregnancies like twins and triplets, they are most commonly
associated with hydatidiform mole, otherwise known as trophoblastic disease.
 In the usual course of trophoblastic disease there continues to be abnormal
proliferation of placental tissue, but the fetus does not develop.  Most
moles are benign, but occasionally they are malignant, called
choriocarcinoma.  Hcg levels get very high, and the uterus must be evacuated
soon after the diagnosis is made, because these patients can hemorrhage like
you wouldn't believe.

Your patient presents a picture that is sometimes seen in postpartum
trophoblastic disease.  In other words there may still be "live"
trophoblastic tissue even though she has delivered.  So your thoughts about
"retained placental tissue" may not be too far off the mark.  The concern
here is that postpartum trophoblastic disease has a higher incidence of
malignancy.

I think your patient should have an hcg level drawn, be started on
antibiotics (for infected retained placental fragments), and depending on her
hcg level and response to antibiotics, possibly a D&C.  I agree this problem
is related to her inability to lactate.

Please forward this message to Jack.  I've had trouble with the computer on
which I had his E-mail.  Thanks.  If there are further questions, please
ask....Victoria Nichols-Johnson, MD