case presentation of molar pregnancy

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Published: 03 September 2022

Molar pregnancy with a coexisting living fetus: a case series

Reda Hemida ORCID: orcid.org/0000-0003-0841-0242 1 ,
Eman Khashaba 2 &
Khaled Zalata 3

BMC Pregnancy and Childbirth volume 22 , Article number: 681 ( 2022 ) Cite this article

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Coexistence of molar pregnancy with living fetus represents a challenge in diagnosis and treatment. The objective of this study to present the outcome of molar pregnancy with a coexisting living fetus who were managed in our University Hospital in the last 5 years.

We performed a retrospective analysis of patients who presented with molar pregnancy with a coexisting living fetus to our Gestational Trophoblastic Clinic, Mansoura University, Egypt from September, 2015 to August, 2020. Clinical characteristics of the patients, maternal complications as well as fetal outcome were recorded. The patients and their living babies were also followed up at least 6 months after delivery.

Twelve pregnancies were analyzed. The mean maternal age was 26.0 (SD 4.1) years and the median parity was 1.0 (range 0–3). Duration of the pregnancies ranged from 14 to 36 weeks. The median serum hCG was 165,210.0 U/L (range 7662–1,200,000). Three fetuses survived outside the uterus (25%), one of them died after 5 months because of congenital malformations. Histologic diagnosis was available for 10 of 12 cases and revealed complete mole associated with a normal placenta in 6 cases (60%) and partial mole in 4 cases (40%). Maternal complications occurred in 6 cases (50%) with the most common was severe vaginal bleeding in 4 cases (33.3%). There was no significant association between B-hCG levels and maternal complications ( P = 0.3).

Maternal and fetal outcomes of molar pregnancy with a living fetus are poor. Counseling the patients for termination of pregnancy may be required.

Trial registration

The study was approved by Institutional Research Board (IRB), Faculty of Medicine, Mansoura University (number: R.21.10.1492).

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Introduction

Hydatidiform mole is a rare complication of early pregnancy characterized by disordered proliferation of trophoblastic epithelium and villous edema. It includes complete (CHM) and partial (PHM) hydatidiform moles [ 1 , 2 ]. Partial hydatidiform mole arises as a result of dispermic fertilization of a haploid oocyte, which produces a triploid set of chromosomes and is commonly associated with congenital fetal malformations [ 3 ]. Hydatidiform moles are usually presented with first trimester vaginal bleeding, passage of vesicles, abdominal pain, excessive nausea and vomiting, and rapid abdominal enlargement [ 1 ]. Hyperthyroidism and preeclampsia may be present in some cases of complete hydatidiform moles [ 4 , 5 ]. Human chorionic gonadotropin (hCG) level is elevated but the level in CHM is higher than PHM [ 6 ].

Although complete hydatidiform moles can be easily diagnosed using routine ultrasound assessments early in the first trimester by appearance of snow-storm appearance of the placenta; PHM may mimic missed or incomplete abortion [ 7 ].

During management of molar pregnancy with a coexisting living fetus; the gynecologist should remind that there are three different types. The most common is twin pregnancy with one normal fetus with a normal placenta and a CHM; the second type is twin pregnancy with a normal fetus and placenta and a PHM; and the third, and most uncommon, is a singleton pregnancy consisting of a normal fetus and a placenta with PM changes [ 8 ]. The latter type was reported to occur in 0.005 to 0.01% of all pregnancies [ 9 ]. It is sometimes called “Sad Fetus Syndrome” [ 7 ]. Pregnancy with a PHM and a normal fetus evolves to a viable fetus in less than 25% of cases [ 8 ]. Such pregnancy has little tendency to invade the myometrium and distant metastasis [ 6 ].

Coexistence of molar changes with an apparently healthy fetus is unusual in a case of familial recurrent hydatidiform mole (FRHM). It should be differentiated from mesenchymal dysplasia by morphologic features and immunohistochemistry [ 10 ].

To the best of our knowledge, there are no available international guidelines for management of molar pregnancy with a living fetus. The available publications are mostly case reports, so the authors prepared this manuscript to present the experience of our University GTD referral clinic in the management and outcome of these rare cases.

Patients and methods

In this case series; a retrospective analysis of the patients presented with molar pregnancy with a coexisting living fetus to Gestational Trophoblastic Clinic, Mansoura University, Egypt in 5 years (from September, 2015 to August, 2020). The data of the patients were extracted from the computer and paper files. We included all cases above 18 years with diagnosed molar pregnancy with a living fetus based on clinical, ultrasound, and serum human chorionic gonadotropin (hCG) criteria. The patients who refused to give initial permission to use their data in future research where excluded from the study.

Clinical characteristics including age, parity, obstetric history, gestational age, presenting symptoms, serum hCG on initial diagnosis, and family history, were all recorded. Mode of termination of pregnancy (miscarriage, induction of abortion, hysterotomy, vaginal, or caesarean delivery) was also reported.

Maternal complications during pregnancy, labor, and puerperium were described. Fetal outcomes (miscarriage, congenital fetal malformations, prematurity, or normal) were reported. The patients and living babies were followed up at least for 6 months after delivery .

The study was approved by Institutional Research Board (IRB), Faculty of Medicine, Mansoura University (number: R.21.10.1492). The excel data and figures are anonymous.

Statistical analysis

Data entry and analysis was done using SPSS program, version 23.0 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp.) was used to analyze the findings. The qualitative data were described in number and percentage. The quantitative data with normal distribution were described in mean and the standard deviation ( \(\pm\) SD). Discrete variables were summarized in median and range. Contingency coefficient Chi square was used to compare nominal variables. The statistical significance was considered when P value was less than 0.05.

From September 2015 to August, 2020; twelve cases of molar pregnancy with living fetus were managed in our hospital. The mean maternal age was 26.0 ( \(\pm\) SD 4.1) years while median parity was 1.0 (range 0–3). Duration of pregnancy ranged from 14 to 36 weeks. The median serum hCG at time of diagnosis was 165,210.0 U/L (range 7662–1,200,000). Ultrasound reports showed well-defined multicystic snowstorm-like mass connecting with placenta (Fig. 1 ). Amniocentesis was performed in one case and revealed a normal diploid female karyotype. During antenatal follow up, the patients who had no complications and requested to undergo conservative treatment were given two injections of 12 mg of betamethasone 24 h apart from 28 weeks of gestation to prevent respiratory distress syndrome.

Ultrasound picture of pregnancy of the case (Z) at 28 weeks showing normal fetus with multiple variable-sized vesicles that cannot be separated from another placenta. The fetus is looking morphologically normal

The fetal outcomes are shown in Table 1 ; as can be noticed that fetuses survived outside the uterus in three cases (25%). The first two cases were delivered by caesarean delivery at 33 and 36 weeks of gestation after development of persistent abdominal pain and dyspnea with marked abdominal enlargement. Polyhydramnios was excluded by ultrasound examination. The third case delivered vaginally at 36 weeks of a neonate with multiple congenital anomalies namely hydrocephalus and macroglossia who died after 5 months. Seven cases continued their pregnancy beyond 20 weeks; five of them delivered prematurely (71.4%). only one case of them survived after neonatal care admission.

For the cases who were subjected to cesarean delivery or hysterectomy; the presence of multiple “grape” vesicles on the maternal surface of the placenta was observed.

Histologic diagnosis was available for 10 of 12 cases and revealed complete mole associated with a normal placenta in 6 cases (60%) and partial mole in 4 cases (40%)( Figs. 2 and 3 ). Immunohistochemistry for P57 gene was performed on two cases (Figs. 2 and 3 ). The first delivered a phenotypically normal alive female baby and its placenta was misdiagnosed as PHM by morphological evaluation but the cytotrophoblast was negative for p57 immunestaining. The second case was diagnosed as dichorionic twins early in pregnancy that was terminated at 14 weeks of gestation because of severe vaginal bleeding. The fetus was phenotypically normal, placenta was histologically normal, and its cytotrophoblast was positive for p57. In addition, there was large amount of molar tissues that was negative for p57 immunostaining demonstrating a diagnosis of a CHM. These data suggest that this conception consists of a dichorionic twins with a living fetus with normal placenta and a CHM (Figs. 2 and 3 ).

Histopathological examination of the coexistent molar tissues of the case (Z): A Complete hydatidiform mole. The picture shows a dilated trophoblastic villous with cistern formation and trophoblastic epithelium hyperplasia (H&E × 100). B Complete hydatidiform mole. The picture shows a negative reaction to p57 IHC (Peroxidase × 100)

Histopathology of the placenta of the second twin of the case (H): A The picture shows normal trophoblastic villi (H&EX100). B P57 immunestaining of the same case shows a diffuse positive reaction in both trophoblastic and stromal cells (Peroxidase × 100)

Maternal complications occurred in 6 cases (50%) with the most common was severe uterine bleeding that was observed in 4 cases (33.3%). Other maternal complications are listed in Table 1 .

Moreover, three of our patients had familial recurrent hydatidiform mole (FRHM).Two of them are sisters. Genetic study through DNA sequencing confirmed NLRP7 mutations that were previously reported [ 11 ]. One of them experienced molar pregnancy with living fetus 3 times when she was aged 25, 27, and 28 years old.

We did not find a significant association between B-hCG level (when considered less than 500,000 and equal or more than 500,000 Unit/liter) and occurrence of maternal complications ( P = 0.3).

Coexistent molar pregnancy with a living fetus represents a diagnostic and management challenge particularly when the couple is interested to continue pregnancy. In a literature review published by Kawasaki et al. [ 8 ]; eighteen cases of molar pregnancies a coexisting living fetus were reported. The mean gestational age at delivery was 24.5 weeks, and only four fetuses could survive outside the uterus (22.2%) indicating a poor fetal outcome. On karyotyping; placenta was diploid in ten cases, indicating that they may be a CHM in a twin pregnancy or associated placental mesenchymal dysplasia that was also reported by Hojberg et al. [ 12 ].

The patients with molar pregnancy with coexistent living fetus who were managed in our university hospital in the last 5 years were presented in this report. Among the 12 reviewed pregnancies; three fetuses survived outside the uterus (25%). However, one of them died after 5 months because of congenital malformations that were reported by other authors [ 3 ]. The overall fetal survival in our series is less than reported in the literature review [ 8 ]. Moreover, Giorgione et al. [ 13 ] reported that overall neonatal survival in their series was 45% (5 of 11); the difference may be related to different patient criteria and neonatal care facilities in different hospitals. Among seven pregnancies continued beyond 20 weeks; five ended in premature deliveries (71.4%), which is much higher than the reported global incidence of prematurity allover pregnancies of 11% [ 14 ].

Amniocentesis is recommended for cases undergoing conservative treatment to exclude chromosomal abnormalities [ 15 ], however, it was performed only in one case in our series. Nine ladies refused the procedure for fear of complications while early pregnancy termination before time of amniocentesis was performed for two patients. In other series [ 13 ], prenatal invasive procedures were performed in 8 of 13 cases (62%). The acceptability of the pregnant ladies to perform prenatal invasive procedures differs from a community to another.

We reported occurrence of maternal complications in 50% of the studied cases; the commonest was severe vaginal bleeding. Although Sánchez-Ferrer et al. [ 15 ] concluded that termination of pregnancy is not indicated if the fetus is normal and continuation to birth is possible in nearly 60% of cases with no increase in maternal risks when the patient is closely monitored after birth until B-hCG is negative. The difference may be due to different number of cases in each study.

Moreover, two of the managed cases (16.7%) were complicated with early-onset preeclampsia and subsequently the pregnancy was terminated at 22 and 14 weeks of gestation. This finding was also reported by Kawasaki et al. [ 8 ]. In our series, we observed one case of complete mole that progressed to GTN (8.3%) and was successfully treated with single-agent chemotherapy, which is similar to a previous case scenario reported by Peng et al. [ 16 ].

The diagnostic challenge of a case of molar pregnancy with a coexisting living fetus is to differentiate two different conditions; singleton conception with a partial mole and dizygotic twins consisting of normal fetus with a complete mole. If the ultrasound picture of a normal fetus of an appropriate size for its gestational age together with an abnormal cystic placenta, a twin pregnancy consisting of a normal fetus and a CHM should be suspected [ 17 ]. Shaaban et al. [ 18 ] suggested that the peculiar “twin peak” sign in ultrasound, in which chorionic tissues extend into the inter-twin membrane, forming a triangular echogenic structure that intervenes the normal twin sac and the molar pregnancy, confirming the presence of a dichorionic twin gestation.

P57 immunestaining was performed in 2 cases of molar pregnancy with apparently normal fetus (Figs. 2 and 3 ) that confirmed these cases had a dichorionic twin pregnancy consisting of a complete mole with a co-twin of normal fetus and placenta. However, these cases may have been misdiagnosed as partial mole especially when the first ultrasound was done late in pregnancy. Other authors also reported cases of term deliveries of a complete hydatidiform mole with a coexisting living fetus [ 16 , 19 , 20 ].

We did not find a significant association between B-hCG level (when considered less than 500,000 and equal or more than 500,000 Unit/liter) and occurrence of maternal complications ( P = 0.3). This finding was in agree with Chale-Matsau et al. [ 21 ] who concluded that the β-hCG levels do not always correlate with disease severity and prognosis in patients with GTD.

With respect to the reported maternal and fetal complications in our study and other reports, it is necessary to fully inform the pregnant woman of the possible maternal and fetal complications, such as preeclampsia, hyperthyroidism, vaginal bleeding, and theca lutein ovarian cysts. The probability of postpartum development into persistent trophoblastic disease is also high.

The limitations of this study are its retrospective design, limited number of cases, and availability immunohistochemical study of only two cases.

Maternal and fetal outcome of molar pregnancy with a living fetus is poor. The incidence of prematurity is high (71.4%). Counseling of the patients for termination of pregnancy may be need. A global guideline for management is required.

Availability of data and materials

Original data and materials are available on request after contacting the corresponding author.

Abbreviations

Gestational trophoblastic neoplasia

Complete hydatidiform mole

Partial hydatidiform mole

B subunit of human chorionic gonadotropin

Standard deviation

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Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Mansoura University, 35111 Elgomhuria street, Mansoura, Egypt

Reda Hemida

Department of Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Eman Khashaba

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R.H: Conception of Idea, collection of data, and editing manuscript. E.K: Statistical analysis and editing manuscript. K.Z: Pathology revision, preparation of figures, and revision of manuscript. All authors read and approved the final manuscript.

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Correspondence to Reda Hemida .

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The study was approved by Institutional Research Board (IRB), Faculty of Medicine, Mansoura University (number: R.21.10.1492). An informed consent for participation in the study was obtained from all participants.

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Hemida, R., Khashaba, E. & Zalata, K. Molar pregnancy with a coexisting living fetus: a case series. BMC Pregnancy Childbirth 22 , 681 (2022). https://doi.org/10.1186/s12884-022-05004-3

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Molar Pregnancy–Induced Hyperthyroidism: The Importance of Early Recognition and Timely Preoperative Management

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Laurel Walfish, Nisha Gupta, Dong Bach Nguyen, Mark Sherman, Molar Pregnancy–Induced Hyperthyroidism: The Importance of Early Recognition and Timely Preoperative Management, JCEM Case Reports , Volume 1, Issue 6, November 2023, luad129, https://doi.org/10.1210/jcemcr/luad129

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Hyperthyroidism due to gestational trophoblastic disease (GTD) is a rare but potentially life-threatening condition. Optimal perioperative management is crucial for favorable outcomes and prevention of thyroid storm. However, scarce data exist defining the ideal approach to this complex clinical presentation. This case report describes a first-time pregnant 32-year-old woman who was found to be biochemically hyperthyroid in the context of a 10-week gestation molar pregnancy. Despite her biochemical values, the patient remained clinically asymptomatic of her thyroid disease. The Gynecology and Anesthesiology services urgently consulted Endocrinology, and empiric treatment for prevention of potential impending thyroid storm was initiated prior to operative uterine evacuation. After 2 uneventful dilation and curettages with chemotherapy and a transient prescription of antithyroid medication, the patient normalized her human chorionic gonadotropin (hCG) level and recovered to biochemical euthyroidism. Other than a pruritic rash that may have been due to propylthiouracil, the patient's hyperthyroidism improved without further complications. This case highlights the importance of recognizing the link between GTD and thyrotoxicosis to allow for timely initiation of appropriate preoperative treatment. Fortunately, the multidisciplinary approach facilitated management to prevent evolution to thyroid storm.

Gestational trophoblastic disease (GTD) is an unregulated proliferation of placental trophoblastic tissue and is an obstetrical emergency affecting about 1 per 1000 pregnancies [ 1 ]. In a typical pregnancy, β-human chorionic gonadotropin (hCG) plays a weak thyrotrophic role that occasionally causes transient gestational hyperthyroidism [ 2 ]. In GTD, significantly elevated hCG levels have the potential to further increase the production of thyroid hormone, leading to thyrotoxicosis. Early preoperative detection and management through a multidisciplinary approach is paramount to avoid thyroid storm. However, scarce data have been reported suggesting the optimal treatment, as GTD-induced hyperthyroidism is a rare clinical entity. This case report describes our management of a woman with GTD and the multidisciplinary efforts taken to safely prevent evolution to thyroid storm.

A 32-year-old woman, in her first pregnancy, at 10 weeks of gestation presented to medical care with a 2-week history of bloating, abdominal pain, and nausea. She denied bleeding or any symptoms of thyroid dysfunction. She had no significant past medical history, and her family history was unremarkable for any thyroid disorders.

On examination, she was afebrile with blood pressure of 115/67 mm Hg and heart rate of 88 beats per minute. Head and neck examination demonstrated a non-tender and normal sized thyroid. There was no evidence of ophthalmopathy, acropachy, pretibial myxedema, or tremor. The remainder of the general examination was unremarkable.

Laboratory findings demonstrated a hCG of over 420 million IUs/L (normal hCG between 8 and 10 weeks gestation is 60 000-90 000 IUs/L) (420 million mIU/mL) [ 3 ]. Pelvic ultrasound was suspicious for a larger than 10-cm molar pregnancy that appeared to invade the posterior myometrium ( Fig. 1 ). Her thyroid profile was consistent with overt biochemical hyperthyroidism with an undetectable thyroid stimulating hormone (TSH; normal range, 0.4-4.4 pmol/L) and free thyroxine (T4) of 43.1 pmol/L (3.34 ng/dL) (normal T4 range, 8.0−18.0 pmol/L) ( Fig. 2 ). Free triiodothyronine (T3) levels and thyroid receptor antibody (TRAb) were not initially obtained.

Ultrasound image of the 10-cm molar pregnancy invading the myometrium.

Trend of thyroid hormones. Thyroid stimulating hormone (TSH; reference range, 0.40-4.40 mIU/L, 1 mIU/L = 1 µIU/mL); free thyroxine (FT4; reference range 8-18 pmol/L, 1 pmol/L = 0.0775 ng/dL); free triiodothyronine (FT3; reference range 3.8-6.0 pmol/L, 1 nmol/L = 64.9 ng/dL). X axis represents day since surgery.

Upon discovery of her suspected invasive mole and biochemical hyperthyroidism, the patient was transferred to our quaternary care center for multidisciplinary specialist evaluation. A diagnostic laparoscopy with uterine evacuation under ultrasound guidance was promptly scheduled. The treating team urgently consulted the Endocrinology service, given the concern for potential impending thyroid storm with the upcoming surgery. The patient was started on intravenous (IV) corticosteroids (hydrocortisone 100 mg IV once and then 50 mg IV every 8 hours) and an antithyroid agent (propylthiouracil [PTU] 200 mg per os [PO] every 4 hours), while rapid acting beta blockers remained on standby. The procedure occurred as planned, without intra-operative evidence of posterior uterine wall invasion, and she was empirically admitted to the intensive care unit postoperatively for observation, where she remained clinically stable. After 24 hours, her PTU was reduced to 200 mg PO twice daily and her corticosteroid therapy was discontinued. Considering the high initial hCG level on presentation, the gynecology service elected to administer one dose of Actinomycin-D with dexamethasone as chemoprophylaxis for the development of gestational trophoblastic neoplasia. The patient was discharged in stable condition from the hospital on postoperative day 3 with PTU 200 mg twice daily to be continued as an outpatient.

Prompt follow-up appointments were organized with Endocrinology and Gynecology for close hCG and thyroid hormone monitoring. Within 2 weeks of the procedure, blood tests demonstrated resolution of the patient's biochemical hyperthyroid status and correlated with declining hCG levels ( Figs. 2 and 3 ). Given that the patient was clinically euthyroid and newly biochemically hypothyroid with a FT4 level of 5.6 pmol/L (0.434 ng/dL), PTU was discontinued on postoperative day 14 ( Fig. 2 ). Further prompting its cessation, the patient had developed a pruritic rash that may have been associated with the antithyroid agent. Nineteen days postoperation, while thyroid function remained unchanged, her hCG levels started to increase ( Fig. 3 ). The final surgical pathology had shown complete hydatidiform mole, yet repeat imaging was suggestive of recurrent invasion. As the hCG levels continued to rise, the patient underwent a second dilation and curettage in combination with 7 cycles of Methotrexate chemotherapy regimen. Thyroid hormone levels remained stable despite the fluctuations of hCG, and the patient showed no evidence of metastatic disease. Following the second procedure and chemotherapy treatment, the patient's hCG decreased post treatment and continued to remain normal several months later, as did her thyroid function ( Figs. 2 and 3 ).

Trend of β-human chorionic gonadotropin (β-hCG; reference range 0.0-4.9 IUs/L, 1 IU/L = 1 mIUmL).

In this report, we present the case of a 32-year-old woman with molar pregnancy–induced hyperthyroidism. This rare clinical entity is mediated by elevated levels of hCG, produced by the mole, that stimulate TSH receptors. In general, the hCG hormone is thought to have a potency of 1 in 4000 compared to TSH itself and therefore only very high levels have clinically significant thyroid effects [ 4 ]. However, in GTD, the hCG hormone is considered to be more stimulating than the hormone produced by normal pregnancy [ 4 ]. Levels of hCG above 100 000 and persistently elevated for several weeks are considered risk factors for thyrotoxicosis [ 4 , 5 ]. For these reasons, the National Comprehensive Cancer Network recommends thyroid function tests to be performed in all patients with a molar pregnancy [ 1 ]. Our patient's extremely increased hCG level, measured at over 420 million IUs/L, had the capability to significantly stimulate her thyroid hormone production. Yet despite this high value, she remained clinically asymptomatic of her thyroid disease.

Features of GTD are shared with other hCG-induced hyperthyroid states, the most frequent being gestational transient thyrotoxicosis (GTT). GTT is present in about 1% to 3% of all pregnancies and is usually limited to the first half of gestation [ 6 ]. The typical biochemical findings include elevated hCG, undetectable TSH, elevated T4, infrequently elevated T3, and the absence of thyroid receptor antibodies. Our patient's laboratory findings were consistent with this described pattern. Furthermore, comparable to how our patient presented, patients with GTT present with hyperemesis gravidarum from the increased hCG levels but rarely have overt clinical symptoms of hyperthyroidism [ 2 , 6 , 7 ]. Typical symptoms of hyperthyroidism during gestation can include failure to gain weight, heat intolerance, excessive sweating, and tachycardia; however, this can sometimes be difficult to differentiate from physiologic changes in pregnancy [ 7 ].

Typically, hCG-induced hyperthyroidism does not require treatment, since the condition resolves when hCG levels decrease through pregnancy [ 2 ]. In contrast, with a molar pregnancy, a return to a biochemical euthyroid state requires surgical uterine evacuation and medical treatment to achieve proper reduction in hCG levels. It is therefore of utmost importance to recognize the link between GTD and thyrotoxicosis and to initiate appropriate preoperative treatment of hyperthyroidism as soon as possible.

Women with GTD-associated hyperthyroidism require pre-emptive medical management of the thyrotoxicosis prior to interventions, as severe consequences can occur if left untreated [ 7 ]. Complications can include extreme hyperthermia, tachycardia, hypertension, coma, or death [ 7 , 8 ]. In general, thyroid storm has a mortality of 10% to 20% and therefore must be managed with extreme caution. In patients undergoing surgery, thyroid storm can be triggered by the surgical stress of the operation or the anesthesia itself [ 7 ]. Ideally, patients should wait until they are euthyroid prior to undergoing surgery, although euthyroidism typically takes weeks to occur. In the case of our patient, surgery was a necessary therapeutic measure to eliminate the inciting agent and was hence performed without delay.

There are currently no evidence-based recommendations for the management of GTD-induced hyperthyroidism. The 2016 American Thyroid Association (ATA) Guidelines recommend treatment of hyperthyroidism due to choriocarcinoma, a similar cancerous variation of GTD, to include both methimazole and treatment directed against the primary tumor (strong recommendation, low quality evidence) [ 7 ]. Our patient underwent both of these treatments processes; however, further specifics of management were left to clinical judgment in the absence of accompanying recommendations. Therefore, a multidisciplinary approach including physicians from Obstetrics and Gynecology, Endocrinology, Anesthesia, and Critical Care facilitated optimal management for our patient and prevented complications.

We opted to treat our patient with high dose steroids and PTU prior to her surgical intervention. High doses of intravenous steroids functioned to reduce the T4 to T3 conversion [ 8 ]. PTU was used over methimazole for its faster action of decreasing circulating T3 levels, given the urgency of the situation. With this management and after 24 hours of observation in the intensive care unit postoperation, the patient was hemodynamically stable without evidence of clinical thyrotoxicosis and the treatment was therefore slowly and successfully weaned.

Our management was comparable to other documented case reports in the literature. Blick et al and De Guzman et al both describe cases of patients presenting with molar pregnancies already in thyrotoxicosis or thyroid storm. Their patients were treated with high dose steroids, PTU, propranolol, and definitive management of evacuation of molar pregnancies which resulted in improvement of thyroid disease [ 5 , 9 ]. In contrast, our patient never showed symptoms of hyperthyroidism and our treatment was empirical. Scarce reports in the literature were found summarizing the approach to clinical management when the patient was not clinically in thyrotoxicosis, such as our patient. Nevertheless, our precautions were crucial to safely evacuate our patient's molar pregnancy. Further preventative measures could have also been taken in terms of choosing the optimal anesthetic during the operation. General anesthesia is less favored over regional anesthesia in the thyrotoxic patient; however, it was unavoidable in our patient undergoing an exploratory laparoscopy [ 10 ].

In conclusion, this case highlights the importance of recognizing the link between GTD and thyrotoxicosis to allow for timely initiation of appropriate preoperative treatment. We do not know if our patient's situation would have devolved without our interventions, but the risk was sufficient to warrant our multidisciplinary approach, which facilitated management to prevent evolution to thyroid storm. Although our patient safely recovered from her GTD-induced hyperthyroid state, more research is needed to define the optimal treatment plan for these atypical presentations.

It is essential to recognize the link between GTD and thyrotoxicosis to allow for initiation of appropriate management as soon as possible.

Women with GTD-associated hyperthyroidism require pre-emptive medical treatment of the anticipated thyrotoxicosis prior to interventions, as severe consequences can occur if left untreated.

A multidisciplinary approach during the perioperative period can facilitate optimal management for the patient and prevent complications.

All authors made individual contributions to authorship. L.W. contributed to the drafting and revision of the manuscript. N.G. contributed to the clinical care of the patient and drafting and revision of the manuscript. D.B.N. contributed to the clinical care of the patient and revision of the manuscript. M.S. contributed to the clinical care of the patient and revision of the manuscript. All authors reviewed and approved the final draft.

No public or commercial funding.

None declared.

Signed informed consent obtained directly from the patient.

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abu-Rustum NR , Yashar CM , Bean S , et al. Gestational trophoblastic neoplasia, version 2.2019, NCCN clinical practice guidelines in oncology . J Natl Compr Canc Netw . 2019 ; 17 ( 11 ): 1374 ‐ 1391 .

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gestational trophoblastic disease

gestational transient thyrotoxicosis

human chorionic gonadotropin

intravenous

propylthiouracil

triiodothyronine

thyrotropin (thyroid stimulating hormone)

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http://orcid.org/0000-0001-8549-1969 Eison De Guzman 1 ,
Hira Shakeel 2 and
Rohit Jain 2
1 Department of Internal Medicine , The George Washington University Hospital , Washington , District of Columbia , USA
2 Department of Endocrinology and Metabolism , The George Washington University Hospital , Washington , District of Columbia , USA
Correspondence to Dr Eison De Guzman; icydeg1{at}gmail.com

A 49-year-old woman, G8P7, presented with 1 week of worsening vaginal bleeding and abdominal cramps in the setting of a recently discovered unplanned pregnancy. Vaginal ultrasound findings and a significantly elevated human chorionic gonadotropin (hCG) level were concerning for molar pregnancy. She developed signs of hyperthyroidism on the night of admission, for which the endocrinology team was consulted. Laboratory data were consistent with hyperthyroidism. The patient was believed to have thyrotoxicosis secondary to molar pregnancy with concern for impending thyroid storm. Her mental health disorder and bacteraemia made taking care of her further challenging. She was started on a beta-blocker, antithyroid agent and intravenous corticosteroids. She underwent an uncomplicated suction dilation and curettage (D&C), with resolution of her symptoms a few days after. At a follow-up appointment, the patient continued to be asymptomatic and was feeling well.

thyroid disease
thyrotoxicosis

https://doi.org/10.1136/bcr-2021-242131

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Molar pregnancy is a relatively rare complication of gestation with an incidence reported in the USA to be 121 per 100 000 pregnancies. 1 This complication occurs when there is an abnormal proliferation of trophoblastic tissue, resulting in a non-viable mass that often resembles grape-like structures. The major risk factors for molar pregnancy are prior gestational trophoblastic disease and increased maternal age, especially greater than age 45. 1

The most common presenting symptom of molar pregnancy is vaginal bleeding. Hyperemesis gravidarum is a classic association, but presents less frequently than vaginal bleeding. 2 An even rarer complication of molar pregnancy is thyrotoxicosis. Although increased thyroid function is often reported in gestational trophoblastic disease, only 5% of these cases show symptoms of hyperthyroidism. It is believed that an elevated hCG level >200 000 IU/L for several weeks is necessary for the development of thyrotoxicosis. 3 Treatment is necessary to alleviate the patient’s symptoms and to prevent progression into thyroid storm. Thyroid storm is a lethal condition that, even when treated, has a mortality rate as high as 50%. 4

We report a case of molar pregnancy in which the patient subsequently developed thyrotoxicosis. This case highlights the rare complications of molar pregnancy, and the importance of monitoring for clinical hyperthyroidism in this patient population. The case demonstrates how effective treatment of thyrotoxicosis in molar pregnancy not only alleviates the patient’s symptoms, but also helps to prevent progression into the highly lethal thyroid storm.

Case presentation

A 49-year-old woman, G8P7, with asthma and bipolar disorder presented to her primary care provider with nausea, vomiting and bilateral breast tenderness. At the visit, a qualitative urine pregnancy test was positive, revealing an unplanned pregnancy. The patient then began to experience intermittent vaginal spotting that eventually increased to soaking multiple pads throughout the day. This was associated with abdominal cramps that prompted her visit to the emergency room. She had seven uncomplicated vaginal deliveries in the past, the most recent of which was 10 years ago. She has no personal or family history of fibroids, cervical cancer or molar pregnancy.

On admission, the patient was haemodynamically stable with generalised abdominal tenderness on examination. According to her last menstrual period, the estimated gestational age was 15 weeks. She was admitted to the obstetrics and gynecology (OBGYN) team. Later that night, she developed a fever of 39.4°C associated with sinus tachycardia, diaphoresis and tremors in her extremities. On day 2 of admission, she was found to have laboratory data consistent with hyperthyroidism at which point the endocrinology team was consulted.

Investigations

Prior to the endocrinology consultation, the patient underwent a vaginal ultrasound that revealed an enlarged and irregular cystic-appearing endometrium without an intrauterine gestational sac ( figures 1 and 2 ). β-hCG level was disproportionately elevated to 414 600 IU/L given the gestational age. These findings were concerning for molar pregnancy. Her thyroid studies showed an undetectable Thyroid-stimulating hormone (TSH) (<0.015 μIU/mL; first trimester reference range 0.60–3.40), elevated free T4 (3.73 ng/dL; first trimester reference range 0.8–1.2) and elevated free T3 (10.0 pg/mL; first trimester reference range 4.1–4.4). Blood cultures from the day she spiked a fever eventually grew Salmonella species. CT chest/abdomen/pelvis did not reveal a source of the infection, nor did it show evidence of metastases.

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Transvaginal ultrasound showing lack of intrauterine sac and abnormal placental tissue with fluid-filled cysts in longitudinal view.

Transvaginal ultrasound showing lack of intrauterine sac and abnormal placental tissue with fluid-filled cysts in transverse view.

Differential diagnosis

The patient’s presentation and workup were consistent with molar pregnancy (nausea, vomiting, vaginal bleeding, ultrasound with no intrauterine sac but with cystic appearance, and significantly elevated hCG). Her laboratory studies showed a new hyperthyroid state (compared with baseline normal Thyroid function tests (TFTs) obtained a few years ago during psychiatric evaluation), and she experienced symptoms of tachycardia, heat intolerance, diaphoresis and tremors. Therefore, the leading differential was thyrotoxicosis secondary to molar pregnancy, as stimulation of TSH receptors by the beta subunit of hCG can cause increased production and release of thyroid hormones. 5

Other causes of hyperthyroidism were also considered but deemed less likely clinically. The patient lacked a goitre, pretibial myxoedema, exophthalmos or lid lag to suggest Graves’ disease, although TSH receptor and thyroid peroxidase antibodies were not collected during the admission. She has no history of any thyroid disorders in the family. There was no preceding viral upper respiratory tract infection or neck tenderness to indicate subacute thyroiditis. Fibrinogen was mildly elevated to 558 mg/dL in the setting of concurrent salmonella bacteraemia. In painless (silent) thyroiditis, T4 is usually disproportionately elevated compared with T3, which was the opposite in this case. 6 The patient’s home medications were reviewed, and no medications were found that are classically linked to thyroiditis. She does have a history of bipolar disorder, but it has been managed with olanzapine and fluoxetine without prior lithium use. There was no recent iodinated contrast media exposure prior to the development of her symptoms. A thyroid ultrasound was not obtained prior to her emergent intervention.

Infection, such as endometritis, was also on the differential before the blood cultures turned positive, given the fever and tachycardia. Although bacteraemia could explain these abnormal vital signs, it does not account for her other symptoms of heat intolerance and tremors. Besides an enlarged endometrium, the vaginal ultrasound did not show signs of endometritis. The patient also lacked productive cough or dysuria to suggest other infectious aetiologies.

Lastly, the patient had multiple admissions in the past with tachycardia that spontaneously resolved. Her tachycardia then was attributed to excessive caffeine consumption (drinking 4–6 cups of coffee in the morning), as well as frequent use of her albuterol inhaler. However, the patient currently only drinks one cup of coffee a day and has not used her albuterol inhaler in over 2 weeks. She also did not have significant anaemia or decreased urine output to suggest hypovolaemia as a cause of the tachycardia.

After reviewing the patient’s case, the endocrinology team reached a consensus that the patient was suffering from thyrotoxicosis secondary to her molar pregnancy. The patient was scheduled for a suction dilation and curettage to evacuate the mole and remove the ultimate source of the β-hCG. On day 2 of admission, she was started on propranolol (not administered due to hypotension) and propylthiouracil (PTU) (500 mg loading dose, followed by 100 mg every 8 hours) to decrease sympathetic hyperactivity and thyroid hormone production, respectively. Although methimazole has a more rapid onset and better side effect profile than PTU, this patient also had significantly elevated free T3 levels, so PTU was chosen for its ability to prevent T4 to T3 conversion. 7 After discussion with the OBGYN team, there was initially low suspicion for infection (before blood cultures resulted), so the patient was also started on intravenous hydrocortisone (300 mg loading dose, followed by 100 mg every 8 hours). The decision to start steroids was based on concern of thyroid storm occurring in the perioperative period. At the time the endocrinology team was consulted, the patient had a Burch-Wartofsky Point Scale score of 40, which suggests impending thyroid storm. 4 Furthermore, steroids also help decrease conversion of T4 to the more active T3 hormone. 8

Overnight, the patient became hypotensive and persistently tachycardic. Due to concerns of sepsis, the OBGYN team performed an emergent suction D&C early on day 3 of admission. Specimen was collecting during the procedure, and pathology revealed diploidy with negative p57 immunohistochemistry stain, consistent with a complete hydatidiform mole.

Outcome and follow-up

After suction D&C, the patient was closely monitored for thyroid storm in the postoperative period, with no worsening of her symptoms. Four days after the procedure, her tachycardia, tremors, diaphoresis and heat intolerance finally resolved. Her thyroid function tests also improved (FT3 3.0 pg/mL, FT4 1.52 ng/dL, TSH 0.016 μIU/mL) ( table 1 ). Her β-hCG level decreased to 14 744 from 414 600 IU/L. Propranolol and PTU were discontinued at that time since the patient was no longer symptomatic. The intravenous steroids were discontinued soon after the procedure due to the patient’s blood cultures turning positive and eventually growing Salmonella species. A CT chest/abdomen/pelvis performed to identify an infectious source was unrevealing. Per discussion with the infectious disease team, the Salmonella bacteraemia was likely secondary to bacterial translocation from the gastrointestinal tract, and the patient was discharged with ciprofloxacin (500 mg two times per day) to complete a 2-week course of antibiotics. She was counselled on molar pregnancy and complications of pregnancy at an advanced maternal age. The importance of contraception use during this postoperative period was emphasised, in order to monitor for a rise in β-hCG that may indicate development of gestational trophoblastic neoplasia (GTN). Imaging is useful not only in diagnosing hydatidiform moles, but also in detecting complications such as GTN metastases, the most common site being the lung. 9 In our patient, a chest x-ray and CT chest/abdomen/pelvis did not show any evidence of metastatic disease. Labwork performed 2 weeks after discharge showed continued improvement of her TFTs and β-hCG levels.

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TFTs and β-hCG (Beta human chorionic gonadotropin) levels

Molar pregnancy is part of a spectrum of diseases known as gestational trophoblastic diseases. It is a complication defined by abnormal benign or malignant proliferation of trophoblastic cells which result in markedly elevated β-hCG levels. Gestational trophoblastic disease can cause secondary hyperthyroidism as a result of structural homology between β-hCG and TSH. Hormones such as TSH, Follicle-stimulating hormone (FSH), Luteinizing hormone (LH) and hCG are heterodimeric glycoprotein hormones that have an alpha subunit and a beta subunit. The alpha subunit is common to all these hormones. Moreover, there is structural similarity between hCG and TSH beta subunits. Laboratory studies have revealed that normal β-hCG has weak thyrotropic activity on thyroid TSH receptors. 10 One unit of β-hCG has the reactivity equivalent to 0.0013 uU of TSH. The level of sialylation of β-hCG determines its bioreactivity on the TSH receptors: the higher the degree of sialylation, the less activity β-hCG will have. The β-hCG produced by hydatidiform moles has greater thyrotropic activity than normal β-hCG due to its decreased sialylation. 11 Moreover, the extent of desialylation of β-hCG varies with each molar pregnancy. One unit of β-hCG produced by Gestational trophoblastic disease (GTD) has thyrotropic activity range from 3.72 to 46.8 uU equivalents of TSH. 12 It is estimated that for every 10 000 IU/L increase in hCG, there is a 0.1 μIU/mL decrease in TSH and 0.1 ng/dL increase in free T4. 13

Increased levels of β-hCG concentration cause a weak hyperthyroid state in a normal pregnancy. The degree of hyperthyroidism is exacerbated by molar pregnancy with elevated levels of β-hCG and decreased levels of sialylation. The extent and development of hyperthyroidism, thyrotoxicosis, and ultimately thyroid storm is determined by multiple factors: the levels of β-hCG, the amount of desialylation, as well as the duration and type of molar pregnancy.

Compared with partial hydatidiform moles, complete hydatidiform moles usually have higher β-hCG levels. 14 Therefore, it is not surprising that complete moles have been associated with more severe hyperthyroidism. In one Turkish study, patients with complete moles were found to have significantly lower TSH levels and higher free T4 levels compared with those with partial moles. 15 The patients diagnosed with complete moles were also significantly older and of higher gravidity than the patients diagnosed with partial moles. Our patient, who was diagnosed with a complete mole, was 49 years old with seven prior pregnancies. A recent case report describing thyroid storm in a complete molar pregnancy also consisted of an older maternal age woman with multiple pregnancies (G7P3033). 16

In the past few decades, physicians have diagnosed molar pregnancies at earlier gestational ages. One Brazilian study found that the average gestational age at time of diagnosis from 1988 to 1992 was 15 weeks, compared with only 10 weeks in 2008–2012. 17 This earlier detection is promoted by the increased utilisation of first trimester ultrasound and β-hCG levels for screening of prenatal conditions. 18 In our patient, the later diagnosis at 15 weeks gestation was likely due to a delay in seeking medical care after having missed her period.

Treatment of thyrotoxicosis or thyroid storm is based on managing the four major elements involved: the precipitating event; the thyroid gland; the peripheral effects of thyroid hormone and systemic decompensation, if any. The precipitating event in our case was molar pregnancy with the definitive treatment being evacuation. Thyroid hormone synthesis can be curbed with PTU or methimazole, and hormone release can be decrease with iodine. PTU and glucocorticoids can dampen the peripheral effects of thyroid hormone by decreasing the rate of conversion of T4 to the more active T3. Beta blockers, specifically propranolol and esmolol, can decrease the peripheral effects of thyroid hormone by blocking the receptors on which T3 acts. In severe illness, plasmapheresis and charcoal plasma perfusion can help remove excess hormone. 19

In our patient, due to active infection, steroids were discontinued after two doses and propranolol was not administered given low blood pressure. She essentially received 5 days of PTU therapy, which was discontinued once her FT4 normalised before discharge. Given that she had suction dilatation and curettage done in an appropriate and timely manner, her thyroid function tests continued to improve following the procedure as did her clinical status.

Patient’s perspective

When I found out I was pregnant, I had no idea about a molar pregnancy. When I realised there was no baby, I was confused. I’ve never had a miscarriage. All my children were live births, so this was strange. I knew something was wrong when I started vomiting so much. I felt like it was killing me. I believe that if I hadn’t come to the doctor, I would have laid in bed and died. I knew I had to come see somebody to find out what was going on with me. I was too sick for a normal pregnancy or even a miscarriage. It took me a while to accept that there was no baby. I was a little sad because I felt like I’ve been punished. Im being honest, I don’t wish this type of pain and illness on anybody. Constantly throwing up, the stomach pain, I don’t want anyone to have to go through this. I want people to know about this disease, so they can avoid what I’ve been through. I am thankful that the surgery went well. I feel that my health is better now. I hope I never experience this again, and that nobody else has to experience it. It’s worse than actually having a baby.

Learning points

In patients with molar pregnancies, it is essential to monitor for rare complications such as thyrotoxicosis.

Treatment of thyrotoxicosis in molar pregnancies, especially those with significantly elevated β-hCG levels and undetectable TSH levels, is important to prevent progression to thyroid storm.

Counselling patients about the risks associated with advanced maternal age pregnancy is necessary for the health of both fetus and mother, and can prevent undesired complications, such as molar pregnancy and thyrotoxicosis in this case.

Ethics statements

Patient consent for publication.

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Contributors EDG, HS and RJ were directly involved in the patient’s care. EDG and HS drafted the manuscript under the supervision of RJ, who provided guidance for the final manuscript. All authors contributed to the final version of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Hydatidiform moles
Hydatidiform molar pregnancies
Molar pregnancies
Hydatidiform mole
Hydatidiform molar pregnancy

Molar pregnancies , also called hydatidiform moles , are one of the most common forms of gestational trophoblastic disease .

Molar pregnancies are one of the common complications of gestation, estimated to occur in one of every 1000-2000 pregnancies 3 . These moles can occur in a pregnant woman of any age, but the rate of occurrence is higher in pregnant women in their teens or between the ages of 40-50 years. There is a relatively increased prevalence in Asia (for example compared with Europe).

A hydatidiform mole can either be complete or partial . The absence or presence of a fetus or embryo is used to distinguish the complete from partial moles:

complete moles are associated with the absence of a fetus

partial moles usually occur with an abnormal fetus or may even be associated with fetal demise

Rarely, moles co-exist with a normal pregnancy ( co-existent molar pregnancy ), in which a normal fetus and placenta are seen separate from the molar gestation.

Chromosomal composition

Ninety percent of complete hydatidiform moles have a 46XX diploid chromosomal pattern. All the chromosomes are derived from a single sperm in 90% or less likely two sperms, suggesting fertilization of a single egg that has lost its chromosomes.

With partial moles, the karyotype is usually triploid (69XXY), the result of fertilization of a normal egg by two sperm, one bearing a 23X chromosomal pattern and the other a 23Y chromosomal pattern.

Complete hydatidiform moles usually occupy the uterine cavity and are rarely located in fallopian tubes or ovaries .

The chorionic villi are converted into a mass of clear vesicles that resemble a cluster of grapes .

In the classic case of molar pregnancy, quantitative analysis of beta-HCG shows hormone levels in both blood and urine greatly exceeding those produced in normal pregnancy at the same stage.

Please refer to the dedicated articles for discussion on the radiographic features:

complete mole
partial mole

A complete mole can progress to invasive mole (~15%) or to gestational choriocarcinoma (~7%).

The term is derived from the Greek word hydatisia meaning "drop of water" and mola meaning "false conception" 7 .

1. Fine C, Bundy A, Berkowitz R, Boswell S, Berezin A, Doubilet P. Sonographic Diagnosis of Partial Hydatidiform Mole. Obstet Gynecol. 1989;73(3 Pt 1):414-8. - Pubmed
2. Narlawar R, Shah J, Patkar D. Images in Radiology: Complete Hydatidiform Mole with Live Pregnancy in a Twin Gestation. J Postgrad Med. 2000;46(4):291-2. - Pubmed
3. Green C, Angtuaco T, Shah H, Parmley T. Gestational Trophoblastic Disease: A Spectrum of Radiologic Diagnosis. Radiographics. 1996;16(6):1371-84. doi:10.1148/radiographics.16.6.8946542 - Pubmed
4. Wagner B, Woodward P, Dickey G. From the Archives of the AFIP. Gestational Trophoblastic Disease: Radiologic-Pathologic Correlation. Radiographics. 1996;16(1):131-48. doi:10.1148/radiographics.16.1.131 - Pubmed
5. Powell M, Buckley J, Worthington B, Symonds E. Magnetic Resonance Imaging and Hydatidiform Mole. Br J Radiol. 1986;59(702):561-4. doi:10.1259/0007-1285-59-702-561 - Pubmed
6. Marisa R. Nucci, Esther Oliva. Gynecologic Pathology. (2009) ISBN: 9780443069208 - Google Books
7. Carey L, Nash B, Wright D. Molecular Genetic Studies of Complete Hydatidiform Moles. Transl Pediatr. 2015;4(2):181-8. doi:10.3978/j.issn.2224-4336.2015.04.02 - Pubmed

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Expectant Management of a Triploid Partial Molar Pregnancy at 26 Weeks' Gestation: A Case Report

Affiliations.

1 Department of Obstetrics and Gynecology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
2 Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada.
3 Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada.
4 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
5 Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.
PMID: 38707263
PMCID: PMC11068434
DOI: 10.1055/a-2299-4409

Introduction Triploid partial molar pregnancies are not viable, and confer maternal risks including preeclampsia, hemorrhage, gestational trophoblastic neoplasia, and trophoblastic embolization. We report a case managed expectantly until 26 weeks' gestation in a patient requesting continuation of pregnancy. Case Presentation This G2P1 presented with fetal anomalies indicative of triploid partial molar pregnancy. The pregnancy was complicated by anemia, hyperthyroidism, supraventricular tachycardia, and threatened preterm labor. Her care involved maternal fetal medicine collaborating with internal medicine, palliative care, anesthesia and critical care. Labor was augmented at 26 weeks' gestation, resulting in vaginal delivery. Postpartum course was notably complicated by acute respiratory distress in the immediate postpartum period, which self-resolved. Postpartum hemorrhage and retained products of conception were additional complications. Conclusion This unique case highlights the role of multidisciplinary collaboration and shared decision making in challenging circumstances.

Keywords: gestational trophoblastic neoplasia; partial molar; perinatal palliative care; triploidy.

The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).

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Published: 21 May 2018

Molar pregnancy with normal viable fetus presenting with severe pre-eclampsia: a case report

Freddie Anak Atuk 1 &
Juliana Binti Mohamad Basuni 1

Journal of Medical Case Reports volume 12 , Article number: 140 ( 2018 ) Cite this article

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While gestational trophoblastic disease is not rare, hydatidiform mole with a coexistent live fetus is a very rare condition occurring in 0.005 to 0.01% of all pregnancies. As a result of the rarity of this condition, diagnosis, management, and monitoring will remain challenging especially in places with limited resources and expertise. The case we report is an interesting rare case which presented with well-described complications; only a few similar cases have been described to date.

Case presentation

We report a case of a 21-year-old local Sarawakian woman with partial molar pregnancy who presented with severe pre-eclampsia in which the baby was morphologically normal, delivered prematurely, and there was a single large placenta showing molar changes.

Even though the incidence of this condition is very rare, recognizing and diagnosing it is very important for patient care and it should be considered and looked for in patients presenting with pre-eclampsia.

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Molar pregnancy is significantly more common in extremes of age [ 1 ]. Hydatidiform mole has been recognized as a clinical entity since the time of Hippocrates and has always aroused interest because of its wide spectrum of presentations and rare spectacular complications [ 2 ]. Asian countries show the highest rates, followed by Africa and Latin America whereas Europe, Australia, and the USA generally report the lowest rates [ 3 ].

Most pregnancies in which molar change has been reported in association with a normal fetus represent a dizygotic twin pregnancy with one complete hydatidiform mole and other normal twin with clearly distinguishable molar regions in the placenta [ 4 ]. The incidence of a normal live fetus and a partial molar placenta such as the case we describe is extremely rare.

A 21-year-old local Sarawakian primigravida woman was diagnosed as having severe pre-eclampsia at 28 weeks and was admitted for blood pressure stabilization and monitoring. On assessment, her fundal height was larger than indicated by date and transabdominal ultrasound scans, which was suggestive of molar changes in the placenta with a viable fetus noted. She went into spontaneous labor a few days later and lower segment caesarean section was done for breech presentation. A grossly normal baby girl weighing 990 g was delivered. Unfortunately, the baby died due to complications of prematurity and sepsis on day 12 of life. The placenta was noted to be large with diffuse cystic changes (Figs. 1 and 2 ). Pathological study showed placental tissue weighed 2300 g measuring 280 × 230 × 70 mm and it was friable with many vesicles of variable sizes ranging from 10 to 12 mm. The histopathological finding was compatible with partial molar pregnancy. Our patient is currently doing well on regular follow-up and her beta-human chorionic gonadotropin (hCG) was normal 1 month after delivery.

Single large placenta with diffuse cystic changes

Partial molar pregnancy coexisting with normal live fetus as seen in our case is an extremely rare condition excluding cases of multiple conceptions. Such an association has been divided into three types: The first and most common is a twin pregnancy with a normal fetus having a normal placenta and a complete mole; the second type is a twin pregnancy with a normal fetus and placenta and a partial mole; and the third and most uncommon occurrence is a singleton normal fetus with partial molar placenta. In cases of a singleton normal fetus with partial molar placenta, the fetus must have a normal karyotype to survive in utero , although its placenta can have some variation, from diploidy of the amnion to triploidy of the chorionic villi [ 4 ].

Molar pregnancy with coexisting fetus carries a significant risk to both mother and the fetus. Maternal risks include abnormal bleeding, pre-eclampsia, eclampsia, hyperthyroidism, anemia, persistent gestational trophoblastic disease, preterm delivery, and abruption [ 1 ]. According to Vejerslev’s review on 113 reports of pregnancies with mole and fetus in which there appeared to be no major malformations or cytogenetic abnormalities, of the 87 who had intended to continue the pregnancy with or without knowledge of accompanying mole, 52 pregnancies (59.8%) proceeded to the 28th week, and a risk for either substantial bleeding or pre-eclamptic symptoms developed in approximately 30% [ 5 ]. On the other hand, fetal complications include abortion, congenital anomalies, preterm, intrauterine growth restriction, and intrauterine fetal death [ 1 ]. In the case we describe, both the mother and baby were affected by those complications namely pre-eclampsia and preterm birth.

Diagnosis will remain a challenge as this condition is very rare which makes it less likely to be suspected in women with pre-eclampsia. Early diagnosis or detection of this condition might not happen in places where detailed ultrasound screening is not a routine for all pregnant women due to lack of facilities and trained sonographer.

Management of molar changes associated with normal-appearing fetus varies and still remains challenging and debatable. The decision to continue the pregnancy will largely depend on the presence or absence of complications to the mother or baby, prior obstetric history, as well as the woman’s wishes after adequate counselling. Post-delivery, the patient needs to be put on close follow-up. The initial hCG value at delivery should be registered and weekly values plotted on a standard regression curve adjusted for local reference standards. This is followed by measuring weekly values until three values are obtained below the detection limit, then every second week for 2 months, and then monthly for 1 year after the first negative value [ 6 ].

Conclusions

Even though a case of partial molar with coexisting normal fetus is a very rare occurrence, it carries a very high risk to the mother and fetus. One of its classic well-described complications or presentation is pre-eclampsia, such as the case we presented. Therefore, a patient who presents with pre-eclampsia needs to be assessed thoroughly not only looking for its severity and complications but also the possible underlying problem, such as a coexisting molar pregnancy.

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Department of Obstetrics & Gynecology Miri General Hospital, Sarawak, Malaysia

Freddie Anak Atuk & Juliana Binti Mohamad Basuni

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Correspondence to Freddie Anak Atuk .

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Atuk, F.A., Basuni, J.B.M. Molar pregnancy with normal viable fetus presenting with severe pre-eclampsia: a case report. J Med Case Reports 12 , 140 (2018). https://doi.org/10.1186/s13256-018-1689-9

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Published : 21 May 2018

DOI : https://doi.org/10.1186/s13256-018-1689-9

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Changing Trends in the Clinical Presentation and Incidence of Molar Pregnancy in Saudi Arabia: A 30-Year Retrospective Analysis.

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Altalib A 1
Al Qahtani N 1
Alosaimi SS 1
Al Hashem MS 1
Almowallad R 1
Al-Rufiei M 1
Alhumaid LI 1

Cureus , 22 Dec 2023 , 15(12): e50936 https://doi.org/10.7759/cureus.50936 PMID: 38259393 PMCID: PMC10801279

Abstract

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Changing Trends in the Clinical Presentation and Incidence of Molar Pregnancy in Saudi Arabia: A 30-Year Retrospective Analysis

Ayman altalib.

1 Obstetrics and Gynaecology, Imam Abdulrahman Bin Faisal University, Khobar, SAU

Noura Al Qahtani

Shrouq s alosaimi, mariam s al hashem, roaa almowallad, maryam al-rufiei, lujain i alhumaid.

Molar pregnancy (MP) incidence and clinical presentation vary significantly worldwide. Recent trends show changes in its clinical representation and incidence, particularly with the adoption of early diagnosis using first-trimester ultrasonography, which has reduced the prevalence of classical second-trimester presentations. This study aimed to analyze the changes in clinical presentation and incidence of MP among the Saudi population over the past 30 years.

In this retrospective study at King Fahad University Hospital, 121 complete mole (CM) pregnancy cases diagnosed and pathologically confirmed were reviewed. This included 87 cases from 2007 to 2022 (recent group) and 34 cases from 1992 to 2006 (older group). Cases of CM diagnosed before January 1992 and other diagnoses such as PM, invasive mole, or choriocarcinoma were excluded; thus, this study is focused on CM in particular. We compared patient age, gravidity, parity, abortion history, gestational age at diagnosis, hyperemesis gravidarum symptoms, anemia symptoms, and hemoglobin levels. Classical symptoms and signs related to CM were also reviewed. Data were analyzed using Microsoft Excel 2021 (Microsoft Corporation, Redmond, Washington, United States) and presented as mean, frequency, and percentage, with chi-squared tests for categorical variables; p<0.05 was considered statistically significant.

The incidence of CM declined from 2.1 per 1,000 deliveries to 0.9 per 1,000 deliveries. Vaginal bleeding was the most common presentation in both the older (91.9%) and recent (67.6%) groups. Hyperemesis gravidarum prevalence was similar in both groups. Theca-lutein cysts were more frequent in the older group (27.5%) than the recent group (8.8%). A significant difference was observed in the occurrence of a large-for-date uterus between the older (63.20%) and recent (23.5%) groups. Notably, 14.7% of patients in the recent group were asymptomatic at diagnosis. Anemia was present in 46 cases (52.8%) of the older group but absent in the recent group, and preeclampsia occurred in 10 cases (11.4%) of the older group but not in the recent group.

Conclusions

Advancements in ultrasound technology, including transvaginal probes with Doppler capabilities, have enabled earlier pregnancy diagnosis, as early as five to six weeks of gestation. Many MP are now diagnosed in the first trimester without the classic clinical symptoms or "snow-storm" ultrasound appearance. The availability of sensitive beta-human chorionic gonadotropin assays has led to the early termination of these pregnancies, marking a significant shift in the management of MP.

Introduction

Hydatidiform mole (HM), a benign gestational trophoblastic neoplasm, presents either as a complete mole (CM) or a partial mole (PM). These forms differ in their histopathological and genetic characteristics. CM is the more prevalent, accounting for 90% of HMs. HM's incidence varies geographically; for instance, in the Republic of Korea, the incidence is 1.1 per 1,000 pregnancies [ 1 ], while in Stockholm, it is 2.08 per 1,000 pregnancies [ 2 ]. In Italy and Turkey, the incidences are 2.3 and 0.7 per 1,000 pregnancies, respectively [ 3 , 4 ]. In Saudi Arabia, the incidence decreased from one in 446 pregnancies in 1988 to 0.9 per 1,000 in 2016 [ 5 , 6 ], possibly due to improvements in diet and socioeconomic conditions [ 7 ].

Risk factors for HM include extreme maternal age and a history of HM. Over recent decades, its clinical presentation has evolved. Historically, symptoms like excessive uterine enlargement, ovarian enlargement from theca-lutein cysts, preeclampsia, hyperemesis gravidarum, thyrotoxicosis, and anemia with elevated beta-human chorionic gonadotropin (ß-hCG) were common in the second trimester but are now rare.

Diagnosis of molar pregnancy (MP), traditionally identified in the late first or early second trimester by a "snow-storm" ultrasound appearance, is now more commonly made in the first trimester. This shift is due to the typical appearance of a complex, echogenic intrauterine mass with small cystic spaces. Histological examination of the conception products is crucial; without it, HM can be missed. Earlier detection has changed the pathology, showing less trophoblastic hyperplasia and hydropic villi [ 8 ].

Several studies indicate a shift in the clinical presentation of HM, with classical symptoms becoming increasingly rare [ 9 - 11 ]. This trend is linked to the widespread use of ultrasonography and early referral for issues like pregnancy dating or vaginal bleeding, facilitating earlier HM diagnosis and termination before complications arise. Notably, this earlier detection has not altered the time to remission or progression to gestational trophoblastic neoplasia [ 12 ]. This study aims to investigate the changes in clinical presentation and incidence of HM in Saudi Arabia over the past 30 years. By examining these alterations, this research hopes to alert medical professionals to the fact that HM can manifest with a variety of symptoms, not only the severe traditional ones. This could ultimately result in an earlier diagnosis and better treatment outcomes for HM-affected women.

Materials and methods

Study design and population

This retrospective study examined cases of CM pregnancy diagnosed at King Fahad University Hospital, a tertiary referral hospital in Eastern Saudi Arabia. The study period was divided into two cohorts: the "recent group" (January 2007 to September 2022) and the "older group" (1992 to December 2006). These periods were allocated to be 15 years for each group because it's the maximum period that could provide us with adequate data regarding the older group, nevertheless, to keep both groups equal in period as possible. Cases of CM diagnosed before January 1992 and other diagnoses such as PM, invasive mole, or choriocarcinoma were excluded. Moreover, some data were not statically analyzed and ultimately not used in this study due to its incomplete availability. The study received ethical approval from the Institutional Review Board of Imam Abdulrahman Bin Faisal University (approval number: IRB-UGS-2022-01-461).

Data collection

Data were collected from the hospital's ward logbook and health information system. Recorded information included patient demographics (age, gravidity, parity, abortion history), clinical details (gestational age at diagnosis, symptoms of hyperemesis gravidarum, anemia), and diagnostic findings (hemoglobin level, classical CM signs like preeclampsia and hyperthyroidism, ultrasonographic findings, and ovarian enlargement by theca-lutein cysts).

Diagnostic criteria and measurements

Ultrasonography was performed differently in the two groups: transabdominal in the older group and transvaginal in the recent group. Uterine volume, considered excessive if at least three to four weeks greater than the expected gestational age, was also assessed. Hyperemesis gravidarum was defined as vomiting more than three times daily with weight loss exceeding 3 kg or 5% of body weight and ketonuria [ 13 ]. Early-onset preeclampsia and hyperthyroidism were defined using specific clinical criteria, including blood pressure and symptomatology. Anemia was classified as a hemoglobin level below 11 g/dL in the first trimester and 10.5 g/dL in the second trimester [ 14 ].

Variables and data analysis

Independent variables comprised patient age, parity, and the time period (i.e., older and recent groups). Dependent variables included various clinical presentation symptoms. The study controlled for the diagnosis of CM. Data were entered and analyzed using Microsoft Excel 2021 (Microsoft Corporation, Redmond, Washington, United States). The results were presented as mean±standard deviation, frequency, percentage, and distribution for categorized variables.

From 1992 to 2006, there were 40,700 deliveries at our facility, with 87 cases of CM pregnancy, equating to 2.1 per 1,000 deliveries. In contrast, from 2007 to 2022, out of 37,500 deliveries, there were 34 cases of CM or 0.9 cases per 1,000 deliveries. The mean gestational age at diagnosis in the older group (1992-2006) was 14 weeks, five days, while in the recent group (2007-2022), it was 10 weeks, three days.

Table Table1 1 presents the frequency distribution of age and parity among patients. In the recent group, patient ages ranged from 18 to 36 years, with a mean age of 32.2 years. In the older group, ages spanned from 16 to 45 years, with a mean of 28.9 years. Patients were categorized into five age intervals: 20 years or younger, 21-25 years, 26-30 years, 31-35 years, and 36 years or older. In the recent group, CM cases were more frequent in patients under 20 years old (23.5%) compared to the older group (5.74%), with a significant difference (p=0.05). In the older group, CM was more prevalent among women aged 31 to over 36 years (26.4%), while in the recent group, it was significantly higher in women aged 36 years or older (52.9%; p=0.01).

NS: statistically nonsignificant

Parity in patients ranged from 0 to over 4. In the older group, CM was more common in multiparous women (41.3%) than nulliparous women (6.9%; p=0.01). Conversely, 44.1% of CM cases in the recent group were in nulliparous women compared to 17.6% in multiparous women, indicating a significant difference (p=0.001).

Table Table2 2 outlines the clinical presentation of patients in both groups. Vaginal bleeding was the most common symptom in both the older and recent groups (91.9% vs. 67.6%, respectively, p<0.001). The incidence of hyperemesis gravidarum was similar in both groups (29.8% in the older group vs. 29.4% in the recent group, p=0.96). Thyrotoxicosis occurred in 3.4% of cases in the older group and 2.9% in the recent group (p=0.89). Ovarian enlargement due to theca-lutein cysts was more frequently observed in the older group (27.5%) compared to the recent group (8.8%, p=0.02).

A notable finding was the significant difference in cases presenting with a large-for-date uterus between the two groups: 63.20% in the older group and 23.5% in the recent group (p<0.001). However, the incidence of small-for-date and equal-for-date uterus presentations was similar between the groups. Interestingly, 14.7% of patients in the recent group were diagnosed early in the first trimester while asymptomatic (p=0.001), a scenario not observed in the older group. Anemia was present in 52.8% of the older group cases but absent in the recent group (p=0.001). Similarly, preeclampsia was noted in 11.4% of the older group but not in the recent group (p=0.001).

The incidence of MP varies globally due to differences in methodologies such as data reporting (population-based or hospital-based), mole classifications, and case detection. Recently, there has been a global decline in MP incidence. In 1988, two local studies from Saudi Arabia reported incidences of one in 446 and one in 676 pregnancies, respectively [ 15 , 16 ]. A more recent 2016 report from Saudi Arabia indicated an incidence of 0.9 per 1,000 pregnancies [ 17 ]. Similar declining trends have been observed in other countries, such as South Korea, where the incidence dropped from 4.4 per 1,000 pregnancies in the 1960s to 1.6 in the 1990s [ 18 ], and in Eastern Nepal, from 4.17 to 2.58 per 1,000 pregnancies [ 19 ]. Risk factors for MP include extreme maternal age, previous MP, ethnicity, geographic area, dietary factors, and blood groups. Animal studies suggest that diet can influence genetic predispositions [ 7 ] and nutritional deficiencies, particularly in vitamin A and folates, are linked to the development of CM pregnancy, leading to the production of immature ovum [ 20 ].

Since the 1995 report by Soto-Wright et al. [ 21 ], many studies have confirmed changes in the clinical presentation of MP [ 8 - 10 , 19 , 22 ]. The widespread use of transvaginal ultrasound in the first trimester has enabled the earlier diagnosis of HM before the appearance of complications and classical "snow-storm" ultrasound images and less marked histopathological features than traditionally seen.

Extreme maternal age is a well-recognized risk factor for CM development. Adolescents face a sevenfold higher risk compared to average-aged women, while women over 40 have nearly double the risk [ 23 ]. Our study aligns with Mangili et al. [ 9 ] in that most cases were in women aged 36 and older, but we also observed a significant increase in cases among women aged 20 years and younger, potentially due to early marriages in rural areas served by our center. The recent group showed a significant rise in nulliparous women, though the impact of nulliparity on CM development remains unclear. Notably, most CM in the older group was diagnosed in the second trimester at a mean gestational age of 14+5 weeks, compared to the first trimester in the recent group at 10+3 weeks, as reported in several studies [ 8 , 10 , 21 , 22 ].

Vaginal bleeding, traditionally the most common presenting symptom, was seen in 92% of the older group compared to 67% in the recent group. This finding is consistent with Soto-Wright et al. [ 21 ] and Mangili et al. [ 9 ], who reported a decrease in vaginal bleeding as a presenting symptom over time. Large-for-date uterus presentations were more prevalent in the older group (63.2%) and less in the recent group (24%). While Braga et al. [ 10 ] found a downward trend in large-for-date uterus presentations, it was not statistically significant (p=0.65). Theca-lutein cysts were more common in the older group (28%) compared to the recent group (9%). Mangili et al. [ 9 ] and Braga et al. [ 10 ] reported varying trends in the presence of theca-lutein cysts over time.

Using high-resolution transvaginal ultrasound and sensitive, quantitative ß-hCG assays has enabled earlier asymptomatic diagnosis in 15% of recent group cases [ 9 , 11 ]. Anemia, secondary to prolonged bleeding, was prevalent in the older group (52.8%) but absent in the recent group, aligning with findings by Mangili et al. [ 9 ] and Agrawal et al. [ 19 ], who also reported high rates of anemia and blood transfusions. Preeclampsia, found in 11.4% of the older group, was absent in the recent group [ 8 , 9 , 17 ].

Our center's policy of submitting any product of conception for histopathological examination and counseling patients post abortion or pregnancy termination about contraception has been crucial. This is especially important as early CM diagnosis might not present with classical histologic features, necessitating careful evaluation by histopathologists.

This study represents the first to examine changes in MP presentation in Saudi Arabia in over 30 years. Data from 1992 to 2022 were accurately obtained from patients' medical records. However, limitations include its retrospective design, reliance on data from a single tertiary referral hospital, the small sample size of MP cases, recall bias, selection bias, information bias, and reverse causality bias which all may impact the generalizability and acuity of results.

Over the past decade, advancements in ultrasound technology, particularly transvaginal probes with Doppler capabilities, and the use of sensitive ß-hCG assays have enabled the early diagnosis of MP, often as early as five to six weeks of gestation and frequently without the classic clinical symptoms or "snow-storm" ultrasound appearance. This early detection, coupled with increased patient awareness, early antenatal clinic visits, and first-trimester ultrasound referrals, has contributed to a decline in the incidence and altered the clinical presentation of MP in Saudi Arabia. Our study reveals these shifts, emphasizing the importance of understanding the evolving patterns of MP for improved diagnosis, management, and patient counseling, particularly for women with higher risk profiles, to enhance outcomes and reduce complications. This research offers valuable insights into the changing landscape of MP in Saudi Arabia, with practical implications for enhancing patient care. Subsequent research directions could examine the alterations in clinical presentation from an alternative standpoint, thereby identifying additional plausible reasons for this noted shift.

Funding Statement

We requested and received a third-party editing service

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study. Imam Abdulrahman Bin Faisal University issued approval IRB-UGS-2022-01-461. The application was reviewed and approved through an expedited review on Tuesday, November 15, 2022

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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Molar pregnancy-case report, marina yuabova.

La Guardia Community College, City University of New York, NY, USA

E-mail : aa

DOI: 10.15761/CCRR.1000430

Molar pregnancy is formed as a result of divergent fertilization process that leads to production of atypical tissue within the uterus. It categorized in two groups: partial and complete.

Complete mole involves absence of the embryo, where partial mole demonstrates presence of fetal parts. Molar pregnancy does not result in viable fetus, early detection and treatment is essential for positive outcome.

Patient has presented with typical signs and symptoms for molar pregnancy including vaginal spotting with dark brown grape like substance, law hemoglobin, fundal height greater then expected (as for gestational age), nausea and vomiting.

Writer will present case of molar pregnancy, risk factors, typical presentation and treatment modality.

moles, hydatidiform moles, molar pregnancy

Introduction

Hydatidiform mole is a product of anomalous conceptions, with prevalence about 1 in 500-1000 pregnancies [6]. All cases could be categorized in to two groups, complete or partial hydatidiform mole. In complete molar pregnancy diffuse swelling of chorionic villi and disseminated thromboplastic hyperplasia without embryo or fetal tissues is characteristic. These cases commonly have a diploid karyotype [4]. In opposite, partial molar pregnancy displays central swelling of the chorionic villi and thromboplastic hyperplasia. Some parts of fetal and embryonic tissues are commonly present [7]. All molar pregnancies included defective ovum flawed maternal chromosomal deoxyribonucleic acid, suggesting only of hydatidiform mole has been identified, one of which is advanced maternal age and history of previous molar pregnancies [7]. Despite the fact there are some evidence accessible in regards to definitive risk of consecutive hydatidiform moles after previous partial or complete moles [3,5]. In cases where fetuses with partial moles are pinpointed, they consistently bear association with congenital anomalies, such as cleft lip and syndactyly [5].

Case Report

A 19-year-old female patient reported to OB-GYN clinic for annual examination during the initial interview she complained of very unusual menstrual bleeding, which began 3 days ago, patient has also reported abdominal cramping, nausea, vomiting and lower back pain. Patient admitted to be sexually active but was using calendar method as birth control. Her last menstrual period was exactly 5 weeks ago. Patients past medical and family history are unremarkable. She denied to have any allergies, denied drinking alcoholic beverages but admitted to be an active smoker; she currently smokes 0.5 packs of cigarettes per day. The patient was alert, oriented and in obvious distress. Her temperature was 98.6 F, blood pressure 119/64 mmHg, heart rate 123 bpm, respiratory rate of 16 breaths per min with a pulse oximetry of 98% on room air. On physical exam her skin was cool and clammy and patient's breathing was mildly labored, with thread peripheral pulses. Her fundal height was 2 cm below umbilicus. Abdomen was soft and mildly tender on lower quadrants bilaterally. Her lower extremities were WNL. During Pelvic examination reported loose discharge of blood, clots and a large amount of brown-colored grapelike material. The cervical OS was dilated to approximately 2cm with some cervical motion tenderness. After patient has been transferred to ER blood was collected and sent to lab for analysis, laboratory results as follows: hemoglobin of 8.6 g/dL, hematocrit of 7.5%, white blood count at 16,000 with 78% neutrophils and 5% bands, platelets at 123,000, international normalized ratio of 1.5, and bicarbonate of 14 mmol/L. Bun was elevated at 38 mg/dL and creatinine was 0.7 mg/dL. Beta HCG was 360,514 mIU/mL. IV line was initiated; patient has received 1000 cc bolus of 0.9% of sodium chloride, which followed with infusion rate at 125 cc per hour. Case has been discussed with OB consult and Pelvic Sonogram was performed. Pelvic- sonogram reviled a cloud like image, with absence for heartbeat. Patient was transferred to OR rapidly and two units of crossed matched blood were infused. Dilatation and curettage was performed in OR.

Surgical pathology confirmed a complete hydatidiform mole. Patient’s recovery was unremarkable; patient was discharged home after 48 hours. The patient was instructed on importance of using reliable method of birth control and monitoring of levels of HCG (first 48 hours post evacuation, weekly until hcg <5 miu/ml, then monthly X 6-12 months).

Molar pregnancies are classified as nonviable conceptions and are medically termed hydatidiform moles [3]. They are masses of cysts or benign tumors with a grape-like appearance that grow rapidly in the womb [3]. The abnormality is caused by a problem at conception, manifested by an excessive presence of placenta with little or no fetal development [10].

Hydatidiform moles are the most common form of benign gestational trophoblastic disease [4]. Often fatal in past centuries, significant medical advances in recent years now permit most women with moles to be cured [6].

Depending on the imbalance of genetic material in the pregnancy, the two major types of hydatidiform moles are classified as either complete or partial [1].

Forming when the sperm fertilizes an egg having no chromosomal or genetic material, a complete molar pregnancy is characterized by the presence of the placenta without an embryo [3].

Normally, the fertilized ovum would die and not implant itself in the womb [3]. In rare instances, this egg implants, triggering the growth of the placenta and the production of human chorionic gonadotrophin (HCG), the pregnancy hormone, therefore all symptoms of pregnancy will be present [5].

Partial-molar pregnancies are formed when; a normal ovum is fertilized by two sperms [3-5]. Instead of forming twins, the excessive presence of chromosomal material and trophoblastic tissue prevents normal fetal development [3]. The fetus does not survive more than three months and dies in the uterus [5-7].

As moles are rare, epidemiological studies vary in reporting incidences [6]. Vassilakos [11] states that the frequencies of moles vary by race and occur more among Asian women. Age is a known factor as higher rates of moles occur in women over the age of 40 and under the age of 20 [4,5,8,11], as well as in women under 16 and over 50 [10].

Women with either mole type have symptoms of vaginal bleeding, nausea and vomiting, and can present hyperthyroidism or preeclampsia [1-5].

Routine first trimester ultrasound examination can identify partial or complete molar pregnancy. The most of cases present as missed pregnancy during ultrasonic examination [10]. Histopathological examinations of products of conception are presently gold standard for diagnosis of gestational molar pregnancy. Abnormally high HCG blood levels and overly large uterine size suggestive of molar pregnancy and will warrant further clinical evaluation [2].

Patients who are diagnosed with molar pregnancy must be evaluated for possible complications such as: overactive thyroid, anemia, and toxemia of pregnancy. Patients should have a complete examination and laboratory testing [6].

After any medical complications have been addressed, a decision must e made concerning the best method of evacuation. Suction curettage is the optimal method of evacuation, regardless of uterine size, in patients who wish to retain reproductive function, because it carries a significantly lower risk of excessive bleeding, infection, and retained molar tissue then methods involving induction with oxytocin or prostaglandin. Rh immune globulin should be given to patient with RH conflict [7].

Patients are monitored to prevent the recurrence of benign moles and the development of malignant neoplasia, which can metastasize to the brain, liver or lungs [3]. Chest x-rays and the analysis of HCG levels for six months to one year are necessary [5]. Recurring moles are treated with methotrexate, a low-level chemotherapy [7].

The American College of Obstetricians and Gynecologists has recommended that after evacuation of a mole, serum HCG levels should be monitored every 1-2 weeks in all patients while the levels are elevated and then at monthly intervals for an additional 6 months once the levels become undetectable (5MIU per milliliter) [9].

Dey M, Dhawan M (2011) Critical care management of molar pregnancy in a peripheral set-up. Med J Armed Forces India 67: 385-387. [Crossref]
Hydatidiform mole and choriocarcinoma UK information and support service. (2013, July 1). RetrievedAugust9, 2014, from http://www.hmole-chorio.org.uk/faqs.html
HardingM (2013, October 18)Hydatidiform mole | Health | Patient.co.uk. RetrievedAugust12, 2014, from http://www.patient.co.uk/health/hydatidiform-mole
Hernandez E (2013, 2021 Copyright OAT. All rights reservneoplasia. Retrieved August 10, 2014, from http://emedicine.medscape.com/article/279116-overview
Hill A (2011, July 26) Molar pregnancy. Retrieved August 15, 2014, from http://www.obgyn.net/molar-pregnancy
LurainJR (2010) Gestational trophoblastic disease I: Epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J Obstet Gynecol 203: 531-539. [Crossref]
Molar pregnancy - NHS Choices (2012, September 18) RetrievedAugust9, 2014, from http://www.nhs.uk/conditions/Molar-pregnancy/Pages/Introduction.aspx
MooreLE, HernandezE (2012, January 30)Hydatidiform mole. RetrievedAugust9, 2014, from http://emedicine.medscape.com/article/254657-overview
Ross S, Berkowitz M, Goldstein DP (2009). Molar pregnancy. The new England Journal of Medicine, 360.
Sebire,N.J., & Seckl,M.J. (2008). Gestational trophoblastic disease: Current management of hydatidiform mole.British Medical Journal,337 (aug15 1), 453-458. doi:10.1136/bmj.a1193
Vassilakos,P. (2012, August 17).Pathology of molar pregnancy. RetrievedAugust9, 2014, from http://www.gfmer.ch/Books/Reproductive_health/Mole.html

Editorial Information

Editor-in-chief.

Andy Goren University of Rome "G.Marconi"

Article Type

Publication history.

Received date: August 15, 2018 Accepted date: August 23, 2018 Published date: August 29, 2018

©2018 Yuabova M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Yuabova M (2018) Molar Pregnancy-Case report. Clin Case Rep Rev 4: doi: 10.15761/CCRR.1000430.

Corresponding author

Assistant Professor, La Guardia Community College, City University of New York, NY, USA

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J Family Community Med
v.23(3); Sep-Dec 2016

Clinical presentation and treatment outcome of molar pregnancy: Ten years experience at a Tertiary Care Hospital in Dammam, Saudi Arabia

Ayman a. al-talib.

Department of Obstetrics and Gynecology, College of Medicine, University of Dammam, Dammam, Kingdom of Saudi Arabia

Objectives:

To study the clinical presentation and treatment outcome of molar pregnancy at a Tertiary Care Hospital in Dammam, Saudi Arabia.

Materials and Methods:

Reviewed medical records of all molar pregnancy cases among all the deliveries at a tertiary care hospital in Dammam from 2005 to 2014, after approval by institutional ethical review committee. Data abstracted included patient's age, parity, presenting symptoms, gestational age at diagnosis, uterine size, ultrasonographic findings, BhCG level at the time of diagnosis and at follow-up after evacuation, and blood loss during evacuation. Data was entered and analyzed using Excel; frequency distribution for categorical variables and descriptive statistics for continuous variables were computed.

Of a total of 25,000 deliveries in ten years, 22 cases of complete molar pregnancy were encountered: 0.9 cases of molar pregnancy per 1000 pregnancies. Majority of patients (63.7%) were older than 35 years, and were nulliparous (45.5%). The commonest symptom was vaginal bleeding (86.4%) followed by hyperemesis gravidarum (41.0%); Hyperthyroidism was seen in 1 patient (4.5%). Ovarian enlargement by theca-lutin cyst was seen in 3 patients (13.6%). The majority of patients (63.6%) had normal BhCG within 9 weeks (63 days) after suction curettage. The majority of the cases followed a benign course.

Conclusion:

Aged older than 35 years seems a risk factor and vaginal bleeding is the commonest presenting symptom. Early booking of pregnant women to antenatal care clinics and routine first trimester ultrasound made diagnosis easier and earlier before complications appear.

INTRODUCTION

Gestational trophoblastic disease (GTD) is a group of rare tumors resulting from abnormal growth of cells of trophoblastic epithelium of the placenta. The most common type of GTD is called a hydatidiform mole (HM), also known as a molar pregnancy. HM can be complete or partial: Complete mole (CM) accounts for the majority of HM which develops when either 1 or 2 sperm cells fertilize an egg containing a nucleus or DNA, with no identifiable fetus, whereas the partial mole contains some fetal tissue but no viable fetus.[ 1 , 2 ]

There is a vast difference in the incidence of molar pregnancy in the different regions of the world. The incidence of molar pregnancy is 0.5-1 per 1000 pregnancies in North America and Europe, 2 per 1000 pregnancies in Southeast Asia, 1 per 250 pregnancies in Philippines, and much higher in Taiwan, 1 per 125 pregnancies.[ 3 , 4 ] These variations may be attributed to the difference in the reporting data source, whether population-based or hospital-based. The other factors that may be responsible for this variation in the occurrence of molar pregnancy include socioeconomic and nutritional factors. In South Korea, the incidence of molar pregnancies has dropped from 4.4:1000 pregnancies in the 1960s to 1.6:1000 pregnancies in1990s mainly due to an improvement in living standards, socioeconomic and nutritional factors.[ 5 ] Low dietary carotene and animal fat consumption is associated with increased risk of molar pregnancy.[ 6 , 7 ] Two reports from Saudi Arabia in 1988, reported incidence of molar pregnancy 1:446 and 1:676 pregnancies;[ 8 , 9 ] whereas, a study in 2003 reported incidence as 0.9 per 1000 pregnancies.[ 10 ] This decrease in incidence may be related to an improvement in socioeconomic and dietary factors as animal studies have shown that diet can reset genetic outline.[ 11 ]

Among various reported risk factors, the most common are extreme maternal age, and previous history of HM. In complete mole, markedly elevated BhCG causes symptoms and complications.[ 12 ] The most common presenting symptom is vaginal bleeding. The diagnosis of molar pregnancy is usually made during the second trimester, and classical signs and symptoms include large uterine size, toxemia, anemia, hyperemesis, respiratory distress, and hypothyroidism.[ 12 ] In recent years, clinical presentation of molar pregnancy has changed largely because of diagnosis of CM at early gestational age.[ 12 ]

The purpose of this study was to look at the clinical presentation and treatment outcome of patients with complete molar pregnancy at a tertiary care teaching hospital in Dammam.

MATERIALS AND METHODS

After approval of institutional ethical review committee, the medical records of all molar pregnancy cases among all the deliveries at a tertiary care hospital in Dammam from 2005 to 2014 were reviewed. Data abstracted included patient's age, parity, presenting symptoms, gestational age at diagnosis, uterine size, ultrasonographic findings, BhCG leve at the time of diagnosis and at follow-up after evacuation, and blood loss during evacuation.

All patients were admitted after diagnosis, and 2 units of packed RBC were cross-matched. All procedures were done under general anesthesia; after dilatation of the cervix to 12 mm, suction curettage was performed and simultaneously an infusion of 40 units of syntocinon (Oxytocin ® , Novartis Pharmaceuticals Ltd., UK) in one liter of normal saline was started.

BhCG with a radioimmunoassay sensitivity of 5 mIU/mL was used. Following evacuation, BhCG levels for all the patients were obtained. Patients were followed weekly in the clinic until 3 consecutive normal BhCG levels one week apart were achieved. Following the normalization of BhCG, patients were followed by monthly BhCG for 6 months. All patients were counseled to use combined contraceptive pills to prevent pregnancy during the period of follow up.

Data was entered and analyzed using Excel 2000 (Microsoft Corporation, Seattle, WA, USA). Statistical analysis included calculation of mean and standard deviation for continuous variables, and frequency distribution for categorical variables.

During the ten year period, a total of 25,000 deliveries were done at this hospital. Twenty-two cases of CM were encountered, i.e., 0.9 case per 1000 pregnancies. The age of patients in the study was 32.5 ± 1.2 years [ Table 1 ]. The majority (63.7%) of patients were older than 35 years, and were nulliparous (45.5%) [ Table 2 ]. Only one patient had a history of 2 consecutive molar pregnancies. The commonest symptom was vaginal bleeding (86.4%) followed by hyperemesis gravidarum (41.0%); hyperthyroidism was seen in 1 patient (4.5%) and none had pre-eclampsia [ Table 3 ]. The mean gestational age at the time of diagnosis was 11.4 ± 0.3 weeks. Uterine size was large for dates for 27.3% cases [ Table 1 ], and small for dates in 18.2% cases. Ovarian enlargement by theca-lutin cyst was seen in 3 patients (13.6%) [ Table 3 ].

Mean age, gestational age at diagnosis, and blood loss for patients with molar pregnancy ( n =22)

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Frequency distribution of age and parity for patients with molar pregnancy ( n =22)

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Signs and symptoms of patients with molar pregnancy ( n =22)

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BhCG level was variable in all patients but not less than 100,000 mIU/ml. Blood loss during evacuation was 468 ± 31 ml [ Table 1 ], and 4 patients (18.2%) required blood transfusion because of low hemoglobin and symptoms of anemia. Time required to obtain normal BhCG values following evacuation was 63 ± 6 days [ Table 1 ]. One patient, who had high BhCG titer (189,000 mIU/ml) at diagnosis, had an invasive mole and was treated with Methotrexate. None of the cases developed choriocarcinoma.

In the present study, 22 cases of CM were encountered out of 25,000 deliveries done at our hospital; 0.9 cases per 1000 pregnancies. This is similar to what has been reported previously.[ 10 ] The major risk factors for developing molar pregnancy are history of previous molar pregnancy and maternal age.[ 12 ] Generally, HM is more common in extreme maternal age. In the present study, 63.7% cases of HM occurred in women older than 35 years, and 18.2% in women less than 20 years of age, a finding consistent with previous studies.

The study by Gockley et al ., indicated that compared to average age women, adolescents had seven times higher risk of developing CM, and older women had two times higher risk.[ 6 ] Similarly, studies have shown a higher risk of CM among women who had a history of previous CM.[ 13 , 14 ] The families with intermarriages have shown familial history of molar pregnancy.[ 15 ] In the present study, one 20 year old patient had two previous consecutive molar pregnancies at the age of 16, and 18 years; there was no familial history of molar pregnancy or intermarriages.

In the last two decades, due to early diagnosis, there has been a change in the clinical picture of HM. Sun et al . reported fewer number of patients with CM presenting with vaginal bleeding. This was attributed to the implementation of early routine ultrasound for pregnant women in the region.[ 7 ] In contrast, a majority of cases in our study presented with vaginal bleeding. The reason for this may be the labeling of any spotting and brownish vaginal discharge by a patient as vaginal bleeding.

In the recent years, patients rarely present with a compound theca-lutin cyst in the ovaries.[ 12 ] In this study, only 3 patients (13.6%) had ovarian enlargement This low number is due to a policy to refer any patient with bleeding or hyperemesis in early pregnancy for ultrasound to exclude twins or molar pregnancy.

Pre-eclampsia in the second trimester, a typical feature of CM, is now rarely seen as the majority of cases are diagnosed early in the first trimester. In our study, the uterine size was large for dates in 27.3% of patients which is similar to what is reported in other studies.[ 16 , 17 ]

In our institution, the standard care for women with the diagnosis of complete mole is suction curettage irrespective of uterine size. Medical methods were not used for any patients because of increased need for subsequent chemotherapy.[ 18 ]

The American College of Obstetricians and Gynecologists recommends that for patients with HM, BhCG levels should be measured 48 hours after evacuation and every 1 to 2 weeks until levels are undetectable. After attaining undetectable levels, follow-up measurements are made at monthly intervals for an additional 6 months.[ 19 ] This short protocol has led to fewer patients lost to follow up, and an initiation of chemotherapy after early diagnosis for patients with potentially malignant changes. This protocol has also resulted in the reduction of the cost of BhCG assays and relief from the anxiety and fear from anticipated GTD.

During BhCG follow up, patients are advised not to get pregnant for at least 6 months after BhCG levels have normalized in case of CM, and for 12 months in GTD. The development of a new generation of reliable OCP has enabled women to avoid pregnancy.[ 20 ] Combined oral contraceptive pills (OCP) are the best choice; all patients in the study used OCP to prevent pregnancy and allowed post-evacuation BhCG monitoring. However, a study showed that the use of OCP before BhCG remission may increase risk of persistent GTD after a molar pregnancy;[ 21 ] other studies showed no increase in the risk of GTD with the use of OCP after molar pregnancy.[ 19 , 22 , 23 ]

The incidence of persistent trophoblastic disease with CM is 8%, and the risk of malignant complications with CM is 0.5%. One patient in the present study developed an invasive mole during follow up and required chemotherapy. Prophylactic chemotherapy after molar evacuation is not standard care in our institution. This patient was 18 weeks pregnant and uterine size corresponded to a 30 weeks pregnant uterus, and BhCG at diagnosis was 189,000 mIU/ml. A study showed that a single course of folinic acid and methotrexate decreased the incidence of post molar GTD from 47.4% to 14.3% ( p < 0.05) in patients with high-risk moles.[ 23 ] Prophylactic chemotherapy may decrease the risk of GTN in women with CM who are at a higher risk of malignant transformation. However, currently, there is limited evidence in support of this practice which is currently not recommended because of the risk of drug resistance, delay in the treatment of GTN, and unnecessary exposure of women to toxic side effects.[ 24 ]

Molar pregnancy is an uncommon condition in our region. Women aged older than 35 years and nulliparous are at a higher risk of developing molar pregnancy, with vaginal bleeding as the commonest presenting symptom. Patients with high BhCG levels (>100,000 mIU/ml) and large for date uteri at diagnosis, are at high risk of developing GTD, and need a careful follow-up thereafter. Early booking of pregnant women to antenatal care clinics and routine first trimester ultrasound has made diagnosis easier and earlier before any complications arise. Histological review for all miscarriages is mandatory for the detection and diagnosis of HM. The majority of cases followed a benign course. The weakness of this study is retrospective review of the data and low number of patients. The hospital-based data from other regions are necessary for the calculation of the real incidence of molar pregnancy.

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COMMENTS

Case Report: Atypical presentation of molar pregnancy
Molar pregnancies, a premalignant form of gestational trophoblastic neoplasia, are characterised by an overgrowth of fetal chorionic tissue within the uterus. 1 In the USA, molar pregnancy occurs in 1 in 1000-1200 pregnancies and in 1 in 600 therapeutic abortions. 2 In the UK, the incidence is estimated at 1/714 live births.
Hydatidiform Mole
Hydatiform mole (also known as molar pregnancy) is a subcategory of diseases under gestational trophoblastic disease (GTD), which originates from the placenta and can metastasize. It is unique because the tumor originates from gestational tissue rather than from maternal tissue. Other forms of gestational trophoblastic disease include gestational choriocarcinoma (which can be extremely ...
Educational Case: Hydatidiform Molar Pregnancy
A history of prior molar pregnancy increases the risk of a repeat molar pregnancy to 1%, which is approximately 10 times the risk for the general population. 7,10,11 The risk of a complete mole is the highest at extremes of maternal age (<15 years and >35 years), and data suggest that ova from older women are more susceptible to abnormal ...
Atypical presentation of molar pregnancy
The classic features of molar pregnancy are irregular vaginal bleeding, hyperemesis, enlarged uterus for gestational age and early failed pregnancy. Less common presentations include hyperthyroidism, early onset pre-eclampsia or abdominal distension due to theca lutein cysts. Here, we present a case of molar pregnancy where a woman presented to the emergency department with symptoms of acute ...
Hydatidiform Mole Clinical Presentation
The typical clinical presentation of complete molar pregnancies has changed with the advent of high-resolution ultrasonography. Most moles are now diagnosed in the first trimester before the onset of the classic signs and symptoms. [ 30, 31, 32] Vaginal bleeding. The most common classic symptom of a complete mole is vaginal bleeding.
Molar Pregnancy
After a molar pregnancy, patients and their partners commonly express concern about the potential for a molar pregnancy in the future. 52 Case series indicate that most patients with a molar ...
Hydatidiform Mole: Practice Essentials, Background, Pathophysiology
Although outcomes in these cases were similar to those of women who had never had a molar pregnancy, the investigators did find that about 1.7% of women with a molar pregnancy did have another molar pregnancy later. ... The changing clinical presentation of complete molar pregnancy. Obstet Gynecol. 1995 Nov. 86(5):775-9. [QxMD MEDLINE Link].
Molar pregnancy with a coexisting living fetus: a case series
The diagnostic challenge of a case of molar pregnancy with a coexisting living fetus is to differentiate two different conditions; singleton conception with a partial mole and dizygotic twins consisting of normal fetus with a complete mole. ... Lurain JR. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and ...
Atypical presentation of molar pregnancy
The classic features of molar pregnancy are irregular vaginal bleeding, hyperemesis, enlarged uterus for gestational age and early failed pregnancy. Less common presentations include hyperthyroidism, early onset pre-eclampsia or abdominal distension due to theca lutein cysts. Here, we present a case of molar pregnancy where a woman presented to ...
Full article: Recurrent Partial Hydatidiform Mole: A Case Report of
Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am ... Haloub K, Freij M. Recurrent hydatidiform molar pregnancy: a case report of 5 consecutive molar pregnancies complicated by HELLP and DIC, and review of literature. ...
VP59.28: A case of complete molar pregnancy: follow‐up with vaginal
Molar pregnancy is a complication in early pregnancies, with a rate of 0.1% in the western countries. The complete hydatidiform mole has a 2-4% risk to convert to choriocarcinoma and 15% risk converting to invasive mole (malignant trophoblastic disease). That is why it is very important to closely follow up these pregnancies for at least 6-12 ...
PDF Molar Pregnancy-Case report
Writer will present case of molar pregnancy, risk factors, typical presentation and treatment modality. ... Molar Pregnancy-Case report Clin Case ep ev, 2018 doi: CCRR.1000430 Volume 4(7): 2-2
(PDF) Molar Pregnancy-Case report
Clinical Case Repor ts and Reviews. Clin Case Rep Rev, 2018 doi: 10.15761/CCRR.1000430 Volume 4 (7): 1-2. ISSN: 2059-0393. Molar Pregnancy-Case report. Marina Yuabova*. La Guardia Community ...
Case report: molar pregnancy with co-existing viable fetus
Pregnancy of a hydatidiform mole with a coexistent live fetus in most cases is a complete molar pregnancy. Partial molar pregnancy with fetus is rare and almost always ends in miscarriage due to triploid fetus. Case Presentation: In this case study, we present a 19-year-old woman who presented with acute vaginal bleeding and pelvic discomfort ...
Molar pregnancy with normal viable fetus presenting with severe pre
Case presentation. We report a case of a 21-year-old local Sarawakian woman with partial molar pregnancy who presented with severe pre-eclampsia in which the baby was morphologically normal, delivered prematurely, and there was a single large placenta showing molar changes.
Molar Pregnancy-Induced Hyperthyroidism: The Importance of Early
This case report describes our management of a woman with GTD and the multidisciplinary efforts taken to safely prevent evolution to thyroid storm. Case Presentation. A 32-year-old woman, in her first pregnancy, at 10 weeks of gestation presented to medical care with a 2-week history of bloating, abdominal pain, and nausea.
Thyrotoxicosis: a rare presentation of molar pregnancy
A 49-year-old woman, G8P7, presented with 1 week of worsening vaginal bleeding and abdominal cramps in the setting of a recently discovered unplanned pregnancy. Vaginal ultrasound findings and a significantly elevated human chorionic gonadotropin (hCG) level were concerning for molar pregnancy. She developed signs of hyperthyroidism on the night of admission, for which the endocrinology team ...
Molar pregnancy
Molar pregnancies are one of the common complications of gestation, estimated to occur in one of every 1000-2000 pregnancies 3 . These moles can occur in a pregnant woman of any age, but the rate of occurrence is higher in pregnant women in their teens or between the ages of 40-50 years. There is a relatively increased prevalence in Asia (for ...
Molar pregnancy
Molar pregnancy occurs 1-2 per 1000 pregnancies, resulting in improper fertilization. Partial mole is a result of fertilization of a haploid normal oocyte with two spermatozoa simultaneously, with the formation of a zygote with a triploid set of chromosomes. Only in around 25% of cases is a variant with euploid fetus (46XX/XY). Several factors determine the prognosis of the fetus in partial ...
PDF Molar pregnancy
Parveen et al.6 reported a case of partial molar pregnancy with normal karyotype of the fetus ending with a live birth on term. Case presentation This is a 22-year-old lady, pregnant at 16 weeks of gestation who is admitted to SBAGAL with evidence of dead fetus in utero and suspected partial molar pregnancy with hCG>10,000IU/ml and vaginal ...
Expectant Management of a Triploid Partial Molar Pregnancy at ...
Introduction Triploid partial molar pregnancies are not viable, and confer maternal risks including preeclampsia, hemorrhage, gestational trophoblastic neoplasia, and trophoblastic embolization. We report a case managed expectantly until 26 weeks' gestation in a patient requesting continuation of pregnancy. Case Presentation This G2P1 presented with fetal anomalies indicative of triploid ...
Molar pregnancy with normal viable fetus presenting with severe pre
Case presentation. We report a case of a 21-year-old local Sarawakian woman with partial molar pregnancy who presented with severe pre-eclampsia in which the baby was morphologically normal, delivered prematurely, and there was a single large placenta showing molar changes. Conclusion
Molar pregnancy ( Case Presentation)
Molar pregnancy ( Case Presentation) A 25-year-old woman presented with irregular vaginal bleeding following evacuation of a molar pregnancy 6 weeks prior. On examination, she was anemic and her uterus was enlarged to 16 weeks size. Ultrasound and beta-hCG levels confirmed incomplete evacuation of molar tissue.
Changing Trends in the Clinical Presentation and Incidence of Molar
Changing Trends in the Clinical Presentation and Incidence of Molar Pregnancy in Saudi Arabia: A 30-Year Retrospective Analysis. ... If so, please take 10 minutes to fill in our survey, and help us make the case for why sustaining open data resources is critical for life sciences research. Take survey Search life-sciences literature ...
Molar Pregnancy-Case report
Writer will present case of molar pregnancy, risk factors, typical presentation and treatment modality. Key Words. moles, hydatidiform moles, molar pregnancy. Introduction. Hydatidiform mole is a product of anomalous conceptions, with prevalence about 1 in 500-1000 pregnancies [6].
Cesarean scar ectopic partial molar pregnancy: A case report and a
In this report, we present a case of cesarean scar ectopic partial molar pregnancy in a 37-year-old woman who presented with complaints of vaginal discharge with streaks of blood and lower abdominal pain. Diagnostic laparoscopy revealed an abnormal mass of brown soft tissue in the anterior wall of the uterus, measuring 13.0 × 9.0 × 2.0 cm ...
[PDF] Recurrent Hydatiform Mole, Clinical Features and Reproductive
Rate of GTN progression after complete and partial moles was 28% and 4% respectively. Viable term pregnancy was achieved in five cases (20%) during follow up while 11cases (44%) resulted in molar pregnancy. Conclusion: Recurrent molar pregnancy in Egypt appears to involve about 10% for a second or more molar pregnancies.
Clinical presentation and treatment outcome of molar pregnancy: Ten
Reviewed medical records of all molar pregnancy cases among all the deliveries at a tertiary care hospital in Dammam from 2005 to 2014, after approval by institutional ethical review committee. ... In recent years, clinical presentation of molar pregnancy has changed largely because of diagnosis of CM at early gestational age.

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Changing Trends in the Clinical Presentation and Incidence of Molar Pregnancy in Saudi Arabia: A 30-Year Retrospective Analysis

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