Thyroid Function in Molar Pregnancies

Introduction: Molar pregnancies represent a significant burden of disease on the spectrum of gestational trophoblastic diseases. Vaginal bleeding being the most common occasionally, molar pregnancy is complicated by hyperthyroidism, which may require treatment. Aims: To determine thyroid function test and association of hyperthyroidism among the cases of molar pregnancy. Methods: This is a hospital-based cross-sectional study conducted in the department of Obstetrics and Gynecology, Nepalgunj Medical College and Teaching Hospital, Kohalpur. Sixty cases of molar pregnancy were included during the study period from February 2020 to January 2021.Patients having history of known thyroid disorders were excluded. Results: Prevalence of molar pregnancy in our study was 5.4 per thousand pregnancies in our hospital. Molar pregnancy and hyperthyroidism, both were common in the age group of 21-35 years. Hyperthyroidism was present in 10% patients. Enlarged thyroid was seen in 3.3%, tremor was present in 3.3%, and palpitation in 21.5%. Five (8.3%) patients with hyperthyroidism were underweight. Majority of patients with hyperthyroidism, beta humanchorionic gonadotrophhin level was more than three lakhs and it was mostly associated with complete hydatidiform mole compared to partial hydatidiform mole. Thyroid storm was not experienced in any of the patients. Conclusion: The rate of molar pregnancy is high. Hyperthyroidism in molar pregnancy is not uncommon. High levels of human chorionic gonadotropin, complete hydatiform mole are directly associated with hyperthyroidism. Awareness of this condition is important for diagnosis and treatment to prevent life threatening complications.

Coriocarcinoma gestacional primario de cuello uterino. Presentación de un caso

Choriocarcinoma represents a type of malignant tumor of gestational trophoblastic disease. It can develop after a molar pregnancy, miscarriage, normal or ectopic pregnancy. Generally its seat site is the uterine body; infrequent places such as the cervix have been described. We report the case of a 37-year-old patient is reported, VI gestations IV deliveries I cesarean section I molar pregnancy, with abnormal uterine bleeding, which is referred to the Hospital Oncology Service. On gynecological examination, an exophytic mass is observed in the cervix. A biopsy was taken that reported: Gestational choriocarcinoma and plasma levels of β-hCG were verified: 13805 IU / L. A total abdominal hysterectomy was performed with preservation of the ovaries. It was concluded as stage I of the International Federation of Gynecology and Obstetrics and 8, according to the score of the World Health Organization (ST I: 8), for which adjuvant was indicated. Currently no evidence of disease. Keywords: Choriocarcinoma, gestational trophoblastic disease, cervix.

Case Report: Acute abdomen presentation revealing a metastatic invasive mole with uterine rupture

Gestational trophoblastic neoplasia refers to the aggressive subset of gestational trophoblastic disease, including invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. These tumors may have atypical clinical presentations that can mislead the diagnosis. The reported case is a 48-year-old woman in perimenopause, without any history of vaginal bleedings nor molar pregnancy, who presented to the Emergency Department with acute abdominal pain. Serum beta human chorionic gonadotropin (β-HCG) was highly elevated at 261 675.23 mIU/ml. A complicated invasive mole was suspected, and an abdominal computed tomography was performed, showing a moderate hemoperitoneum associated to complex cystic and solid uterine mass, with a common left iliac adenomegaly and multiple pulmonary nodules. MRI showed a multiloculated cystic uterine mass with zones of hemorrhage recalling an invasive mole with perforation of the posterior uterus wall, associated to a high abundance hemoperitoneum. The diagnosis of a metastatic invasive mole complicated of uterine rupture and hemoperitoneum was retained. A surgical intervention was decided immediately and a subtotal hysterectomy with bilateral annexectomy was done. Pathologic examination of the specimen was positive for an invasive mole. The patient was proposed for chemotherapy. This case study will increase awareness of unusual clinical presentations of gestational trophoblastic neoplasia We believe that our case will contribute to the literature not only because of the rarity of this entity in perimenopausal period, but also due the atypical clinical presentation as acute abdomen without vaginal bleeding nor history of molar pregnancy evacuation

Choriocarcinoma (stage IV) despite two normal dilation and curettages: A case report

Choriocarcinoma is a highly metastatic subtype of gestational trophoblastic neoplasia (GTN) following pregnancy. It can arise from any type of pregnancy (50% occur after term pregnancies, 25% after molar pregnancies, and 25% after early pregnancy loss and ectopic pregnancies) (Soper, 2006). This case report describes an interesting diagnostic conundrum with normal histology findings on two separate endometrial dilation and curettages (D&C) and a unilateral oophorectomy in the context of high clinical suspicion for molar pregnancy that progressed to stage IV choriocarcinoma with brain and lung metastasis. The patient presented to our hospital nearly aphasic but would only say “molar pregnancy”. Due to her brain metastasis and worsening intraparenchymal hematoma, she underwent craniotomy confirming the diagnosis. After stabilization, she was transferred to a quaternary care center to complete chemotherapy with etoposide, methotrexate, actinomycin, cyclophosphamide, and vincristine and had a good response. At this time, there is no clear explanation for normal histology on two separate D&Cs and a unilateral oophorectomy in the context of a classic case of choriocarcinoma with progression from a molar pregnancy. It reminds us as providers that medicine remains an imperfect science and requires astute clinical judgement to properly treat patients when diagnostic data such as pathology findings and lab values appear to be incongruent with the larger clinical picture.

When a vesicular placenta meets a live fetus: case report of twin pregnancy with a partial hydatidiform mole

Background Hydatidiform moles exhibit a distinctive gross appearance of multiple vesicles in the placenta. The advances in cytogenetic technologies have helped uncover novel entities of hydatidiform moles and enabled elaborate diagnoses. However, management of a vesicular placenta with a coexistent live fetus poses a bigger challenge beyond hydatidiform moles. Case presentation A 33-year-old woman was referred to our department for suspected hydatidiform mole coexistent with a live fetus at 24 weeks’ gestation. The patient had conceived through double embryo transplantation, and first-trimester ultrasonography displayed a single sac. Mid-trimester imaging findings of normal placenta parenchyma admixed with multiple vesicles and a single amniotic cavity with a fetus led to suspicion of a singleton partial molar pregnancy. After confirmation of a normal diploid by amniocentesis and close surveillance, the patient delivered a healthy neonate. Preliminary microscopic examination of the placenta failed to clarify the diagnosis until fluorescence in situ hybridization showed a majority of XXY sex chromosomes. The patient developed suspected choriocarcinoma and achieved remission for 5 months after chemotherapy, but relapsed with suspected intermediate trophoblastic tumor. Conclusion We report a rare case of twin pregnancy comprising a partial mole and a normal fetus that resembled a singleton partial molar pregnancy. Individualized care is important in conditions where a vesicular placenta coexists with a fetus. We strongly recommend ancillary examinations in addition to traditional morphologic assessment in such cases.

Extrauterine Epithelioid Trophoblastic Tumor (ETT) Arising from an Antecedent Undiagnosed Molar Pregnancy Presenting as an Adnexal mass: A Case Report

Introduction/Objective Epithelioid trophoblastic tumor (ETT) is an extremely rare neoplasm derived from chorionic type intermediate trophoblast. ETT usually follows an antecedent term pregnancy but can also follow spontaneous abortions or molar pregnancy. ETT most often arises from the endometrium, followed by the cervix. Extrauterine ETT are extremely rare, with few cases reported in literature. Methods/Case Report A 41-year-old woman with three term pregnancies presented with abdominal pain, ten years after her last pregnancy. Imaging findings of a 3.5 cm adnexal mass coupled with an elevated serum β-hCG (~ 900 mIU/ml), led to the suspicion of an ectopic pregnancy. Hysterectomy with salpingectomy revealed a 4.7 cm, tan- yellow, necrotic mass in the adnexal region abutting but distinct from the uterine serosa. Histologic evaluation showed a well- circumscribed tumor with pushing borders. The tumor cells were epithelioid with well-defined eosinophilic cytoplasm, monomorphic nuclei, frequent mitosis, and abundant geographic necrosis. The tumor cells were positive for β-hCG, GATA-3, PLAP and inhibin, with focal weak staining squamous markers p63 and p40. DNA fingerprinting analysis, performed to confirm the diagnosis of ETT, revealed a homozygous tumor with two copies of non-maternal genes indicating that the antecedent index gestation giving rise to the tumor was an undiagnosed hydatidiform mole. Following surgery, serum β-hCG levels were normal and the patient is currently on surveillance. Results (if a Case Study enter NA) NA Conclusion We present an extremely rare case of extrauterine ETT arising from a previously undetected molar pregnancy. The diagnosis should be suspected when a mass is observed at extrauterine sites with elevated β-hCG levels in patients with or without vaginal bleeding. Histologic differential of squamous cell carcinoma needs to be ruled out with immunostains. Due to its rarity and highly variable presentation, this entity remains a diagnostic challenge. DNA fingerprinting analysis demonstrating non-maternal genes can help confirm the diagnosis of ETT.

Placental Mesenchymal Dysplasia, An Exceedingly Rare Entity and Challenging Diagnosis

Introduction/Objective Placental mesenchymal dysplasia (PMD) is an extremely rare entity with an incidence of only 0.02/1000 deliveries. Methods/Case Report We present a case of a 26 year-old female Gravida 3, Para 1 with intrauterine pregnancy at 37 weeks of gestation. Fetal ultrasound showed mildly cystic upper portion of the placenta. The noninvasive prenatal testing was negative for triploidy. A viable healthy female infant was delivered with no maternal complications. On gross examination, placenta was heavy with approximately 25% incomplete cotyledons. Placental maternal surface showed, spongiform cut surfaces admixed with multiple cystic structures ranging in size from 0.5 to 1.5 cm and markedly dilated blood vessels. Histopathologic examination revealed markedly enlarged villi, mesenchymal hyperplasia, and hyper vascularity of small vessels. No trophoblast proliferation was identified. Subsequently, the diagnosis of PMD was made. Results (if a Case Study enter NA) NA Conclusion PMD is a rare anomaly which is characterized by placentomegaly and grape like vesicles resembling molar pregnancy. Etiologies include imbalance of paternal and maternal alleles, androgenetic and bi-parental mosaicism, and Beckwith Weidman Syndrome (BWS). Differential diagnosis includes partial molar pregnancy, complete mole with co-existing normal fetus, hemangioma, subchorionic hematoma, confined placental mosaicism and hydropic complications. Histologic features, ancillary studies including immunohistochemistry and genetic testing are helpful in differentiating PMD. PMD is an underdiagnosed entity with increased risk of premature delivery and intrauterine fetal death. It is pertinent for the clinicians to be aware of this entity for optimal patient management.