Myomectomy scar pregnancy ‒ a serious, but scarcely reported entity: literature review and an instructive case

Objectives Uterine myomas are a frequent finding in reproductive age women with an estimated incidence 12–25%. 1. Treatment of uterine myomas to facilitate good pregnancy rates and outcome, such as hysteroscopic, laparoscopic, abdominal resection uterine artery embolization among others were evaluated in terms of pregnancy outcome. While the literature is replete of the pregnancy complication of uterine rupture after myomectomies, 2–4 there are very few publications evaluate a relatively rare pregnancy complication associated with placental implantation within the uterine cavity at the site of the previous myomectomy, namely the myomectomy scar pregnancy (MSP). Despite their relative rarity, this type of pathologically adherent placenta rightfully belongs to the well-known entity of placenta accreta spectrum (PAS). Case presentation We present a complicated case of MSP and review the available literature to raise attention to its clinical appearance, its prenatal diagnosis so appropriate intrapartum management can be planned. Conclusions Despite the rarity of MSP, continuous attention should be given at every single routinely scheduled or indication driven obstetrical US scan following myomectomies to evaluate the placental site implantation regardless of the route and technique of their initial surgical procedure.

A rare cause of postpartum vaginal bleeding

Background Invasive mole is a trophoblastic disease (GTD) caused by trophoblast cells invading the myometrium during pregnancy. The GTD range also includes mole hydatidiform, choriocarcinoma, and placental site trophoblastic tumor (PSTT). Invasive moles are most common following molar pregnancies; however, they can even rarely occur after a full-term birth. Despite the fact that pathology is the only way to make a clear diagnosis, clinic and radiologic evaluation can be helpful. We wanted to highlight a rare incidence of invasive mole following a healthy full-term delivery in this case. Case presentation A 28-year-old female patient presented with intermittent prolonged severe vaginal bleeding for 2 weeks after a term healthy vaginal delivery. In workup, beta human chorionic gonadotropin levels (b-hCG) value was 7540 mIU/ml. After suspicion of gestational trophoblastic neoplasm (GTN), the patient was sent to ultrasonography (US) and magnetic resonance imaging (MRI). GTN was confirmed by radiological and clinical findings, and a conclusive diagnosis of an invasive mole was made histopathologically. Conclusion Invasive mole should be considered in the differential diagnosis in patients with postpartum bleeding and a persistently high b-hCG level after a healthy term delivery.

Classification and etiologies of gestational trophoblastic disease

Various forms of trophoblastic diseases were reported in the literature, including complete and partial of hydatidiform moles, gestational choriocarcinomas, placental-site and epitheloid trophoblastic tumors. Among patients who suffer from hydatidiform mole, gestational trophoblastic neoplasia can be easily diagnosed by using the levels of the human chorionic gonadotropin (hCG). Therefore, complex investigations are not usually necessary in measuring the levels of hCG, physical examination and assessments. In addition, patients’ medical history can help the attending physicians to draw an adequate treatment plan for patients with gestational trophoblastic neoplasia. However, Pelvic Doppler ultrasonography might also be used for additional assessments, including the presence or absence of pregnancy, measurement of the uterine volume and size. Additionally, it determines the vasculature and spread of the neoplasm within the pelvic region. Furthermore, genetic analysis can be used to differentiate between the types of the disease. Moreover, among the reported staging and classification systems, the international federation of gynecology and obstetrics (FIGO) seems to be the best efficacious modality for the determination of the prognosis of the various types of the disease to properly choose the best treatment modality.

A rare case of placental site trophoblastic tumor

Placental site trophoblastic tumor (PSTT) is a very rare tumor of young women and unique form of gestational trophoblastic disease (GTD) representing a neoplastic transformation of intermediate trophoblastic cells that play a critical role in implantation. It accounts for 1-2% of all GTNs, incidence of it being 1 in 1,00,000 pregnancies. It displays a wide clinical spectrum from benign lesion within uterus to highly metastatic features with widespread features of metastasis and can be difficult to control even with surgery and chemotherapy. Unlike other forms of GTD, it is characterized by low β-hCG levels because it is a neoplastic proliferation of intermediate trophoblastic cells. PSTT can develop following all kind of pregnancies, whereas approximately 50% of PSTT cases occur after a normal pregnancy and other cases follow abortion, term delivery, ectopic pregnancy and molar pregnancy. Histopathologically, PSTT has proliferation of intermediate trophoblastic cells and absence of villi. It shows less invasion of vascular tissue and using immune histochemistry revealed that PSTT cells expressed HPL more than β-hCG, characterized by increased expression of the HPL in histological section as well as serum. The most common presenting symptoms of PSTT are irregular vaginal bleeding associated with uterine sub involution. Patient can also be presented with amenorrhea, nephritic syndrome, abdominal pain, galactorrhea and hemoptysis. Hence any case of unusual bleeding should be investigated with dilation and curettage and βHCG levels. Although the majority of patients of the non-metastatic PSTT are cured by hysterectomy but in metastatic cases, it requires aggressive treatment with chemotherapy and radiation. Due to its seldom occurrence and uncharacteristic clinical presentation, to reach a correct diagnosis and management is a surgeon’s nightmare and can be very challenging.