Caz atipic de molă hidatiformă completă – prezentare de caz

Introduction

Hydatidiform mole is a tumor with its origin from the trophoblast, being part of the spectrum of the gestational trophoblastic diseases (GTD)⁽¹⁾. A molar pregnancy, even thought is a rare condition, that appears at 1 in 600 to 1 in 1200 pregnancy, depending of the region, is the most common of all the GTDs.

Molar pregnancy represents an aberrant fertilization. During the conception, a sperm cell which contains 23 pairs of male chromosomes meets the oocyte which contains 23 pairs of female chromosomes, and together they make a complete cell with 46 pairs of chromosomes. A molar pregnancy, also called mola hydatidiform, can be partial or complete.

A partial mola hydatidiform happens when two sperm cells fertilize an egg, resulting in cell with 69 pairs of chromosomes⁽²⁾. In this case, a fetus can be noticed, but the pregnancy is not viable. On the other hand, a complete molar pregnancy takes place when a sperm cell – or even two – fertilizes an egg which contains no chromosomes at all. Usually, the cell dies, but, in some cases, it implants into the uterus, resulting in an abnormal pregnancy, where only the trophoblast develops, without a fetus^(1,3,4).

The clinical features can be suggestive for a molar preg­nan­cy, such as vaginal bleeding early in the pregna­ncy or externalization of grape-like clear vesicles; a larger uterus comparing with a uterus in a normal pregnancy for the gestational age; and, also, symptoms present in a normal pregnancy, such as nausea, vomiting and breast sensibility, usually more intensified^(1,5).

The paraclinical investigations also play a key role in the diagnosis of a molar pregnancy. Considering that this is a trophoblastic disease, where a trophoblast is formed, regardless of whether it’s a complete or a partial mole, the beta-hCG hormone is still secreted, making the pregnancy test positive. In the case of a complete hydatidiform mole, the serum beta-hCG level is usually higher than the presumed gestational age, possibly exceeding 100,000UI/L⁽⁶⁾. Instead, in a partial molar pregnancy, the level of serum beta-hCG is in the range of a normal pregnancy, according to the gestational age, which makes it harder to diagnose sometimes⁽⁷⁾.

Ultrasound – especially transvaginal ultrasound – allows the diagnosis of a molar pregnancy, a characteristic image of honeycomb pattern, which represents the hydropic degeneration of chorionic villi^(8,9) or a “snowstorm” image, described as a central heterogeneous mass with hyperechoic areas divided by multiple cystic areas that fill the uterine cavity⁽¹⁰⁾. Another imaging sign is the presence of theca-lutein cysts, due to high levels of beta-hCG^(11,12).

In rare cases, a molar pregnancy can have different complications. They occur more frequently in a complete molar pregnancy⁽⁵⁾. The possible complications can be: uncontrollably vaginal bleeding that can lead to a hysterectomy, ovarian enlarged cysts, uterine infections, persistent gestational trophoblast neoplasia, when molar tissues outstands and continues to grow, and choriocarcinoma, which is the malignant form, that can lead to metastasis⁽¹³⁾. Extremely high levels of serum beta-hCG can raise the suspicion of choriocarcinoma, along with X-rays or CT scan that shows pulmonary metastasis, ultrasound that can show uterine or pelvic tumors or MRI scan that reveal cerebral or liver metastases. The most definitory criteria of diagnosis is the histopathological results, which is usually available after the curettage of a molar pregnancy^(14,15). Therefore, every molar pregnancy should have a follow-up that includes the serum beta-hCG levels⁽¹⁶⁾.

The standard treatment for molar and complete hydatidiform mole is the suction curettage. The material needs to be sent for the histopathological examination in order to confirm the diagnosis and to exclude a malignant variant⁽¹⁾. A follow-up is necessary after every suction curettage, for both types of molar pregnancy. The follow-up means surveilling the serum levels of beta-hCG, in order for them to return to normal and to maintain for a period of time. In complete molar pregnancy, we measure the level of beta-hCG for eight weeks, and if after this period the levels are normal, the follow-up would be done for another six months from the day the curettage was performed. If the serum level of beta-hCG takes longer than eight weeks to normalize, the follow-up would be for six months from the moment the level became normal. It is important to mention the fact that the patient must use contraception during this time, in order to not have a positive beta-hCG from the normal pregnancy. The type of contraception that is recommended is either hormonal or barrier^(16-18).

Case report

We present the case of a 50-year-old woman who came at the hospital for post-intercourse vaginal bleeding. 

The patient’s history revealed a vaginal birth 20 years before, three abortions and one pregnancy that stopped developing. Also, the patient claimed regular periods, the only exception being a 10-day amenorrhea four months ago. The patient associated multiple pathologies, such as arterial hypertension, type 2 diabetes mellitus, asthma, obesity, recurrent intrauterine devices (IUTs), and a surgical history that included an appendicectomy, a cholecystectomy and a right salpingectomy for an extrauterine pregnancy.

Later in the examination, we found out that a minimal brown vaginal bleeding was present for two weeks, denying any sort of special or characteristic texture.

The patient also stated a normal gynecological examination and a normal transvaginal ultrasound two months before, but we didn’t possess any medical documents.

No symptoms of pregnancy were showing, nor the patient claimed any type of sign or symptom, except the vaginal bleeding and the 10-day amenorrhea which was thought to be a sign of menopause.

Speculum examination didn’t reveal any vaginal bleeding or the presence of grape-like vesicles, only a brownish spotting on the vaginal walls. Due to increased abdominal fat tissue, the vaginal examination could not appreciate the size of the uterus.

Ultrasound imaging showed the enlargement of the uterus, with a real, filled cavity (Figure 1). The cavity showed a curious image of some mixed hypoechogenic and hyperechogenic structures, with little Doppler activity (Figure 2) and a normal ultrasound image for the left ovary, with normal follicles visible.

Since the clinical signs and the ultrasound image weren’t conclusive, the decision of performing a hysteroscopy was made. Technical problems were met during the hysteroscopy, after the presence of blood clots and active bleeding who made it challenging to visualize the uterine cavity (Figure 3), therefore a dilatation and curettage (D&C) was needed. Once the dilatation of the cervix was made, the exteriorization of grape-like vesicles followed. Right after the suction curettage was performed, and about 200 mL of intrauterine blood with vesicles were extracted, our patient started to bleed excessively, and the hemostasis methods failed. Thus, the medical committee, along with the patient, who was still conscious, decided to perform a hysterectomy in order to stop the critical bleeding. The decision of performing a hysterectomy with adnexectomy was taken because the patient was in the premenopausal period, had no wish for future pregnancy and, also, the extreme fertility age made her predisposed to an increased risk of trophoblastic neoplasia (Figure 4).

The serum beta-hCG levels were measured after the surgical intervention, with a value of 15,080/mUI/mL, that were more suggestive for a complete type of molar pregnancy. The postoperative evolution of the patient was favorable, without any other complication. The histopathological result confirmed a complete molar pregnancy. A patient’s follow-up schedule was made, until the serum levels of beta-hCG were back to normal.

Discussion

Hydatidiform mole is a gestational trophoblastic disease caused by a fecundation anomaly, and it is characterized by abnormal trophoblastic proliferation and the existence of hydropic degeneration of the chorionic villi^(1,19). A molar pregnancy usually mimics a normal pregnancy, but a complete molar pregnancy usually has more prominent clinical signs compared with the partial type, such as vaginal bleeding, extreme hyperemesis gravidarum, uterine enlargement greater than the gestational age, elevated beta-hCG serum levels, passage of grape-like vesicles through the vagina, hyperthyroidism and early preeclampsia⁽⁵⁾. However, nowadays, due to easy access for prenatal care and easy access to image testing, many patients present at the hospital with little to no characteristic signs for hydatidiform mole⁽¹⁾. The standard treatment for a molar pregnancy is suction curettage, but several complications may occur. Hysterectomy may be indicated in selected cases, particularly in women who have completed childbearing, in patients with uncontrolled hemorrhage, or when there is an increased risk of persistent gestational trophoblastic neoplasia⁽²⁰⁾.

The case that we presented, of a complete molar pregnancy, is notable for the discrepancy between the minimal symptoms – limited vaginal bleeding, without the presence of vesicles – and the unusual surgical management required, emergency hysterectomy⁽²¹⁾. The patient only presented light vaginal bleeding, without the passage of vesicular tissues or any other specific symptom. Moreover, the ultrasonographic findings were not strongly indicating a hydatidiform mole, making the diagnosis challenging. The decision of performing a diagnosis hysteroscopy was made, but in this case, the poor images, due to the bleeding, led to a dilation and curettage, which finally made the diagnosis clear, along with the passage of vesicles. Thus, this case highlights the limitations of relying exclusively on classical clinical and ultrasonographic features for diagnosis. In contemporary practice, complete molar pregnancies may present with subtle findings, requiring correlation between clinical presentation, serum beta-hCG levels, imaging studies and histopathological examination. Histopathology remains the definitive diagnostic method, especially in cases with atypical ultrasound appearance⁽²²⁾.

Furthermore, the need for an emergency hysterectomy caused by the vaginal bleeding was an unexpected complication, taking into consideration the fact that the patient had no important vaginal bleeding in her history. Nevertheless, the decision of a hysterectomy should be properly weighed, and the patient’s wishes should be respected, if possible. In our case, the definitive surgical management became necessary despite the initially mild clinical presentation, demonstrating that complications may still occur even when we have minimal symptomatic case. Although hysterectomy reduces the risk of persistent trophoblastic disease, it does not completely eliminate it. Therefore, serial postoperative beta-hCG monitoring remains essential to ensure the complete remission and allow the early detection of gestational trophoblastic neoplasia.

Conclusions

This case emphasizes the evolution and sometimes the misleading presentation of complete molar pregnancy. Minimal symptoms combined with nonspecific ultrasound findings may mask the diagnosis and delay the treatment. Clinicians should maintain the suspicion for gestational trophoblastic disease in patients presenting with abnormal bleeding, even in the absence of classical clinical signs or ultrasound features.

Autor corespondent:   Romina-Marina Sima E-mail: romina.sima@umfcd.ro

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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