Molar pregnancies are an uncommon and very frightening complication of pregnancy.

The formal
medical term for a molar pregnancy is “hydatidiform mole.” Simply put, a molar pregnancy is an
abnormality of the placenta (afterbirth), caused by a problem when the egg and sperm join together
at fertilization. The following is a brief review of this complicated subject.

Types of Molar Pregnancy 

There are two types of molar pregnancy, complete and partial. Complete molar pregnancies have only
placental parts (there is no baby), and form when the sperm fertilizes an empty egg. Because the egg
is empty, no baby is formed. The placenta grows and produces the pregnancy hormone, called HCG,
so the patient thinks she is pregnant. Unfortunately, an ultrasound (sometimes called a sonogram) will
show that there is no baby, only placenta. A partial mole occurs when 2 sperm fertilize an egg.
Instead of forming twins, something goes wrong, leading to a pregnancy with an abnormal fetus and
an abnormal placenta. The baby has too many chromosomes and almost always dies in the uterus.
Thus, molar pregnancies are “accidents of nature” that are not anyone’s fault. They are not caused by
behavior, but they are more common in older women and in certain geographic locations. Also,
although most molar pregnancies occur after a miscarriage, some occur after an ectopic (tubal)
pregnancy or even a normal delivery.

Risk Factors 
The incidence of molar pregnancy varies depending on where one lives. For example, in the US about
1 out of every 1000 pregnancies is a molar pregnancy. In Southeast Asia the incidence is 8 times
higher. Interestingly, women from Mexico, Southeast Asia, and the Philippines have higher rates than
white US women, who themselves have higher rates than black US women. Age over 40 is a risk
factor for molar pregnancy, as is having a prior molar pregnancy. In fact, the chance of having
another molar pregnancy is about 1 out of 100. The reasons for the geographic and age differences
are currently unknown.

Symptoms and Diagnosis 

Women with a molar pregnancy usually feel pregnant and complain of vaginal spotting or bleeding.
Many women with molar pregnancies develop nausea and vomiting. Some even develop rare
complications like thyroid disease or very early preeclampsia (toxemia). Preeclampsia occurring earlier
than 20 weeks is very worrisome for a molar pregnancy. The doctor or midwife more than likely will
check them for a possible miscarriage, and may order or perform an ultrasound (sonogram). The
pelvic exam may reveal a larger, or smaller, than expected uterus. It may also reveal enlarged
ovaries, caused by non-cancerous ovarian cysts stemming from abnormally high amounts of the
pregnancy hormone HCG. The ultrasound will often show a “cluster of grapes” appearance or a
“snowstorm” appearance, signifying an abnormal placenta. If a baby is present it’s a possible partial
mole, while if the baby is absent it’s probably a complete mole. Treatment consists of a D&C (dilation
and curettage) of the uterus, where a small vacuum device is inserted into the uterus, under
anesthesia, to remove the molar pregnancy. This must be done very carefully or excessive bleeding
and blood clots to the lungs can occur. The placental tissue is sent to the pathologist, who looks under
the microscope to make the final diagnosis. An HCG level, and sometimes a thyroid level, are also
obtained. In unusual cases, where the patient has completed her childbearing, a hysterectomy may be
preferable. Although most cases of molar pregnancy occur after a miscarriage, some occur after
ectopic pregnancies or a normal pregnancy. Therefore, women with abnormal bleeding or a persistent
cough (especially if it produces blood) should see their doctor for an HCG level to make sure they do
not have a molar pregnancy.

Follow-up
After evacuating a molar pregnancy it is critically important that the patient see her doctor frequently,
as molar pregnancies can recur. Follow-up usually consists of a baseline chest x-ray, review of the
pathology specimen, physical examination of the vagina and uterus every 2 weeks until the uterus
returns to normal then every 3 months for a year, contraception like the pill or shot with no attempt to
become pregnant for 1 year, and, most importantly, weekly HCG blood levels until zero then every
month for a year. As one can see, this involves a lot of trips to the lab and the doctor’s office! This is
important because molar pregnancies can “come back” even after a thorough D&C. When they come
back the patient may need chemotherapy to prevent the microscopic placental cells from spreading to
other organs like cancer. Fortunately, this only occurs in about 20% of complete molar pregnancies; it
is even more uncommon with partial molar pregnancies. Many women are frustrated when their doctor
recommends waiting one year to become pregnant. This is actually important, because a rise in HCG
levels may indicate a normal pregnancy when the patient is trying to get pregnant, or a recurrent
molar pregnancy, which requires chemotherapy. To avoid this confusion we ask for a 1 year period
without becoming pregnant.

Treatment for recurrent molar pregnancy

When the HCG levels drop then increase again it means that the molar pregnancy has grown from
microscopic cells in the wall of the uterus to larger cells. These cells can act like a cancer, and
metastasize (spread) to other organs, like the lungs, brain, bones, and vagina. Treatment for
recurrent molar pregnancy, called gestational trophoblastic neoplasia, or GTN, in medical terms,
usually consists of a chemotherapy medication called methotrexate. Fortunately, methotrexate is a
pretty “easy” chemotherapy on the system, and can be given as an intramuscular shot. Sometimes
only 1 shot is necessary. In other cases, multiple shots, or even the addition of other medications, is
necessary. Also, when GTN is suspected, the patient usually gets a CT scan of the brain, lungs, and
abdomen, and a battery of blood tests. Again, weekly HCG tests are obtained until they fall to zero,
then careful follow-up is undertaken for a year. Patients can expect an almost 100% cure rate using
chemotherapy.

Future Pregnancy
Fortunately, the risk of having another molar pregnancy is about 1% (1 in 100). Most doctors will
perform an ultrasound to make sure the pregnancy is normal when a patient has had a prior molar
pregnancy. It is also a good idea to send the placenta to the pathologist after the delivery just to
make sure there are not abnormal areas.

Abstract
Molar ectopic pregnancies are rare events. We present an unusual case in
which a patient with irregular uterine hemorrhage in the presence of
increasing serum beta-human chorionic gonadotropin levels had no placental
tissue in uterine curetting. Sonography revealed a complex hypo-echoic lesion
in the right adnexa. A preoperative diagnosis of tubal choriocarcinoma was
considered and hysterectomy done. On gross examination, tube was partially
ruptured, adherent to the myometrium and showed a vesicular friable lesion
in the lumen of the right fallopian tube. This was confirmed using stringent
histological criteria of circumferential trophoblastic proliferation , hydrops,
scalloped villi, and stromal karyohexis to be a hydatidiform mole.
Postoperatively beta hCG levels fell to normal within 5 weeks.

Introduction
Partial or complete hydatidiform mole affects approximately 1 in 500 to 1000
pregnancies 1 . The median maternal age is 31(range, 15-54) years and median
gestational age is10 (range, 5-27) weeks 3 . Tubal ectopic hydatidiform moles
are rare lesions and only 40 cases have been reported in the world literature 2 .
We report an unusual case of molar pregnancy in the right fallopian tube
which presented as an adherent adenexal mass and was diagnosed on USG as
a choriocarcinoma

Case Report
A 42-year old woman, gravida 2, Para 1, presented with mild bleeding per
vaginum after three months of amenorrhea. On examination, the patient was
in good general health and hemodynamically stable with soft non tender
abdomen. Pregnancy kit test was positive. Pelvic sonography revealed a uterus
devoid of an obvious gestational sac but revealed the presence of a complex
hypo echoic lesion which was reported to be in the lower body and cervical
area. Dilatation and curettage yielded a scant amount of endometrial tissue
with no villi or trophoblastic tissue present at histopathologic assessment. Her
beta-hCG levels were extremely elevated (114,048 mIU/ml by Monobind
Elisa). Repeat transvaginal sonography revealed inhomogeneous myometrium
with a hypo echoic shadow in the right adnexal region.

In the presence of rapidly increasing beta-hCG levels, a diagnosis of tubal

choriocarcinoma was suspected clinically. Additional investigations including
lung radiographs revealed no abnormalities. Subsequently laprotomy and
hysterectomy with bilateral salpingo-opherectomy was performed and sent for
histopathological examination.

Grossly uterus and cervix appeared normal with a dilated and engorged right
fallopian tube. Cut surface of the tube revealed showed a dilated cavity filled
with hemorrhagic friable growth with small grape like vesicles grossly
invading into the surrounding myometrium.

Microscopic examination of the fallopian tube growth revealed vesicular

edematous avascular placental villi with prominent cisternae formation and
surrounding prominent pervillous trophoblastic proliferation. The lesion was
seen extending into the smooth muscle lining and surrounding parametrial
tissue.
A diagnosis of ectopic complete hydatidiform mole was reached. The case also
showed a speedy recovery with rapid decline in beta-HCG levels decreasing to
5mIU/ml within a week post surgery.

Discussion
Partial or complete hydatidiform mole affects approximately 1 in 500 to 1000
pregnancies 1 . The median maternal age is 31(range, 15-54) years and median
gestational age is10 (range, 5-27) weeks 3 . Tubal ectopic hydatidiform moles
are rare lesions and only 40 cases have been reported in the world literature 2 .

Sonographically, a hydatidiform mole, a placental site trophoblastic tumor,

and choriocarcinoma typically exhibit a heterogeneous, hypo-echoic, solid
mass with cystic vascular spaces. Fowler DJ el (2006) 3 concluded after an
extensive study that routine pre-evacuation ultrasound examination identifies
less than 50% of hydatidiform moles. Moreover detection rates are higher for
complete compared to partial moles, and improve after 14 week’s gestation.
Hence, histopathological examination of products of conception remains the
current gold standard for identification .Transvaginal sonography has enabled
early diagnosis of interstitial (corneal) pregnancies in which an ectopic
gestation is located within the uterine myometrium, eccentric to the
endometrial cavity 4 .

Burton JL et al 2 investigated the apparently high incidence of tubal ectopic

hydatidiform moles in women for a period of ten years and concluded that
tubal ectopic hydatidiform mole is a rare entity and demonstrated that it is
over diagnosed.
Polar trophoblastic proliferation and hydropic villi are features of early
placentation and and of hydropic abortion 2 . Sheets of extra villous
trophoblast may be particularly prominent in tubal ectopic gestation. Sebire
NJ et al 1 also state that the pathologist should be aware that the degree of
extravillous trophoblastic proliferation may appear more florid in ectopic
gestation as compared with evacuated uterine products of conception 1 .
Hence, molar pregnancies should only be diagnosed when strict criteria
regarding morphological abnormalities are met. These include circumferential
trophoblastic proliferation, hydrops, scalloped villi, and stromal
karyohexis 2 (Fig 1 a, b). DNA flow-cytometric analysis may also be performed.

Cortes-Charry R et al in their study concluded that the prevalence of

gestational trophoblastic disease (GTD) in ectopic pregnancy was 0.16:1000
deliveries which is high, It is important to apply strict morphologic criteria for
GTD when a sample of ectopic pregnancy is analyzed and to monitor those
patients with careful beta-hCG followup 5 . Galvez CR et al 6 state that
choriocarcinoma associated with ectopic pregnancy, is extremely rare and in
general very aggressive. Therefore histological examination of the tubes is
mandatory in all ectopic pregnancies.

Laproscopy will remain the main method of treatment for women with ectopic
pregnancy, as it provides obvious advantages over open surgery. Most cases
have been treated with salpingectomy without complications, persistence or
recurrences. However, Pasic RP et al 7 have advised that salpingotomy should
be the surgical method of choice for the majority of women , as it results in a
higher subsequent pregnancy rate, although there is a higher recurrent ectopic
pregnancy rate and persistent trophoblastic disease rate when compared with
women treated with salpingectomy 7 .
This case demonstrates the strict morphological criteria that should be met for
diagnosis of hydatiform mole in ectopic tubal pregnancy. Final diagnosis of
gestational trophoblastic neoplasia in ectopic pregnancy is made by
histopathological evaluation but in cases on medical management appropriate
monitoring of beta-hCG titers following conservative management of
suspected ectopic pregnancy is important, not only to diagnose persistent
ectopic gestation, but also to rule out the presence of malignant trophoblastic
disease. 8