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

The formal medical term for a molar pregnancy is ³hydatidiform 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 ³accidents 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 ³cluster of grapes´ appearance or a ³snowstorm´ 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

Fortunately. Future Pregnancy Fortunately. the patient usually gets a CT scan of the brain. and a battery of blood tests. weekly HCG tests are obtained until they fall to zero. contraception like the pill or shot with no attempt to become pregnant for 1 year. called gestational trophoblastic neoplasia. and vagina. is necessary. in medical terms. Abstract . and can be given as an intramuscular shot. this involves a lot of trips to the lab and the doctor¶s office! This is important because molar pregnancies can ³come back´ even after a thorough D&C. most importantly. or a recurrent molar pregnancy. Many women are frustrated when their doctor recommends waiting one year to become pregnant. like the lungs. 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. because a rise in HCG levels may indicate a normal pregnancy when the patient is trying to get pregnant. and abdomen. and. or GTN. bones. This is actually important. this only occurs in about 20% of complete molar pregnancies. and metastasize (spread) to other organs. Treatment for recurrent molar pregnancy. brain. 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. These cells can act like a cancer. multiple shots. usually consists of a chemotherapy medication called methotrexate. lungs. To avoid this confusion we ask for a 1 year period without becoming pregnant. In other cases. Also. Again. Patients can expect an almost 100% cure rate using chemotherapy. methotrexate is a pretty ³easy´ chemotherapy on the system. When they come back the patient may need chemotherapy to prevent the microscopic placental cells from spreading to other organs like cancer. As one can see. when GTN is suspected. then careful follow-up is undertaken for a year. or even the addition of other medications. which requires chemotherapy.returns to normal then every 3 months for a year. it is even more uncommon with partial molar pregnancies. Fortunately. Sometimes only 1 shot is necessary. weekly HCG blood levels until zero then every month for a year. 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.

This was confirmed using stringent histological criteria of circumferential trophoblastic proliferation . Sonography revealed a complex hypo-echoic lesion in the right adnexa. tube was partially ruptured. 15-54) years and median gestational age is10 (range. scalloped villi. 5-27) weeks 3 . adherent to the myometrium and showed a vesicular friable lesion in the lumen of the right fallopian tube. Tubal ectopic hydatidiform moles are rare lesions and only 40 cases have been reported in the world literature 2 . On gross examination. 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. A preoperative diagnosis of tubal choriocarcinoma was considered and hysterectomy done.Molar ectopic pregnancies are rare events. Introduction Partial or complete hydatidiform mole affects approximately 1 in 500 to 1000 pregnancies 1 . and stromal karyohexis to be a hydatidiform mole. Postoperatively beta hCG levels fell to normal within 5 weeks. hydrops. The median maternal age is 31(range. 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 .

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. Repeat transvaginal sonography revealed inhomogeneous myometrium with a hypo echoic shadow in the right adnexal region. The lesion was seen extending into the smooth muscle lining and surrounding parametrial tissue. Grossly uterus and cervix appeared normal with a dilated and engorged right fallopian tube. .048 mIU/ml by Monobind Elisa). 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.A 42-year old woman. Additional investigations including lung radiographs revealed no abnormalities. Pregnancy kit test was positive. gravida 2. Her beta-hCG levels were extremely elevated (114. Subsequently laprotomy and hysterectomy with bilateral salpingo-opherectomy was performed and sent for histopathological examination. In the presence of rapidly increasing beta-hCG levels. Microscopic examination of the fallopian tube growth revealed vesicular edematous avascular placental villi with prominent cisternae formation and surrounding prominent pervillous trophoblastic proliferation. the patient was in good general health and hemodynamically stable with soft non tender abdomen. On examination. Para 1. a diagnosis of tubal choriocarcinoma was suspected clinically. Dilatation and curettage yielded a scant amount of endometrial tissue with no villi or trophoblastic tissue present at histopathologic assessment. presented with mild bleeding per vaginum after three months of amenorrhea.

Fowler DJ el (2006) 3 concluded after an extensive study that routine pre-evacuation ultrasound examination identifies less than 50% of hydatidiform moles. Hence.A diagnosis of ectopic complete hydatidiform mole was reached. The median maternal age is 31(range. . histopathological examination of products of conception remains the current gold standard for identification . Tubal ectopic hydatidiform moles are rare lesions and only 40 cases have been reported in the world literature 2 . Moreover detection rates are higher for complete compared to partial moles. 5-27) weeks 3 . Sonographically.Transvaginal sonography has enabled early diagnosis of interstitial (corneal) pregnancies in which an ectopic gestation is located within the uterine myometrium. The case also showed a speedy recovery with rapid decline in beta-HCG levels decreasing to 5mIU/ml within a week post surgery. 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. solid mass with cystic vascular spaces. 15-54) years and median gestational age is10 (range. hypo-echoic. a hydatidiform mole. eccentric to the endometrial cavity 4 . a placental site trophoblastic tumor. and improve after 14 week¶s gestation. and choriocarcinoma typically exhibit a heterogeneous. Discussion Partial or complete hydatidiform mole affects approximately 1 in 500 to 1000 pregnancies 1 .

Galvez CR et al 6 state that choriocarcinoma associated with ectopic pregnancy. Hence.16:1000 deliveries which is high. as it results in a higher subsequent pregnancy rate. Most cases have been treated with salpingectomy without complications. DNA flow-cytometric analysis may also be performed. However.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. although there is a higher recurrent ectopic pregnancy rate and persistent trophoblastic disease rate when compared with women treated with salpingectomy 7 . as it provides obvious advantages over open surgery. is extremely rare and in general very aggressive. persistence or recurrences. 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 . Therefore histological examination of the tubes is mandatory in all ectopic pregnancies. 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 . scalloped villi. Cortes-Charry R et al in their study concluded that the prevalence of gestational trophoblastic disease (GTD) in ectopic pregnancy was 0. and stromal karyohexis 2 (Fig 1 a. . Laproscopy will remain the main method of treatment for women with ectopic pregnancy. hydrops. Pasic RP et al 7 have advised that salpingotomy should be the surgical method of choice for the majority of women . These include circumferential trophoblastic proliferation. b). molar pregnancies should only be diagnosed when strict criteria regarding morphological abnormalities are met.

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. 8 . but also to rule out the presence of malignant trophoblastic disease.This case demonstrates the strict morphological criteria that should be met for diagnosis of hydatiform mole in ectopic tubal pregnancy.