Spontaneous uterine perforation due to

invasive mole – a rare case

Farah Farhana Maren 1 , Muhammad Syarif 2
General practitioner 1 / Department of Obstetrics and Gynecology RSUD PasarRebo
Jl. Let.Jend T.B Simatupang No.30 Jakarta timur,13670
farhana.f49@gmail.com, 081278392225

Introduction

Invasive mole is one variety of trophoblastic diseases. it can lead acute

abdominal pain due to hemoperitoneum as a result of uterine perforation. It can happen
because complete or partial mole which invades wall of uterus to myometrium. the
treatment of invasive mole is usually doing curettage procedure until hysterectomy. In
this case, laparotomy and continuing with hysterectomy is main treatment as reduce to
maternal tragic consequencses such as hemorrhagic shock due to haemoperitoneum and
massive bleeding as complication of invasive mole.

Case report

A woman, 37 years old is G4P3A0 was admitted 4-6 weeks of gestation came to
emergency department with acute abominal pain and vaginal bleeding. 5 hours before
she came to hospital, her abdomen was uncomfortable, she decided massage her
stomach with tradional massage. After that she was getting worse.

Phycisal examination showed patient in shock condition with blood presure

90/60mmHg , HR: 120 x/minute, RR: 24 x/minute, Abdomen was tense and pain whole
of abdomen. On vaginal examination we found active bleeding, with opened portio,
slinger pain,with no adnexal mass.

We performed plano test the result was positive without US exam, it suspected
ruptured ectopic pregnancy with hemoperitoneum. The laboratory result before
operation were; Hemoglobin : 9,3 WBC: 36.900 , plateletes :276.000 and hematocrite
:27%. We decided laparotomy exploration.
 Intra-operative findings, after peritoneum was open, we found blood and blood
clot about ± 500 cc. On exploration, the uterus was perforated in posterior corpus part
with size 2 x 1 cm and uterine wall thickness , 0,5 cm (figure-1) and came out
conseption tissue with bubble appeariance (suspected mole hydatidiform) The both of
ovarium and tube within normal limit. We decided to perform total hysterectomy.

Figure-1. uterine perforation

After uterus was taken, the uterus speciment was slice and we found the mole
was invaded to the myometrium (figure-2). We plan to check β hCG level and
hystopathology test.

Figure-2. Invasive mole in myometrium

Discussion

In part of ASIA, trophoblastic disease is common, with reported incidence rates

as high as 2 per 1000 pregnacies, and abnormal vaginal bleeding is usually presented
in this condition1. Invasive mole is one variety of trophoblastic disease, it can lead
acute abdominal pain due to hemoperitoneum as a result of uterine perforation. More
than 50% cases, acute abdominal pain due to uterine perforation maybe first symptom
of choriocarsinoma2. It’s quite hard to diagnose invasive mole, by looking up US test, it
only recognized moderate fluid was considered in peritoneal cavity. The diagnosis of
invasive mole rets on demonstration of complete hydatidiform mole invading
myometrium or the presence of vili in metastatic lesion3. In this case, due to acute
abdominal pain and vaginal bleeding our patient came to hospital, first we guessed that
maybe rupture of ectopic pregnancy causing this, base on physical examination, so we
dicided to do laparotomy. For saving the life of patient with perforating mole,
emergency laparotomy is the best choice, it can prevent from landing up in life
threatening4. For reduce to maternal tragic consequencses such as hemorrhagic shock
due to haemoperitoneum, the laparotomy was perfomed in our case and end up with
total hysterectomy. Eventhough, an invasive mole is generally less malignant that
choriocarsinoma, it maybe associated with fatal metastases5. In this case we plan to
check β hCG level and wait for hystopathology result, to know possibility of this
invasive mole can lead fatal metastases or not.

Conclusion

The main treatment of hemoperitoneum as result of perforation by mole is

emergency laparotomy. there are many incidences of gestasional trophoblastic diseases
with heavy complication like invasive mole undetected. base on experience and
literrature early detection with US test in first trimester of gestasion can help in
reducing consequences of gestation trophoblastic disease.
References

1. Y.S Hextan. Ngan, Secki.J. Michael et.al. Update on the diagnosis and
management of gestational trophoblastic disease. International Journal Of
Gynecology and Obstetrics.2015; december (131);s123-s126
2. Bagga G.Garima, Chavan Rohidas, Pajai Sandhya, Nandu Vipal. A rare case of
spontaneous uterine perforation with haemoperitoneum after normal pregnancy
due to choriocarcinoma. Journal of South Asian Federation Of Obstetrics –
Gynecology.2017;april-june;9(2);124-126
3. Kumar sunesh, Vimala N, Mittal Sureeta. Invasive mole presenting as acute
haemoperitoneum. JK Science.2004;6(3);159-160
4. Rao Lakshmi, Tripurasundari M, et.al. Perforating Hydatidiform Mole at 8
weeks of gestation : A surgical emergency.. International Journal Of Scientific
Study 2015.5; 251-253
5. Mamour Gueye, et.al. Choriocarcinoma with uterine rupture presenting as acute
haemoperitoneum and shock. International Journal of reproduction,
contraception, obstetrics and gynaecology.2017;march;6(3);1141-1143