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Partial Mole in Ectopic Pregnancy

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Partial Mole in Ectopic Pregnancy Gynecol Surg (2006) 3: 141–143 DOI 10.1007/s10397-006-0177-1 CASE REPORT Ghazi Fadel Ghazi . Peter O. Donovan Partial mole in ectopic pregnancy Received: 16 December 2005 / Accepted: 23 December 2005 / Published online: 8 March 2006 # Springer-Verlag Berlin / Heidelberg 2006 Abstract Objective: To evaluate the incidence of molar examination revealed a bulky anteverted uterus with no pregnancy in the fallopian tube pregnancy. Setting: adnexal masses. No tenderness over the pelvic area or Outpatient clinic. Patient: 32-year-old Asian woman. cervical excitation could be identified. Intervention: Left salpingectomy. Outcome: Molar ectopic The pregnancy test in the hospital was positive. An pregnancy. Result: Ectopic partial mole pregnancy. Con- ultrasound scan was arranged, which showed a bulky clusion: Molar pregnancy can occur in ectopic pregnancy. anteverted uterus with thin (4 mm) endometrium. No Clinically, molar pregnancy mimics normal tubal ectopic evidence of intrauterine pregnancy was seen, and both pregnancy. ovaries appeared normal. In the left adnexa there was a 44×25×38-mm complex mass. It appeared to be in the Keywords Tubal ectopic pregnancy . Molar pregnancy fallopian tube, and there was also a hydrosalpinx at the medial section. No free fluid was identified. The findings were consistent with ectopic pregnancy. The patient’s beta Case report human chorionic gonadotropin (BHCG) level on the day of admission was 12,894 U/l, and her haemoglobin level was A 32-year-old Asian woman with four children was 13 g/dl. She was RH-positive. referred to the early pregnancy unit in January 2005. She A diagnosis of left tubal pregnancy was made, and the was 11 weeks pregnant and was having vaginal bleeding patient was prepared for surgery on the same day of that had started 7 days before admission and had included admission. She was grouped and saved, and a diagnostic the passing of clots, which had settled. She had no laparoscopy was done. Both ovaries and the right tube were associated pelvic or shoulder pain. Her past medical and normal, but a left tubal pregnancy could be seen actively surgical history was not significant. She was not a smoker bleeding in the tube. Laparotomy was performed, and the and had no allergies. laparoscopic findings were confirmed. The left tube was On examination her pulse was 88, blood pressure found to be ruptured. A left salpingectomy was done and 120/68, and temperature 36.9ºC. High vaginal and chla- the specimen sent to histopathology. The patient recovered mydia swabs were taken. The chest examination was clear, uneventfully and was discharged home on the 3rd day and the heart examination showed S1, S2. Abdominal after admission. Her haemoglobin level on discharge was examination showed tenderness over the left iliac fossa 10.3 g/dl. The swab results came back positive only for with no guarding or rigidity. The vulva was smeared with Candida, and the patient’s general practitioner was blood, and there was brown blood in the vagina. Internal informed. The histopathology report suggested partial hydatidi- form mole of ectopic pregnancy (Fig. 1). Therefore, the patient was notified to be seen in the gynaecology clinic 6 weeks from the procedure for follow-up of the partial molar * G. F. Ghazi ( ) pregnancy. She was advised to refrain from getting Department of Obstetrics and Gynaecology, Addenbrooke’s Hospital, pregnant until her HCG levels had been normal for 6 Hills Road, Cambridge, CB2 2SB, UK months. She was also advised to avoid using the hormonal e-mail: [email protected] pill for contraception and to use barrier methods instead. The follow-up plan was for weekly urine samples until P. O. Donovan Department of Obstetrics and Gynaecology, normal levels were achieved, followed by fortnightly and Bradford Royal Infirmary, then monthly levels for 1 year, with a serum sample 3 Bradford, UK months following the date of the original procedure. 142 that the condition is overdiagnosed. A paper from France published in 1995 showed that there were only two cases of hydatidiform mole seen in a 16-year period. The uncommon frequency of this pathology is difficult to state precisely. This can be due to the limited possibilities of the diagnosis. These are inherent to the lack of statement of ectopic pregnancy, a nonsystematic histological test [9]. Anecdotal data from Charing Cross Hospital, which is one of the three major tertiary centres that deal with molar pregnancies in the United Kingdom, suggest that there is difficulty interpreting the findings in ectopic pregnancies. Indeed, more ectopic pregnancies than uterine pregnancies are locally overdiagnosed as hydatidiform mole, with only 15% of referrals being confirmed as molar in one series. Only 40 cases of tubal ectopic hydatidiform mole have been reported in the world literature. Although rare, all such specimens require appropriate histologic identifica- tion for follow-up and counselling. In a review of all cases referred to Charing Cross Hospital between 1986 and 2004 with a diagnosis of Fig. 1 Partial hydatidiform mole of ectopic pregnancy possible hydatidiform mole in a tubal pregnancy, only two cases of 132 were found to be ectopic partial mole. In five Results and discussion cases, the final diagnosis was ectopic complete mole, and one case was nonspecified ectopic molar pregnancy. Hydatidiform moles are abnormal gestations characterised Therefore, eight cases (6%) of possible molar pregnancy by the presence of hydropic changes affecting some or all in ectopic conception had a final diagnosis of definite of the placental villi associated with circumferential hydatidiform mole. None of the cases in this series proliferation of trophoblast tissue [1]. They arise due to developed persistent gestational trophoblastic disease, abnormal fertilisation. In a complete mole, the chromo- and HCG concentrations spontaneously returned to normal somal component is 46XX, with a genome that is entirely during surveillance in all cases of confirmed diagnosis of paternal in origin [1, 2]. This usually occurs when an empty hydatidiform mole. ovum is fertilised by a haploid spermatozoon, which Therefore, strict criteria should be established to avoid subsequently duplicates. Occasionally, cases can occur by overdiagnosing molar pregnancy and inappropriately fertilisation with two sperm [3]. In contrast, a partial mole exposing patients to chemotherapy agents. arises from dispermic fertilisation of a haploid ovum, The most important diagnostic feature is the presence of resulting in a triploid genome [4]. definite abnormal, nonpolar trophoblast proliferation that is Partial or complete hydatidiform mole affects approxi- circumferential in nature, often demonstrating a vacuolated mately one in 500–1,000 pregnancies [5]. On theoretical phenotype, and which may be associated with sheets of grounds, a similar proportion of ectopic pregnancies should pleomorphic extravillus trophoblast fragments [10, 11]. also be complicated by molar changes, as the underlying Immunohistochemical markers such as P57KIP2, which abnormality preceding both partial and complete hydatid- has been recently described, can also be useful for iform moles is an abnormal androgenic chromosomal diagnosing early moles, even on the basis of minimal constitution of the conceptus, which is therefore present tissue, because this protein is not expressed in the villus before the implantation regardless of the implantation site trophoblast or the stroma of complete hydatidiform moles [6]. [12]. Histologic discrimination between partial mole, It is clinically important to distinguish molar pregnancy complete mole, and hydropic abortion can be a challenge from nonmolar hydropic changes because the former can to the histopathologist; therefore, ploidy identification by cause persistent trophoblastic disease. Furthermore, the flow cytometric DNA analysis helps in the differential blighted ovum is a common feature in ectopic pregnancy diagnosis between diploid and triploid moles. It does not and can easily be misinterpreted as a true hydatidiform help distinguish complete mole from hydropic abortion. mole [7]. Although BHCG levels are elevated in tubal molar Another significant complication that has been men- pregnancies, they are generally in the lower range because tioned in the literature is the ability of the tubal molar implantation in the fallopian tube might preclude adequate pregnancy to produce metastasis to distant organs. Pulmo- vascularisation, thereby leading to low HCG levels. There nary metastasis has been found in a patient with mole of the is no distinctive difference in BHCG levels between molar fallopian tube coexisting with intrauterine pregnancy. This tubal pregnancies and ectopic pregnancy. Thus, an early was successfully treated with Actinomycin D [8]. ectopic molar pregnancy is not distinguishable from a Some papers in the literature have emphasised the rarity nontrophoblastic tubal pregnancy on the basis of HCG of ectopic molar pregnancies, whereas others have stated levels [13]. 143 The risk of persistent trophoblastic disease is no greater 3. Jacobs PA, Szulman AE, Funkhouser J, Matsuura JS, Wilson than after uterine molar gestations, approximately 0.5% for CC (1982) Human triploidy: relationship between parental origin of the additional haploid complement and development partial mole and 15% for complete [14]. The diagnosis of of partial hydatidiform mole. Ann Hum Genet 46:223–231 apparently primary tubal choriocarcinoma with no con- 4. Depypere HT, Dhont M, Verschraegen-Spae
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