The incidence of hydatidiform mole with a coexistent live foetus varies between 1/22000 and 1/100,000 deliveries.We report a case of a G2P1L1 with a live foetus of 28 weeks gestation with multiple cystic changes in the placenta. The human chorionic gonadotropin (hCG) levels were markedly elevated. The patient presented with PIH and spotting per vaginum. Two weeks later, she had severe bleeding and delivered a live male foetus. There was a single large placenta exhibiting changes of hydatidiform mole. The foetus was morphologically normal.
Introduction
The incidence of hydatidiform mole with a
coexistent live foetus varies between 1 in 22,000 and 1 in 100,000 deliveries . There are three possibilities of a mole with a coexistent live foetus.3,4
a) Dizygotic foetus with a complete mole and a normal foetus.
b) Partial Hydatidiform mole.
c) Coexisting blighted ovum with diffuse hydropic change and a normal foetus
Case History
We report a case of a G2P1L1 with a live foetus of 28 weeks gestation with multiple cystic changes in the placenta.
This 25 year old lady had one normal delivery and was admitted with bleeding PV with unsure dates. On examination the uterine size corresponded to 30 weeks, foetal heart were noted and BP was 150 / 90 mm Hg. Urine albumin was absent.
Ultrasound done 15 days back showed a single live foetus of 28 week gestation with a markedly thickened placenta with multiple cysts throughout the substance suggestive of molar change (Fig 1). bhCG levels were markedly elevated in the range of 16,1445 mIu /ml. A malformation scan done revealed no obvious congenital anomalies. She was put on antihypertensives and was given inj. betamethasone IM. She was counselled regarding the likelihood of developing complications like preeclampsia, eclampsia, PTD and abruption. The risk of foetal morbidity and mortality due to the molar change were explained.
One week later, she presented with bleeding PV and was fully dilated and effaced and delivered a live male child weighing 1.34 kg . The foetal maturity corresponded to 30 weeks. The foetus was phenotypically normal .
The placenta was single, large exhibiting diffuse cystic changes consistent with hydatidiform mole. It weighed 2 kilos and there was a retroplacental clot weighing 140 gm.
Histopathology report of the placenta showed mild hydropic changes.
The neonate was initially kept on a ventilator and by day 20 was started on feeds. However a few days later, the baby developed signs of sepsis and was started on antibiotics. X-ray picture was suggestive of pneumonia. The baby’s condition gradually deteriorated and he succumbed of klebsiella pneumonia one and a half months after delivery.
Karyotyping revealed an XY pattern.
hCG of the mother sent three weeks after delivery were 64 mIu /ml.
X ray chest was normal.
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Fig. 1 : Ultrasound picture of foetus with placenta showing hydropic changes. |
Fig. 2 : Placenta with molar changes. |
| Period |
1903-1989 |
| No.of cases |
113 |
| Survival |
31.9% |
| Intrauterine death |
39.8% |
| Neonatal death |
22.1% |
| Malformations |
2.7% |
| Malignancy |
11.5% |
| None of the children delivered before 28 weeks survived. |
Discussion
A literature search from 1903 to 1989 by Vejerslev et al revealed 113 reports of pregnancies with a mole and foetus in which there appeared to be no major malformations or cytogenetic abnormalities, 87 of those were intended to continue.1
The survival percentage was 31.9, IUD 39.8, neonatal death 22%, malformations 2.7%, the rate of malignancy 11.5.
Counselling
The decision to terminate or to continue the pregnancy with the aim of delivering a viable child must be based on clinical findings and prior obstetric history.
Prenatal diagnosis by CVS or amniocentesis is necessary for determination of the karyotype in a normally developing foetus. Of the two amniocentesis is preferable.2
On the finding of a normal karyotype, attempted continuation of the pregnancy includes a risk of about 30% for either substantial bleeding or preeclamptic symptoms; in about 15% the severity of the pregnancy requires termination on clinical grounds irrespective of foetal development.
Also PTD has no obvious correlation with the length of pregnancy.
Recurrence risk : 0.6.-2% of subsequent pregnancies.
Post delivery FU
The initial hCG value at delivery should be registered and weekly values plotted on a standard regression curve adjusted for local reference standards.
This is followed by measuring weekly values until 3 values are obtained below the detection limit then every second week for two months and then monthly for one year after the first negative value.
References
- Vejerslev LO. Clinical management and diagnosis possibilities in hydatidiform mole with coexistent foetus. Obstet Gynecol Surv 1991; 46 : 577-88.
- McDonald TW, Ruffolo EH. Modern management of gestational trophoblastic disease. Obstet Gynecol Surv 1983; 38 : 67-83.
- Jones WB, Lauresen NH. Hydatidiform mole with coexistent foetus. Am J Obstet Gynecol 1975; 122 : 267-72.
- Stellar MA, Genest RD, Bernstein MR, Lage JM, Goldstein DP, Berkowitz RS. Natural history of twin pregnancy with complete hydatidiform mole and coexisting foetus. Obstet Gyneol 1994; 83 : 35-42.
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