Hydatidiform mole coexistent with a twin live fetus: a national collaborative study in Japan

Management of a complete mole and coexisting fetus in post-dobbs world

BACKGROUND

Twin pregnancies consisting of a complete hydatidiform mole and a coexistent fetus (CMCF) are rare and associated with a high rate of maternal-fetal morbidity and mortality. Management of these pregnancies remains controversial and increasingly challenging following the Dobbs versus Jackson Women's Health decision given the viability of the coexisting twin fetus.

CASE

This case looks at the diagnosis, management, and maternal-fetal outcomes of a viable fetus coexisting molar pregnancy at a large academic center in an abortion-restricted state.

CONCLUSION

CMCF pregnancies are associated with a high risk of morbidity and mortality and are increasingly difficult to manage following the Dobbs decision. Testing platforms, which identify genetic abnormalities in the first trimester, are increasingly important as access to abortion care in the United States is restricted.

Multiple pregnancy with complete hydatidiform mole and coexisting normal fetus in a retrospective cohort of 141 patients

BACKGROUND

Multiple pregnancy with a complete hydatidiform mole and a normal fetus is prone to severe obstetrical complications and malignant transformation after birth. Prognostic information is limited for this rare form of gestational trophoblastic disease.

OBJECTIVE

This study aimed to determine obstetrical outcomes and the risk of gestational trophoblastic neoplasia in women with multiple pregnancy with complete hydatidiform mole and coexisting normal fetus, and to identify risk factors for poor obstetrical and oncological outcomes to improve patient information and management.

STUDY DESIGN

This was a retrospective national cohort study of 11,411 records from the French National Center for Trophoblastic Disease registered between January 2001 and January 2022.

RESULTS

Among 11,411 molar pregnancies, 141 involved histologically confirmed multiple pregnancy with complete hydatidiform mole and coexisting normal fetus. Roughly a quarter of women (23%; 33/141) decided to terminate pregnancy because of presumed poor prognosis or by choice. Among the 77% of women (108/141) who continued their pregnancy, 16% of pregnancies (17/108) were terminated because of maternal complications, and 37% (40/108) ended in spontaneous miscarriage before 24 weeks' gestation. The median gestational age at delivery in the remaining 47% of pregnancies (51/108) was 32 weeks. The overall neonatal survival rate at day 8 was 36% (39/108; 95% confidence interval, 27-46) after excluding elective pregnancy terminations. Patients with free beta human chorionic gonadotropin levels <10 multiples of the median were significantly more likely to reach 24 weeks' gestation compared with those with free beta human chorionic gonadotropin levels >10 multiples of the median (odds ratio, 7.0; 95% confidence interval, 1.3-36.5; P=.022). A lower free beta human chorionic gonadotropin level was also associated with better early neonatal survival (the median free beta human chorionic gonadotropin level was 9.4 multiples of the median in patients whose child was alive at day 8 vs 20.0 multiples of the median in those whose child was deceased; P=.02). The overall rate of gestational trophoblastic neoplasia after a multiple pregnancy with complete hydatidiform mole and a normal fetus was 26% (35/136; 95% confidence interval, 19-34). All 35 patients had low-risk International Federation of Gynecology and Obstetrics scores, and the cure rate was 100%. Termination of pregnancy on patient request was not associated with lower risk of gestational trophoblastic neoplasia. Maternal complications such as preeclampsia and postpartum hemorrhage were not associated with higher risk of gestational trophoblastic neoplasia, and neither were high human chorionic gonadotropin levels or newborn survival at day 8.

CONCLUSION

Multiple pregnancy with complete hydatidiform mole and coexisting fetus carries a high risk of obstetrical complications. In patients who continued their pregnancy, approximately one-third of neonates were alive at day 8, and roughly 1 in 4 patients developed gestational trophoblastic neoplasia. Therefore, the risk of malignant transformation appears to be higher compared with singleton complete moles. Low levels of free beta human chorionic gonadotropin may be indicative of better early neonatal survival, and this relationship warrants further study.

Partial hydatidiform mole and coexisting fetus after frozen embryo transplantation: a case report

Hydatidiform mole and coexisting fetus is a very rare condition of which etiology is still inconclusive. It may occur after assisted reproduction, often leading to the death of normal embryos and other serious complications. We report a case of partial hydatidiform mole and coexisting fetus after frozen embryo transplantation. More than two months after the patient underwent transplantation with two blastocysts (scored 4AB and 4BC), B-ultrasound showed a single live fetus with a large dense dotted strong echo area. The patient was treated with chemotherapy after the termination of pregnancy due to persistently increased human chorionic gonadotropin levels. Many studies have described trophoblast quality as a strong predictor of pregnancy. In the case in question, in addition to partial hydatidiform mole caused by multiple sperm entering the egg, we also speculate that the condition may be related to the poor quality of the trophoblastic ectoderm of the transferred embryo. In the process of assisted reproduction, the transfer of embryos with poor trophoblastic ectoderm in multiple embryo transfers may adversely affect pregnancy outcomes.

A complete hydatidiform mole and coexisting viable fetus in a twin pregnancy: a case report with literature review

INTRODUCTION

A twin pregnancy involving a hydatidiform mole (HM) coexisting with a developing fetus is an extremely rare obstetric complication, which typically presents as a complete hydatidiform mole with a coexisting fetus (CHMCF) or a partial hydatidiform mole with a coexisting fetus (PHMCF).

CASE PRESENTATION

A 26-year-old woman was admitted to our hospital due to a small volume of vaginal bleeding during the 31st week of pregnancy. The patient was previously healthy, and an intrauterine singleton pregnancy was detected by ultrasound on day 46 of gestation; however, bunch-of-grapes sign was observed in the uterine cavity at 24 weeks. The patient was subsequently diagnosed with CHMCF. As the patient insisted on continuing her pregnancy, she underwent hospital monitoring. Vaginal bleeding occurred in the 33rd week again and received a course of betamethasone, then continued pregnancy after bleeding stopped spontaneously. In the 37th week, a male infant weighing 3090 g was delivered by cesarean section, with an Apgar score of 10 at 1 min and a karyotype of 46XY. Placental pathology confirmed the diagnosis of a complete hydatid tumor.

CONCLUSION

In this report, a case of CHMCF was maintained by monitoring of blood pressure, thyroid function, human chorionic gonadotrophin, and fetal condition during pregnancy. A live newborn was delivered by cesarean section. CHMCF is a clinically rare disease with high risks; thus, it should be diagnosed carefully using several tools, including ultrasound, magnetic resonance imaging, and karyotype analysis and dynamically monitored if the patient decides to continue the pregnancy.

Gestational Trophoblastic Disease with Coexisting Progressing Pregnancy: Personalised Treatment Modalities

Purpose

Gestational trophoblastic disease (GTD) coexisting with a steadily progressing pregnancy is an extremely rare condition presented in the literature as a single case or case series of successful delivery. The purpose of this study was to describe five cases of GTD and present possible management strategies for such patients.

Methods

Clinical data of five pregnancies with coexisting GTD were identified within the Almazov National Medical Research Centre from 2018 to 2021.

Results

Three cases of multiple pregnancies with complete hydatidiform moles and two cases of singleton pregnancies with intraplacental choriocarcinoma and invasive hydatidiform moles were identified. Three pregnancies were prolonged and ended with preterm deliveries. Malignant transformation of the GTD accounted for 60% of the cases. The condition of newborns was based on the level of prematurity and functional immaturity, and in all cases, it was aggravated by anemia.

Conclusion

GTD coexisting with progressing pregnancy is threatened by the risks of preterm delivery, miscarriage, hemorrhage, and disease progression and requires monitoring in a multidisciplinary clinic experienced in the management of patients with malignant tumors during pregnancy. In cases of prolonged pregnancy against the background of GTD, we suggest the following monitoring during pregnancy: pelvic, abdominal ultrasound/MRI (without contrast), prenatal invasive fetal karyotype testing in cases of singleton pregnancy, lung X-ray/CT with uterine shielding, weekly assessment of β-hCG levels, and dynamic monitoring of the fetus. The following postnatal monitoring should be performed: morphological examination of the placenta, weekly assessment of β-hCG levels up to normalization, then monthly assessment up to six months, and control of β-hCG level of the newborn.

Twin pregnancy combining complete hydatidiform mole and healthy fetus: Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Twin pregnancy combining a complete mole and a normal fetal pregnancy with its own healthy trophoblast is a rare entity. A partial molar pregnancy almost always ends in miscarriage due to a triploid fetus.

CASE PRESENTATION

We report the case of a 43-year-old female patient admitted for bleeding during the 20th week of pregnancy. Pelvic ultrasound showed the combination of a complete hydatidiform mole and a normal fetal pregnancy. The decision to medically terminate the pregnancy was taken after consultation with the family. Examination of the placenta and histological study confirmed the diagnosis of complete hydatidiform mole associated with a normal fetus. The evolution was uneventful.

CLINICAL DISCUSSION

Twin pregnancy combining a complete mole and a normal fetal pregnancy with its own healthy trophoblast is a rare entity that should not be misdiagnosed. There is still no consensus in terms of therapeutic attitude, the dilemma remains and the decision should always include the couple after a thorough explanation of all the risks.

CONCLUSION

Our case reaffirms that to successfully manage this rare yet life-threatening condition, heterotopic pregnancy should be included in the differential diagnosis for any gravid women presenting with persistent abdominal pain, abnormal bleeding and/or extrauterine mass.

Twin pregnancy with complete hydatidiform mole and co-existing fetus: A report of 15 cases with a clinicopathological analysis and DNA genotyping

Complete hydatidiform mole (CHM) with co-existing fetus (CHMCF) is very uncommon. In this study, we investigated the clinicopathological features and DNA genotype in 15 CHMCF. Seven patients (46.7%) developed post-molar gestational trophoblastic disease (GTD), 5 of which had lung metastasis. CHMCF was histologically characterized by a mixed pattern of CHM and the non-molar placenta, mimicking partial hydatidiform mole and placental mesenchymal dysplasia. p57 immunostaining showed a divergent staining pattern, positive in the normal placenta and negative in the CHM component. DNA genotyping of the CHM villi demonstrated exclusively paternal alleles consisting of homozygous/monospermic (n = 9) and heterozygous/dispermic patterns (n = 5) at multiple informative loci. We conclude that CHMCF confers a high risk for post-molar GTD. DNA genotyping contributes significantly to the precision diagnosis of CHMCF.

Case Report of a Triplet Pregnancy with Complete Hydatidiform Mole and Coexisting Twins

Background

Triplet pregnancy with complete hydatidiform mole and coexisting twin fetuses is extremely rare with an unknown incidence.

Case

Here, we present a case report of a pregnancy with twin fetuses and concurrent hydatidiform mole that resulted in the preterm delivery of one viable baby, the unfortunate intrauterine demise of the other twin, and successful treatment of gestational trophoblastic neoplasia in the postpartum period.

Conclusion

This case highlights several important questions that arise for women who choose to carry a multiple gestation pregnancy with complete hydatidiform mole and describes complications that can occur. It is imperative to accurately assess risks and counsel individuals who elect to carry these pregnancies to provide the best possible outcomes.

Twin/Multiple Gestations With a Hydatidiform Mole: Clinicopathologic Analysis of 21 Cases With Emphasis on Molecular Genotyping and Parental Contribution

Complete hydatidiform moles (CHMs) and partial hydatidiform moles (PHMs) are abnormal gestations characterized by vesicular chorionic villi accompanied by variable trophoblastic hyperplasia, with or without embryonic development. CHMs are purely androgenetic (only paternal [P] chromosome complements), mostly homozygous/monospermic (~85%) but occasionally heterozygous/dispermic, whereas PHMs are overwhelmingly diandric triploid (2 paternal [P] and 1 maternal [M] chromosome complements) and heterozygous/dispermic (>95%). The presence of a fetus in a molar pregnancy usually indicates a PHM rather than a CHM; however, CHMs and PHMs rarely can be associated with a viable fetus or a nonmolar abortus in twin pregnancies and rare multiple gestation molar pregnancies have been reported. A "one-oocyte-model," with diploidization of dispermic triploid zygotes, has been proposed for twin CHM with coexisting fetus, and a "two-oocyte-model" has been proposed for twin PHM with coexisting fetus. Among 2447 products of conception specimens, we identified 21 cases of twin/multiple gestations with a molar component, including 20 CHMs (17 twins, 2 triplets, 1 quintuplet) and 1 PHM (twin). P57 immunohistochemistry was performed on all; DNA genotyping of molar and nonmolar components was performed on 9 twin CHMs, 1 triplet CHM, 1 quintuplet CHM, and 1 twin PHM. All CHM components were p57-negative and those genotyped were purely androgenetic. Twin CHMs had genotypes of P1M1+P2P2 in 5, P1M1+P1P1 in 1, and P1M1+P2P3 in 1, consistent with involvement of 1 oocyte and from 1 to 3 sperm-most commonly a homozygous CHM but involving 2 sperm in the whole conception-and compatible with a "one-oocyte-model." The triplet CHM was P1M1+P1P1+P2M2 and the quintuplet CHM was P1M1+P2M2+P2M2+P3M3+P4P4, consistent with involvement of 2 sperm and at least 2 oocytes for the triplet and 4 sperm and at least 3 oocytes for the quintuplet. The twin PHM had a P1M1+P2P3M2 genotype, consistent with involvement of 2 oocytes and 3 sperm. p57 immunohistochemistry is highly reliable for diagnosis of CHMs in twin/multiple gestations. Refined diagnosis of molar twin/multiple gestations is best accomplished by correlating morphology, p57 immunohistochemistry, and molecular genotyping, with the latter clarifying zygosity/parental chromosome complement contributions to these conceptions.

Complete Molar Pregnancies with a Coexisting Fetus: Pregnancy Outcomes and Review of Literature

Objective  The objective of the study was to review the obstetric outcomes of complete hydatidiform molar pregnancies with a coexisting fetus (CHMCF), a rare clinical entity that is not well described. Materials and Methods  We performed a retrospective case series with pathology-confirmed HMCF. The cases were collected via solicitation through a private maternal-fetal medicine physician group on social media. Each contributing institution from across the United States ( n  = 9) obtained written informed consent from the patients directly, obtained institutional data transfer agreements as required, and transmitted the data using a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant modality. Data collected included maternal, fetal/genetic, placental, and delivery characteristics. For descriptive analysis, continuous variables were reported as median with standard deviation and range. Results  Nine institutions contributed to the 14 cases collected. Nine (64%) cases of CHMCF were a product of assisted reproductive technology and one case was trizygotic. The median gestational age at diagnosis was 12 weeks and 2 days (9 weeks-19 weeks and 4 days), and over half were diagnosed in the first trimester. The median human chorionic gonadotropin (hCG) at diagnosis was 355,494 mIU/mL (49,770-700,486 mIU/mL). Placental mass size universally enlarged over the surveillance period. When invasive testing was performed, insufficient sample or no growth was noted in 40% of the sampled cases. Antenatal complications occurred in all delivered patients, with postpartum hemorrhage (71%) and hypertensive disorders of pregnancy (29%) being the most frequent outcomes. Delivery outcomes were variable. Four patients developed gestational trophoblastic neoplasia. Conclusion  This series is the largest report of obstetric outcomes for CHMCF to date and highlights the need to counsel patients about the severe maternal and fetal complications in continuing pregnancies, including progression to gestational trophoblastic neoplastic disease. Key Points CHMCF is a rare obstetric complication and may be associated with the use of assisted reproductive technology.Universally, patients with CHMCF who elected to manage expectantly developed antenatal complications.The risk of developing gestational trophoblastic neoplasia after CHMCF is high, and termination of the pregnancy did not decrease this risk.

Molar pregnancy in the last 50 years: A bibliometric analysis of global research output

Molar pregnancy is a gestational trophoblastic disease characterized by an abnormal growth of placental tissues because of a nonviable pregnancy. The understanding of the pathophysiology and management of molar pregnancy has significantly increased in the recent years. This study aims to determine the characteristics and trends of published articles in the field of molar pregnancy through a bibliometric analysis. Using the Scopus database, we identified all original research articles on molar pregnancy from 1970 to 2020. Bibliographic and citation information were obtained, and visualization of collaboration networks of countries and keywords related to molar pregnancy was conducted using VOSviewer software. We obtained a total of 2009 relevant papers published between 1970 and 2020 from 80 different countries. The number of publications continued to increase through the years. However, the number of publications in molar pregnancy is still low compared to the other research fields in obstetrics and gynecology. The USA (n = 421, 32.1%), Japan (n = 199, 15.2%), and the UK (n = 191, 14.6%) contributed the greatest number of publications in this field. The top journals which contributed to the field of molar pregnancy include AJOG (n = 91), Obstetrics and Gynecology (n = 81), and the Gynecologic Oncology (n = 57). The most cited articles in molar pregnancy include papers on the genetics and chromosomal abnormalities in molar pregnancies. The focus of current research in this field was on elucidating the molecular mechanism of hydatidiform moles. Our bibliometric analysis showed the global research landscape, trends and development, scientific impact, and collaboration among researchers in the field of molar pregnancy.

A high-risk gestational trophoblastic neoplasia derived from a complete hydatidiform mole with coexisting fetus identified by short tandem repeats analysis: A case report

A complete hydatidiform mole coexisting with a fetus (CHMCF) is a rare form of twin pregnancy. High-risk gestational trophoblastic neoplasia (GTN) can occur after a CHMCF pregnancy, although the frequency is low. In cases of GTN, the clinical diagnosis and that based on the International Federation of Gynecology and Obstetrics (FIGO) scoring system can differ. This case report concerns a patient with a choriocarcinoma that was initially diagnosed and treated as a low-risk stage III GTN following a live birth from a CHMCF pregnancy. We used short tandem repeat (STR) analysis to identify the causative pregnancy as the patient's earlier complete hydatidiform mole. Clinicians should anticipate a high-risk GTN when treating persistent trophoblastic disease (PTD) in patients with a non-typical course.

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A fetus and a complete hydatidiform mole can coexist as a twin pregnancy.

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A complete hydatidiform mole coexisting with a fetus can rarely cause choriocarcinoma.

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Short tandem repeat analysis can be used to identify causative pregnancies.

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Causative pregnancy is a risk factor for persistent trophoblastic disease.

Differentiating complete hydatidiform mole and coexistent fetus and placental mesenchymal dysplasia: A series of 9 cases and review of the literature

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Twin mole and placental mesenchymal dysplasia are set apart by patient symptoms, labs, and imaging.

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Continuing with a twin mole pregnancy does not appear to increase the risk of GTN.

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Twin mole pregnancy does carry an increased risk of miscarriage and pre-term labor.

To identify the differentiating features in clinical presentation, management, and maternal/fetal outcome in complete hydatidiform mole and coexistent fetus compared with placental mesenchymal dysplasia.

Between 1997 and 2015, five women with complete hydatidiform mole and coexistent fetus and four women with placental mesenchymal dysplasia were managed at the University of California San Francisco. Clinical features were analyzed and compared with previously published data.

Of the five cases of complete hydatidiform mole and coexistent fetus, two had live births. β-hCG levels were > 200,000 IU/L in all cases. On imaging, a clear plane between the cystic component and the placenta favored a diagnosis of complete hydatidiform mole and coexistent fetus. None of the patients went on to develop gestational trophoblastic neoplasia (GTN), with a range of follow-up from 2 to 38 months. Combining this data with previously published work, the live birth rate in these cases was 38.8%, the rate of persistent GTN was 36.2%, and the rate of persistent GTN in patients with reported live births was 27%. Of the four cases of placental mesenchymal dysplasia, all four had live births. One patient developed HELLP syndrome and intrauterine growth restriction; the remaining three were asymptomatic.

Maternal symptoms, fetal anomalies, β-hCG level, and placental growth pattern on imaging may help differentiate between complete hydatidiform mole and coexistent fetus and placental mesenchymal dysplasia. There was not an increased risk of gestational trophoblastic neoplasia in patients with complete hydatidiform mole and coexistent fetus who opted to continue with pregnancy.

Gestational Trophoblastic Disease: Current Evaluation and Management

This review summarizes the current evaluation and management of gestational trophoblastic disease, including evacuation of hydatidiform moles, surveillance after evacuation of hydatidiform mole and the diagnosis and management of gestational trophoblastic neoplasia. Most women with gestational trophoblastic disease can be successfully managed with preservation of reproductive function. It is important to manage molar pregnancies properly to minimize acute complications and to identify gestational trophoblastic neoplasia promptly. Current International Federation of Gynecology and Obstetrics guidelines for making the diagnosis and staging of gestational trophoblastic neoplasia allow uniformity for reporting results of treatment. It is important to individualize treatment based on their risk factors, using less toxic therapy for patients with low-risk disease and aggressive multiagent therapy for patients with high-risk disease. Patients with gestational trophoblastic neoplasia should be managed in consultation with an individual experienced in the complex, multimodality treatment of these patients.

Gynecologic cancer in pregnancy

Cancer complicates 1 in 1000 pregnancies. Multidisciplinary consensus comprised of Gynecologic Oncology, Pathology, Neonatology, Radiology, Anesthesiology, Maternal Fetal Medicine, and Social Work should be convened. Pregnancy provides an opportunity for cervical cancer screening, with deliberate delays in treatment permissible for early stage carcinoma. Vaginal delivery is contraindicated in the presence of gross lesion(s) and radical hysterectomy with lymphadenectomy at cesarean delivery is recommended. Women with locally advanced and metastatic/recurrent disease should commence treatment at diagnosis with chemoradiation and systemic therapy, respectively; neoadjuvant chemotherapy to permit gestational advancement may be considered in select cases. Most adnexal masses are benign and resolve by the second trimester. Persistent, asymptomatic, benign-appearing masses can be managed conservatively; surgery, if indicated, is best deferred to 15-20 weeks, with laparoscopy preferable over laparotomy whenever possible. Benign and malignant germ cell tumors and borderline tumors are occasionally encountered, with unilateral adnexectomy and preservation of the uterus and contralateral ovary being the rule. Epithelial ovarian cancer is exceedingly rare. Ultrasonography and magnetic resonance imaging lack ionizing radiation and can be employed to evaluate disease extent. Tumor markers, including CA-125, AFP, LDH, inhibin-B, and even CEA and ßhCG may be informative. If required, chemotherapy can be administered following organogenesis during the second and third trimesters. Because platinum and other anti-neoplastic agents cross the placenta, chemotherapy should be withheld after 34 weeks to avoid neonatal myelosuppression. Bevacizumab, immune checkpoint inhibitors, and PARP inhibitors should be avoided throughout pregnancy. Although antenatal glucocorticoids to facilitate fetal pulmonary maturation and amniotic fluid index assessment can be considered, there is no demonstrable benefit of tocolytics, antepartum fetal heart rate monitoring, and/or amniocentesis. Endometrial, vulvar, and vaginal cancer in pregnancy are curiosities, although leiomyosarcoma and the dreaded twin fetus/hydatidiform mole have been reported. For gynecologic malignancies, pregnancy does not impart aggressive clinical behavior and/or worse prognosis.

Twin pregnancy with metastatic complete molar pregnancy and coexisting live fetus

We present a case of a 34-year old G1P0 female with twin-gestation and positive prenatal screening. Initial ultrasounds demonstrated a normal live fetus with an indeterminate but persistent placental lesion. The patient presented at 23 weeks of gestational age with vaginal bleeding. On examination, a 2 cm vaginal lesion was identified. Further cross-sectional imaging demonstrated a normal appearing fetus with a mixed solid and cystic placental lesion as well as an additional lesion in the vagina. Metastatic workup revealed diffuse pulmonary metastases. Intravascular embolization was carried out to minimize the bleeding from the vaginal lesion, followed by the delivery of the fetus with an urgent Caesarean section and treatment with chemotherapy. Pathology and genetics testing confirmed diagnosis of a complete molar pregnancy with a coexisting live fetus. This case highlights the importance of any unexpected findings within the placenta or the uterus in a pregnant patient. The radiologist should maintain a high index of suspicion for gestational trophoblastic disease in such cases, communicate clearly with the clinical team and suggest appropriate additional imaging.

A challenging case of twin pregnancy with complete hydatidiform mole and co-existing normal live fetus - A case report and review of the literature

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Twin pregnancy with complete hydatidiform mole and co-existing normal live fetus is rare.

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Antenatal and postpartum complications such as gestational trophoblastic neoplasia are common.

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Patients require close clinical monitoring and urgent delivery in the setting of complications.

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Follow-up with serum β-HCG is important for the diagnosis of persistent trophoblastic disease.

Hydatidiform mole coexisting with a normal live fetus in a twin pregnancy is extremely rare. Management of these cases is challenging due to the risk of severe antepartum and post-partum complications. Herein, we report the case of a 24-year-old gravida 2 para 1 who presented at 28 weeks gestation with severe preeclampsia, vulvar edema and a serum β-HCG of 285,000 IU/mL. Ultrasonography demonstrated a single live intra-uterine pregnancy with concurrent hydatidiform mole. Conservative management with magnesium sulfate and anti-hypertensive medications was initiated however the patient developed HELLP syndrome and required urgent delivery at 33 weeks. Copious molar tissue was removed from the uterus during delivery. Four weeks post-partum, her β-HCG had dropped to 14,000 IU/ml and continued to decline at 6 weeks (2900 IU/ml). However, at eight weeks, it increased to 3500 IU/ml and the patient was treated with nine cycles of intramuscular methotrexate. Current guidelines for management of a twin pregnancy with coexistent mole recommend close clinical monitoring if the mother and fetus are stable and urgent delivery in the setting of complications. During the postpartum period, careful follow up with clinical evaluation and serial serum β-HCG is important for the diagnosis and treatment of persistent trophoblastic disease.

Multiple metastatic gestational trophoblastic disease after a twin pregnancy with complete hydatidiform mole and coexisting fetus, following assisted reproductive technology: Case report and literature review

OBJECTIVE

Twin pregnancy with complete hydatidiform mole and coexisting fetus (CHMCF) is rare and associated with severe complications during pregnancy and subsequent gestational trophoblastic disease (GTD). We encountered a case of multiple metastatic GTD after a twin pregnancy with CHMCF, following conventional in vitro fertilization (IVF). Only one case of metastatic GTD after CHMCF due to assisted reproductive technology (ART) has been reported. Here, we present the clinical course and reveal the clinical features of CHMCF after ART through a literature review.

CASE REPORT

A 42-year-old primigravida woman had an abnormal pregnancy (i.e., CHMCF) by IVF. She had persisting severe vaginal bleeding, which led to termination of her pregnancy at 10 weeks of gestation. Pathohistological examination revealed that this was a case of CHMCF. Five weeks after the termination, the serum β-human chorionic gonadotropin level was still extremely high, and systemic contrast-enhanced computed tomography revealed a tumor in the uterine corpus and more than 30 lung nodules. After 11 cycles of combination chemotherapy with etoposide, methotrexate, actinomycin-D, cyclophosphamide, and vincristine (EMA/CO) to treat high-risk GTD, hysterectomy was needed as radical therapy.

CONCLUSION

Cases of CHMCF following ART may also have higher malignant potential and higher risk of GTD development and become more aggressive biologically. The clinical course of CHMCF after ART seems to be almost the same as that without ART based on the results of literature review.

Choriocarcinoma with multiple lung metastases from complete hydatidiform mole with coexistent fetus during pregnancy

Gestational trophoblastic neoplasm (GTN) is a serious morbidity of complete hydatidiform mole with coexistent fetus (CHMCF) and usually develops after termination of pregnancy. Here we report a case of choriocarcinoma derived from CHMCF during pregnancy. A 33-year-old multiparous woman with suspected CHMCF was admitted with a severe cough. Computed tomography revealed multiple lung metastases. Cesarean section and hysterectomy were performed at 31 weeks of gestation on diagnosis of high-risk GTN from International Federation of Gynecology and Obstetrics (FIGO) scoring. A live female infant weighing 1390 g was delivered. Choriocarcinoma was diagnosed from pathological findings. The patient received multi-agent chemotherapy and was discharged on the 40th postoperative day. In conclusion, CHMCF can result in high-risk GTN during pregnancy. For a suspected GTN, diagnosis from FIGO scoring should determine treatment strategy. If patients with CHMCF wish to continue their pregnancy, careful follow-up, including regular chest radiography and ultrasonography, is warranted.

A twin pregnancy with a hydatidiform mole and a coexisting live fetus: prenatal diagnosis, treatment, and follow-up

Twin molar pregnancy with a hydatidiform mole and a coexisting live fetus is a rare form of gestational trophoblastic disease associated with an increased risk of obstetric complications and poor perinatal outcome. Prenatal diagnosis is essential for couple counseling and follow-up in Tertiary Reference Centers. Magnetic resonance imaging is important for the diagnostic differentiation of placental mesenchymal dysplasia and exclusion of myometrial invasion. Here we present a case of twin molar pregnancy with a hydatidiform mole and a coexisting live fetus diagnosed at gestational week 14 using two-dimensional (2D) and three-dimensional (3D) ultrasound and magnetic resonance imaging. We also describe the obstetric management and postmolar follow-up.

[Twin pregnancy with complete hydatidiform mole]

The paper describes a case of twin pregnancy with complete hydatidiform mole (CHM). According to the data available in the literature, the concurrence of CHM with a normal placenta and a viable fetus occurs in 1 per 20,000-100,000 pregnancies, requires a differential diagnosis with partial hydatidiform mole and placental mesenchymal dysplasia, and is characterized by a high rate of complications. In this concurrence, the frequency of persistent trophoblastic disease is as high as 50%. In this case, the pregnancy ended in a spontaneous abortion at 16-17 weeks of pregnancy. A morphological examination determined the fetus without congenital malformations with normal placental weight and structure and the adjacent intact placental tissue with the macro- and microscopic signs of CHM. The diagnosis was confirmed by the lack of р57 expression in the villous trophoblast and stroma in the tissue of the hydatidiform mole. The patient was diagnosed with persistent trophoblastic disease at 2 months after the abortion.

[Twin pregnancy involving a molar pregnancy and living fetus with progression to invasive mole: about two cases]

La grossesse gémellaire associant une môle complète et une grossesse singleton normale possédant son propre trophoblaste sain est une entité rare. La majorité des études montre que le pronostic d'une telle association comprend un risque un peu plus accru d’évolution vers une tumeur trophoblastique gestationnelle. Nous rapportons deux cas de patientes qui ont consulté pour des métrorragies du premier trimestre et dont l’échographie a objectivé une grossesse gémellaire associant une grossesse molaire et une grossesse évolutive singleton et dont l’évolution était marqué par une mole invasive.

Twin Pregnancy with a Complete Hydatidiform Mole and a Coexisting Live Fetus: Rare entity

A hydatidiform mole with a coexisting live fetus is a rare occurrence and the optimal management for this condition is not yet known. We report the case of a 32-year-old woman (gravida 3, para 2) who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in March 2012 at 13 gestational weeks with abdominal pain and vaginal bleeding. An ultrasound examination revealed a hydatidiform mole pregnancy coexisting with a live fetus. After extensive counselling, the patient and her husband opted for a conservative management approach. Unfortunately, a hysterotomy had to be performed at 17 gestational weeks due to severe haemorrhage. The postoperative period was uneventful and histopathology results confirmed one complete mole with a coexisting fetus and normal placenta. The patient's serum β-human chorionic gonadotropin level remained normal for 18 months following her surgery.

Medical termination of a partial hydatidiform mole and coexisting fetus during the second trimester: A case report

Partial hydatidiform mole and coexisting fetus (PHMCF) is a rare condition that presents a dilemma for physicians and the parents of the fetus, particularly when PHMCF is detected during the second trimester of pregnancy. The present study reports a case of PHMCF terminated by induction of labor via administration of Rivanol at 17 weeks. Follow-up measurements of serum β-human chorionic gonadotropin (β-HCG) levels, as well as imaging studies, indicated the presence of persistent trophoblastic disease (PTD) and lung metastases. The patient was therefore admitted for three courses of chemotherapy. Subsequently, the metastases receded and β-HCG levels decreased to within the normal range. The patient demonstrated no disease recurrence for 1 year. Following a review of the relevant literature, to the best of our knowledge, all PHMCF cases terminated by medical induction of labor during the second trimester resulted in the development of PTD and lung metastases. However, three cases of PHMCF that were terminated by caesarean section during the third trimester did not develop PTD or metastases. The present study therefore hypothesized that medical termination may not be a safe therapeutic strategy for the treatment of PHMCF during the second trimester, and that pregnancy should be allowed to continue empirically.

[Twin pregnancy with complete hydatiform mole and coexistent fetus: Report of 4 cases and review of literature]

OBJECTIVE

Twin pregnancy with complete hydatiform mole and coexistent fetus is a rare clinical condition, occurring in 1 in 22,000 to one in 100,000 pregnancies. Continuation of pregnancy in these cases is controversial because of a high risk of immediate and long-term maternal morbidity. It allows, however, in 33 % of the case the delivery of a healthy child.

METHODS

This retrospective study included all patients presenting a complete hydatiform mole coexisting with a live twin fetus antenatally diagnosed between 2007 and 2012 in the level III maternity of the Strasbourg University Hospital. Informations concerning diagnostic circumstances, pregnancy follow-up and outcome were studied.

RESULTS

Four pregnancies were included in the study, all of them were spontaneous. Medical termination of pregnancies was related to maternal reasons in the four cases. One before 17 weeks of gestation, the three other after 2 weeks of gestation, leading to delivery of a healthy child. All patients developed a mild to severe preeclampsia. One patient developed a gestational trophoblastic disease, requiring chemotherapy by methotrexate. There was no fatal evolution.

CONCLUSION

Twin pregnancy with complete hydatifom mole and coexistent fetus is associated with increased risk of gestational trophoblastic disease. This risk is not increased by continuation of pregnancy. In case of prenatal diagnosis of complete hydatiform mole coexisting with a live twin fetus, patients should be aware of the potential high risk of morbidity and a regular follow-up during and after the pregnancy should be intaured. In absence of maternal complications, continuation of the pregnancy is possible.

Sonographic findings and perinatal outcome of multiple pregnancies associating a complete hydatiform mole and a live fetus: a case series

BACKGROUND

The aim of this case series was to present the ultrasonographic findings, clinical features, management, and outcome of multiple pregnancies with complete hydatidiform mole and coexisting fetus (CHMCF).

METHODS

Sonographic features and obstetrical and perinatal outcomes of seven cases with CHMCF were analyzed retrospectively.

RESULTS

A total of seven cases was included in the analysis. Six cases were twins and one case was quadruplet. The mean ± SD maternal age was 25.3 ± 1.9 years (median: 25; range: 23-29). The mean gestational age at diagnosis was 16.1 ± 4.6 weeks (median: 17; range: 11-23). Two pregnancies were achieved by ovulation induction. Two couples opted for pregnancy termination. Four pregnancies resulted in fetal loss between the 11th and 23th week of gestation. One pregnancy ended with the preterm delivery of a live-born neonate at 34 weeks due to pre-eclampsia. One patient developed persistent trophoblastic disease, which was treated by hysterectomy. The mean ± SD time for β-human chorionic gonadotropin clearance was 3.7 ± 0.5 weeks (median: 4; range: 3-4) in the six patients without persistent trophoblastic disease.

CONCLUSIONS

Spontaneous fetal loss is the most likely outcome for CHMCF. However, on the basis of our experience, we recommend carefully monitored continuation of pregnancy as long as maternal complications are not present or are controllable.

Gynecologic malignancy in pregnancy

Gynecologic malignancy during pregnancy is a stressful problem. For the diagnosis and treatment of malignancy during pregnancy, a multidisciplinary approach is needed. Patients should be advised about the benefits and risk of treatment. When selecting a treatment for malignancy during pregnancy, the physiologic changes that occur with the pregnancy should be considered. Various diagnostic procedures that do not harm the fetus can be used. Laparoscopic surgery or laparotomy may be safely performed. The staging approach and treatment should be standard. Systemic chemotherapy during the first trimester should be delayed if possible. Radiation therapy should preferably start postpartum. Although delivery should be delayed preferably until after 35 weeks of gestation, termination of pregnancy may be considered when immediate treatment is required. Subsequent pregnancies do not increase the risk of malignancy recurrence.

The interplay of Graves' disease and twin molar pregnancy

Twin molar pregnancy with coexistent viable fetus in a patient with Graves' disease is a rare entity. The patient is a 37-year-old woman who was hospitalised owing to persistent vomiting and vaginal bleeding. The pregnancy test was positive and the pelvic ultrasound disclosed twin gestation of complete mole and a coexistent viable 12-week fetus. β-Human chorionic gonadotropin (β-HCG) and free thyroid hormones were both elevated. The patient was also a diagnosed case of Graves' disease prior to this pregnancy. Given the risks for perinatal complications, the patient was offered early termination of pregnancy. She, however, decided to continue her pregnancy and control the hyperthyroidism with an antithyroid drug (ATD). A week after her discharge from the hospital, she had spontaneous abortion and the histopathology of the abortus revealed complete hydatidiform mole and a 13-week fetus.

Does cerclage improve neonatal outcomes in a molar pregnancy and a coexistent fetus? A case report

Background

Complete hydatiform mole and coexistent viable fetus is very rare. The use of a cervical cerclage for cervical indications in the presence of this condition has never been reported. Although the diagnosis was made postnatal, the objective is to present a case with good neonatal outcome.

Case presentation

A patient presented with vaginal spotting around 23 weeks. She has a history of four preterm deliveries. Her cervix was dilated and a cerclage was placed. She presented again with PPROM around 25 weeks. She went into spontaneous preterm labor and delivered a viable fetus that is a healthy girl today. Eventually the pathology of the placenta showed a complete hydatidiform mole.

Conclusion

It is necessary to inform patients about the potential risks and poor outcomes of this condition. For those who desire all potential interventions, cerclage placement could be considered.

Complete hydatidiform mole presenting as a placenta accreta in a twin pregnancy with a coexisting normal fetus: case report

A twin pregnancy with a complete hydatidiform mole and a coexisting normal fetus (CHMF) is a rare clinical scenario, and it carries many associated pregnancy and postnatal risks. Limited numbers of case studies exist reporting an outcome of live birth, and only three prior cases report the presentation of a hydatidiform mole as a placenta previa. We report a case of CHMF with the molar component presenting antenatally as a placenta previa, which ultimately resulted in placenta accreta at the time of delivery. A live male infant was delivered at 34 weeks' gestation via planned cesarean section, and a hysterectomy was performed following unsuccessful removal of the molar component. We additionally utilized previously described methods of placing internal iliac balloons and ureteral stents prior to delivery. In such a high-risk pregnancy with a known molar previa component, these surgical preparation measures may be of benefit.