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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 16-18

Partial hydatidiform molar gestation following assisted conception


Department of Embryology, The Bridge Clinic, Plot 724 CAD, Umaru Dikko Street, Jabi, Abuja, Nigeria

Date of Web Publication10-Sep-2018

Correspondence Address:
John Chukwuzitelu Ekweani
The Bridge Clinic, Umaru Dikko Street, Jabi, Abuja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajiac.ajiac_6_16

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  Abstract 


Molar gestation, with its attendant risk to progress to frank choriocarcinoma, has been reported in the literature. It can follow both spontaneous and assisted conceptions. With the growing popularity of assisted conception techniques for the management of infertility in our setting, it is important to bring to the fore that similar complications could occur and hence should inform the counseling of patients before and during such procedures. We present a 39-year-old nullipara who had in vitro fertilization and frozen embryo transfer. Eight weeks later, she was diagnosed with missed abortion and had manual vacuum aspiration at a private hospital in Zaria. Histopathological examination revealed partial hydatidiform mole, and she was subsequently managed at a tertiary health center in Zaria with six cycles of methotrexate chemotherapy because she was low risk based on the International Federation of Gynecologists and Obstetricians criteria. She was monitored with monthly serum beta-human chorionic gonadotropin (β-HCG) and was placed on combined oral contraceptive pills. The serum β-HCG levels fell to almost undetectable levels and remained so after four cycles of the chemotherapy regimen. Molar pregnancy can follow assisted conception in our environment. This underscores the importance of pretransfer cytogenetic and histopathological assessment of any specimens aspirated following every incomplete/missed abortion. This case also brings to the fore the importance of referral of similar cases to higher levels of care for expert/multidisciplinary management.

Keywords: Frozen embryo transfer, gestation,in vitro fertilization, partial mole


How to cite this article:
Ekweani JC, Oguntayo AO, D. Kolawole A O, Zayyan MS. Partial hydatidiform molar gestation following assisted conception. Afr J Infertil Assist Concept 2017;2:16-8

How to cite this URL:
Ekweani JC, Oguntayo AO, D. Kolawole A O, Zayyan MS. Partial hydatidiform molar gestation following assisted conception. Afr J Infertil Assist Concept [serial online] 2017 [cited 2018 Dec 11];2:16-8. Available from: http://www.afrijiac.org/text.asp?2017/2/1/16/241013




  Introduction Top


With the growing popularity and affordability of in vitro-fertilization and embryo transfer (IVF-ET) techniques and its wide applications for the treatment of infertility in our environment, care should be taken to note some of its less common yet potentially life-threatening complications – molar pregnancy.[1],[2],[3] Molar pregnancies are derived from abnormally proliferating syncytiotrophoblastic and cytotrophoblastic cells that may result from the fertilization of an ova with either a single sperm that later undergoes division or by two sperms.[4],[5] Partial moles are triploidic (containing a complement of maternal chromosomes) while complete moles are diploidic (with compliment of chromosomes derived entirely from the father).[2],[3],[6]

Apart from complications such as hyperemesis gravidarum, electrolyte imbalances, anemia, and early-onset preeclampsia/eclampsia one of the most feared complications is its propensity to transform to frank choriocarcinoma which is the malignant variant of gestational trophoblastic disease.[2],[7] The incidence of molar pregnancy following IVF-ET may be similar to that following spontaneous pregnancies and ranges from 1 in 1500 to 1 in 125.[2] They may coexist with normal fetus in multiple gestations.[8],[9] One of the most common presentations is vaginal bleeding and diagnosis is by taking a meticulous history, physical examination, and relevant investigations. Confirmation of the diagnosis is by histology. Treatment involves counseling, resuscitation, and administration of appropriate cytotoxic agents guided by patient's clinical condition and the World Health Organization/International Federation of Gynecology and Obstetrics (WHO/FIGO) risk scoring systems. Surgical intervention in the form of hysterectomy may be indicated in some cases.[2],[3]

We present this rare case of partial hydatidiform molar gestation following IVF-ET for a patient managed for tubal factor infertility in a tertiary health center in northern Nigeria.


  Case Report Top


Mrs. LVT was a 39-year-old married woman who was Para 0 + 1 and whose last menstrual period was 12 weeks before presentation to the gynecological clinic.

She was referred from a private hospital in Zaria with a histological diagnosis of partial hydatidiform mole. There was no complaint on presentation.

She was initially managed for primary infertility at a private hospital in Abuja where she had in-vitro- fertilization and double-embryo transfer. The procedure was complicated by ovarian hyperstimulation syndrome (OHSS) which necessitated cryopreservation of the embryos. She was treated and had a stimulated frozen embryo transfer of two embryos, 10 weeks later. She was stable after the transfer and had a positive pregnancy test, 2 weeks later. She had a pregnancy scan; however, she could not recall the details. Eight weeks later, she noticed spotting per vaginam following which she presented to a private hospital in Zaria. An ultrasound scan was done, and a diagnosis of missed abortion was made. She had a manual vacuum aspiration, and the specimen was taken for histopathological examination. There was the need to have a repeat uterine evacuation as vaginal bleeding persisted after the previous one. Fleshy aspirates were noted. Histopathological results revealed partial hydatidiform mole necessitating her referral to our center for subsequent management.

Menarche was at 14 years. She had menstrual flow of 6 days in a regular 28–30-day cycle. There was no history of dysmenorrhea, dyspareunia, postcoital bleeding, or intermenstrual bleeding. She had no contraceptive history and had two Papanicolaou smears. She had an abdominal myomectomy 7 years before presentation. She also had a partial thyroidectomy for nontoxic multinodular goiter 3 years earlier. There was no known background medical condition. Her mother was hypertensive.

The systemic review was normal.

She was married in a monogamous, nonconsanguineous family setting. She neither smoked cigarettes nor took alcohol.

On examination, she was a young healthy-looking woman who was not in any form of distress, she was not pale, anicteric, cyanosed, well hydrated, and axillary temperature was 36.9°C.

Her respiratory rate was 22/min, and the chest was clinically clear.

The blood pressure was 116/70 mmHg; the apex beat was not displaced; and the heart sounds were normal.

The abdomen was full, moved with respiration with a Pfannenstiel scar that healed by primary intention. She had normal female hair distribution. There were no areas of tenderness. There was no organomegaly.

Pelvic examination revealed a normal vulva and vagina with no ulcerations or swellings. The cervix was 2 cm long, closed, and posteriorly located. The uterus was 16-week size, anteverted, and mobile. The left adnexal fullness was noted. There were no masses or fluid in the pouch of Douglas. The examination finger was stained with normal vaginal secretions.

Other investigations were requested to ascertain the stage of the disease and fitness for subsequent management which included serum (β subunit of human chorionic gonadotropin) beta-human chorionic gonadotropin (β-HCG) (value was 12,000 ng/ml), chest X-ray (normal), serum urea, electrolytes and creatinine with liver function tests (normal), full blood count, and differentials (normal) with grouping and cross-matching of a unit of compatible blood. An abdominopelvic ultrasound scan was normal.

A diagnosis of histologically confirmed partial hydatidiform mole following assisted conception on background infertility was made.

She was noted to be low risk based on the FIGO scoring system and was counseled in light of the above findings to have single-agent chemotherapy with methotrexate. Possible side effects of the regimen were explained to her. She underwent six cycles of chemotherapy with folinic acid as rescue. She was placed on combined oral contraceptive pills throughout the period of chemotherapy and follow-up. During the chemotherapy, she had monthly serum β-HCG which came down to <1 ng/ml in the last two cycles of the chemotherapy.

She continued her contraceptives pills till 6 months after completion of the chemotherapy then she was referred for continued management of infertility.


  Discussion Top


It is important to underscore the importance of this case as it shows that molar pregnancies can follow assisted reproduction. It is a rare occurrence that has not been documented within this setting hitherto. The above client was at risk considering her age which can translate to poor egg quality. The patient's age may have been a factor in this process as she was already 39 years old at presentation. The quality of egg produced at this age may not be optimum. Her age also predisposes apart from having hydatidiform mole to also having other aneuploidic fetuses (e.g., Down and Edward syndromes).[10]

The management of the above patient was successful because she presented early to a health facility on the occurrence of symptoms, she was managed by competent medical personnel, and she was adequately counseled.

The place of counseling cannot be overemphasized especially for a patient anxious for her infertility against her advanced reproductive age. The cost of the procedure among other social factors surrounding infertile couples in our traditional African society had the potential to further complicate the matter. The cooperation, participation, and understanding of this patient/spouse in her management are hence crucial.

It is also important to note that had she been managed as a normal abortion case by quacks who would have missed histological examination of the specimen, the diagnosis of hydatidiform mole would have also been missed. Hence, this underscores the importance of histology for every specimen evacuated following abortions.[2],[3]

The place of multidisciplinary approach in the management involving the gynecologist, radio-oncologist, radiodiagnosis, chemical pathologist, hematologist, family planning counselors, and other social workers also needs to be noted. They may be involved during the initial investigations, follow-up, and psychological rehabilitation.

The prevention of complications associated with assisted reproductive techniques is key. Complications can occur during ovulation induction, ovum retrieval, embryo transfers, pregnancy, and delivery. These can include OHSS which this patient had in the initial stages necessitating freezing of the zygote. We also have multiple gestations and their attendant gynecologic and obstetric risk. Others include abortion, anemia, hyperemesis, and molar gestation.[8] There are also long-term risks associated with some of the drugs used in the process, for example, breast cancer, thromboembolic disease, and homocysteinemia which are singly or aggregately linked to the patient's age (≥39 years as in the patient in review).[1],[10],[11]

Preventive measures can include using donor egg, surrogacy, and some modifications to the assisted reproductive techniques which include as follows: mild stimulation protocols with smaller doses of gonadotropin-releasing hormone (GnRH) analogs, coasting GnRH antagonist protocols, usage of intravenous albumin at the time of oocyte retrieval, in vitro maturation, natural/modified natural cycle IVF, and preimplantation cytogenetic analysis/preimplantation genetic diagnosis. It has also been postulated by some that intracytoplasmic sperm injection by ensuring that single sperm is injected in a single ovum, the chances of dispermic fertilization is reduced. They may also benefit from intracytoplasmic morphologically selected sperm injection (IMSI).

Preimplantation genetic diagnosis may be a good option for clients who are in the older reproductive age group and desire IVF with their own eggs. However, it is limited by the cost, and that larger studies are required to verify these among other assertions.[1],[11]


  Conclusion Top


The above case report has shown that it is possible for hydatidiform mole to occur following IVF-ET for the management of tubal factor infertility and that it can be managed successfully provided laid guidelines are strictly followed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gautam A. Complications of IVF. J Obstet Gynecol India 2010;60:297-8.  Back to cited text no. 1
    
2.
Decherney AH, Goodwin MT, Laufer N. Current Diagnosis and Treatment Obstetrics and Gynecology. 10th ed. United States of America: McGraw-Hill Companies Inc.; 2007. p. 885-95.  Back to cited text no. 2
    
3.
Savage P, Secki M. Gestational trophoblastic disease. In: Edmonds DK, editor. Dewhurst's Textbook of Obstetrics and Gynaecology. 8th ed. London, UK: Wiley-Blackwell Publishing; 2012. p. 66-75.  Back to cited text no. 3
    
4.
Ulug U, Ciray NH, Tuzlali P, Bahçeci M. Case report: Partial hydatidiform mole following the transfer of single frozen-thawed embryo subsequent to ICSI. Reprod Biomed Online 2004;9:442-6.  Back to cited text no. 4
    
5.
Fluker MR, Yuzpe AA. Partial hydatidiform mole following transfer of a cryopreserved-thawed blastocyst. Fertil Steril 2000;74:828-9.  Back to cited text no. 5
    
6.
Pal L, Toth TL, Leykin L, Isaacson KB. High incidence of triploidy in in vitro fertilized oocytes from a patient with a previous history of recurrent gestational trophoblastic disease. Hum Reprod 1996;11:1529-32.  Back to cited text no. 6
    
7.
Shozu M, Akimoto K, Kasai T, Inoue M, Michikura Y. Hydatidiform moles associated with multiple gestations after assisted reproduction: Diagnosis by analysis of DNA fingerprint. Mol Hum Reprod 1998;4:877-80.  Back to cited text no. 7
    
8.
Montes-de-Oca-Valero F, Macara L, Shaker A. Twin pregnancy with a complete hydatidiform mole and co-existing fetus following in vitro fertilization: Case report. Hum Reprod 1999;14:2905-7.  Back to cited text no. 8
    
9.
Barash A, Zalel Y, Lifschitz-Mercer B, Czernobilsky B. A partial hydatidiform mole following in vitro fertilization and embryo transfer. J Assist Reprod Genet 1993;10:171-3.  Back to cited text no. 9
    
10.
Huang X, Wang H, Zhao X, Xu X, Chen Q. Gestational trophoblastic disease following in vitro fertilization. Arch Gynecol Obstet 2007;275:291-3.  Back to cited text no. 10
    
11.
Serour GI, Rhodes CA, Sattar MA, Aboulghar MA, Mansour R. Complications of assisted reproductive techniques: A review. Assist Reprod 1999;9:214-32.  Back to cited text no. 11
    




 

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Case Report
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