A 43 y.o. 17 wk pregnant woman comes to the ED after an MVC. She was a restrained driver T-boned on the passengers side and co pain in the chest and abdomen.
CT of the abdomen shows nodules in the lungs.
A CT of the chest was also done because of the nodules
more nodules were noted
What did the US of the uterus show?
Our patient had a malignant molar pregnancy with mets to the lung. A molar pregnancy or hydatidiform mole occurs when there is an abnormal growth of trophoblasts, the cells that normally develop into the placenta. There are three major types of gestational trophoblastic neoplasia(molar pregnancies)
1.A complete molar pregnancy –an empty egg is fertilized by one or two sperm and all the genetic material is from the father. The father’s chromosomes are duplicated. There is no embryo and a cystic degeneration of chorionic villi, leading to the “cluster of grapes” appearance on US. There is a genetic association with molar pregnancies associated with an abnormality on chromosome 19.
2. An incomplete molar pregnancy- contains the mother’s chromosomes as well as two sets of the father’s chromsomes. This can occur when two sperm fertilize an egg. These patients usually present with a missed abortion.
3. Choriocarcinoma- is a malignancy that rarely develops after a molar pregnancy. It can result from tissue left in the uterus after a miscarriage, abortion or the delivery of a healthy baby.
A p57 stain is a nuclear stain used to detect double sets of chromosomes. In a normal pregnancy the gene is present because it is expressed by the mother. In a complete molar pregnancy it is absent. The products of conception are also tested for more than two sets of chromosomes(FISH ploidy) incase it is a molar pregnancy with one set of maternal chromosomes and two sets of paternal chromosomes. This is done because of a 15% risk of choriocarcinoma after a complete molar pregnancy.
One in every 1,000 pregnancies is a molar pregnancy.
Suction D&C was performed on 5/13/22 under general anesthesia, and tissue was sent to pathology. During procedure, trans-abdominal ultrasound was performed to guide D&C and confirm that the uterus was empty at the end of the procedure. Will need to await final pathology to determine follow up plan, but discussed the importance of following her beta-hCG to 0 and trending it thereafter per NCCN guidelines. Patient received DMPA injection 5/13/22 before discharge, with the plan to continue injections for birth control. Patient was discharged with plan to follow up in Fellows clinic on 6/1/22. Patient was ordered for weekly bHCG. The patient had no sequellae from her MVC.
Spontaneous regression of lung mets has been reported after gestational trophoblastic neoplasm and the level of HCG will determine whether she requires chemo.
Duffy L, Zhang L, Sheath K, et al. The diagnosis of choriocarcinoma in molar pregnancies: a revised approach in clinical testing. J Clin Med Res 2015 Dec;7(12):961-966.
Lurain J.Gestational trophoblastic disease I: epidemiology,pathologic, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J Obstet Gynecol. 2010;203(6):531-539.
Slim R, Mehio A. The genetics of hydatidiform moles: new lights on an ancient disease. Clin Genet. 2007;71(1):25-34.