Gowri Dorairajan1
(1)
Obstetrics and Gynecology, JIPMER, Puducherry, India
A woman was admitted with a diagnosis of molar pregnancy in her third pregnancy. She presented in her 4th month of pregnancy due to spotting from the vagina. At admission, she was mildly anaemic. Abdomen revealed a uterine size of 32 weeks with no foetal parts. Sonography confirmed a complete mole. She was planned for elective evacuation after all the preoperative investigations were done. A consultant uneventfully completed the suction evacuation. 2 h after the procedure, she was found to be tachypneic and pale. Her pulse was 120/min, and blood pressure was 90 mm of Hg systolic. She had tachypnea and dyspnea. Abdomen appeared distended. Initially, I thought that she has gone in for adult respiratory distress syndrome due to metastases of the mole, but the abdominal distension was not fitting into the diagnosis. I decided to do a scan, and to my surprise, I found that the uterus which was found to be 12 weeks size showed a possible invasion by the molar tissue on the anterior wall. We took her up for laparotomy as in spite of resuscitation her condition did not stabilize.
There was a 3 × 4 cm irregular perforated area on the anterior wall through which molar tissue was protruding (Fig. 7.1), and there was brisk bleeding from the partially ruptured myometrium.
Fig. 7.1
Intraoperative photograph showing molar tissue perforating from the fundus of the uterus
We proceeded with hysterectomy. I presume that it was not perforation at the procedure of evacuation, but the invasion of the myometrium by the molar tissue (confirmed so by histopathology) which caused the weakening, and the brisk bleed got precipitated following the handling during the evacuation procedure. She later required chemotherapy due to persistent trophoblastic disease.
The following case once again makes me wonder why a few women are not fated to have their children. She was a case of the recurrent mole. In the first pregnancy, the mole was evacuated uneventfully, and the follow-up was uneventful. In the second conception after 2 years, she was diagnosed with repeat molar pregnancy. The same was evacuated, but she developed the persistent gestational trophoblastic disease and feature suggestive of an invasive mole in the uterus. She underwent chemotherapy. There was complete clearance with undetectable βhCG levels for nearly 2 years. She attempted pregnancy again. This time, she presented at 10 weeks of pregnancy in shock with haemoperitoneum. Urgent laparotomy confirmed rupture of the uterus with invasive molar tissue. Hysterectomy was carried out. She underwent multidrug chemotherapy (EMA-CO regimen). It has been now two years, and her βhCG levels have been undetectable for the last 6 months.
Bruner and colleagues [2] reported a woman who presented with rupture due to gestational trophoblastic neoplasia 1 month after the evacuation of molar pregnancy. Their patient had only tachycardia. She was neither very pale nor had low blood pressure. The diagnosis was confirmed on contrast CT scan of the pelvis which confirmed blood around the heterogeneous uterus.
Boufettal and Samouh [1] reported a multigravida admitted in haemorrhagic shock due to rupture of uterus filled with molar pregnancy. Sánchez-Ferrer and colleagues [5] reported another interesting case of complete hydatidiform with twin live foetus. Histopathology and other techniques proved it. Since the twin foetus was alive and morphologically normal and had a normal karyotype, so the pregnancy was opted to be continued after counselling. However, she had rupture of the uterus at 15 weeks of pregnancy requiring a hysterectomy. She later required chemotherapy for the persistent trophoblastic disease. In yet another case reported by Ozdemir et al. [4], the woman presented with features of rupture due to placenta percreta at 21 weeks. She had two previous molar pregnancies for which suction evacuation and curettage had been done. The rupture was managed by suturing with two layers. The abnormal placentation in the index pregnancy could be due to the curettage or may be due to the gestational trophoblastic disease causing weakening of the myometrium.
Kaczmarek and co-authors [3] reported intrapartum rupture and foetal death in a woman who had been earlier treated with chemotherapy for gestational trophoblastic neoplasia with chemotherapy. Though this case has been reported nearly 20 years back, it is worth mentioning for the rarity and for bringing out the need for vigilance in such cases during subsequent pregnancies.
Thus, one has to be vigilant about ruptured uterus in a woman with an ongoing invasive mole as well as a woman who has had a previous gestational trophoblastic disease where the invading molar tissue might have weakened the uterus and can rupture in subsequent pregnancy and labour.
References
1.
Boufettal H, Samouh N. Uterine rupture during a hydatidiform mole. Pan Afr Med J. 2014;18:293. doi:10.11604/pamj.2014.18.293.5055. 14. French.PubMedPubMedCentral
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Bruner DI, Pritchard AM, Clarke J. Uterine rupture due to the invasive metastatic gestational trophoblastic neoplasm. West J Emerg Med. 2013;14(5):444–7. doi:10.5811/westjem.2013.4.15868.CrossRefPubMedPubMedCentral
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Kaczmarek JC, Kates R, Rau F, Kohorn E, Curry S. Intrapartum uterine rupture in a primiparous patient previously treated for invasive mole. Obstet Gynecol. 1994;83(5 Pt 2):842–4.PubMed
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Ozdemir A, Ertas IE, Gungorduk K, Kaya C, Solmaz U, Yildirim G. Uterine preservation in placenta percreta complicated by unscarred uterine rupture at the second trimester in a patient with repeated molar pregnancies: a case report and brief review of the literature. Clin Exp Obstet Gynecol. 2014;41(5):590–2 ISSN: 0390–6663.PubMed
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Sánchez-Ferrer ML, Hernández-Martínez F, Machado-Linde F, Ferri B, Carbonel P, Nieto-Diaz A. Uterine rupture in twin pregnancy with normal fetus and complete hydatidiform mole. Gynecol Obstet Invest. 2014;77(2):127–33. doi:10.1159/000355566. Epub 2013 Oct 17.CrossRefPubMed