Reporte de un caso: embarazo gemelar con un feto vivo y mola completa / Case report: twin pregnancy with a live fetus and complete mole

RESUMEN La coexistencia de una mola completa y un feto vivo es una condición infrecuente que puede evolucionar con múltiples complicaciones tanto maternas como fetales; entre ellas aborto, preeclampsia, hipertiroidismo, metrorragia, parto pretérmino y enfermedad trofoblástica gestacional persistente. No existe consenso internacional respecto al manejo de esta condición, aun conociéndose el mal pronóstico para el feto y los elevados riesgos maternos asociados. El siguiente es un reporte de un caso clínico de embarazo gemelar con feto vivo y mola completa, diagnosticado a las 12+1 semanas. Luego de realizar consejería, y en contexto de la legislación chilena en el año 2015, se decide continuar con el embarazo. La paciente es monitorizada en policlínico de alto riesgo obstétrico con controles seriados de b-HCG, ecografía fetal y RNM pélvica. Desde las 13 semanas presenta hipertensión arterial que se maneja con antihipertensivos orales; posteriormente, a las 20+2 semanas, desarrolla un cuadro de preeclampsia severa por lo que, en conjunto con la paciente, se decide realizar histerectomía en bloque. Dada la persistencia de valores de b-HCG elevados a las 12 semanas post interrupción del embarazo, se decide tratamiento con metotrexato. El caso fue analizado en Comité de Ginecología Oncológica donde se decidió seguimiento con b-HCG, lográndose la negativización a las 38 semanas post metotrexato. Se confirmaron valores negativos de b-HCG por 6 meses, tras lo cual fue dada de alta.

ABSTRACT The coexistence of a complete mole and an alive fetus is a rare condition that can evolve with multiple complications both maternal and fetal; among them abortion, preeclampsia, hyperthyroidism, uterine bleeding, preterm labor and persistent gestational trophoblastic disease. There is no international consensus regarding the management of this condition, despite the poor prognosis for the fetus and the associated high maternal risks. The following is a report of a clinical case of twin pregnancy with live fetus and complete mole, diagnosed at 12+1 weeks. After counseling, and in the context of Chilean legislation in 2015, it is decided to continue with pregnancy. The patient is monitored in a high-risk pregnancy outpatient clinic with follow ups b-HCG, fetal ultrasound and pelvic MRI. From 13 weeks, the patient presents high blood pressure that is managed with oral antihypertensives; and later, with 20+2 weeks, developed severe preeclampsia which is why, in conjunction with patient, it was decided to perform a block hysterectomy. Given the persistence of elevated b-HCG values at 12 weeks post-termination of pregnancy, treatment with methotrexate was decided. The case was analyzed in the local Committee of Oncological Gynecology, in which it was decided to follow the b-HCG curve, achieving negative values at 38 weeks post-methotrexate. Negative values of b-HCG were confirmed for 6 months, after which it was discharged.

Mola hidatiforme como manifestación ginecobstétrica en el curso de las enfermedades reumáticas / Hydatiform mole as a gynecological manifestation in the course of rheumatic diseases

Las enfermedades reumáticas pertenecen a un grupo que provocan manifestaciones clínicas en varios sistemas de órganos de la anatomía humana. Las complicaciones ginecobstétricas no son las que con mayor frecuencia se presentan. La enfermedad trofoblástica gestacional agrupa un conjunto de lesiones benignas como la mola hidatiforme y la neoplasia trofoblástica gestacional. Este trabajo se propone presentar un caso con los elementos clínicos e imagenológicos que permiten llegar al diagnóstico de una mola hidatiforme. Se trata de una paciente de 48 años de edad, con diagnóstico de lupus eritematoso sistémico, que acude con manifestaciones clínicas que permitieron llegar al diagnóstico de enfermedad trofoblástica gestacional con mola hidatiforme completa. Las enfermedades reumáticas, en especial el lupus eritematoso sistémico, provocan complicaciones ginecobstétricas. La enfermedad trofoblástica gestacional con mola hidatiforme completa, a pesar de ser una rara entidad, afecta considerablemente el bienestar biopsicosocial de las pacientes y disminuye su percepción de calidad de vida relacionada con la salud(AU)

Rheumatic diseases fit in a group that cause clinical manifestations in various organ systems of the human anatomy. Gyneco-obstetric complications are those that occur less frequently. Gestational trophoblastic disease groups together benign lesions such as hydatidiform mole and gestational trophoblastic neoplasia. This paper intends to present a case with the clinical and imaging elements that allow the diagnosis of hydatidiform mole. We present a 48-year-old female patient with a diagnosis of systemic lupus erythematosus, who presents with clinical manifestations that led to the diagnosis of gestational trophoblastic disease with complete hydatidiform mole. Rheumatic diseases, especially systemic lupus erythematosus, cause gyneco-obstetric complications. Although being a rare entity, the gestational trophoblastic disease with complete hydatidiform mole greatly affects the biopsychosocial wellbeing of patients and decreases their perception of health-related quality of life(AU)

Eclampsia como manifestación clínica de enfermedad trofoblástica gestacional: reporte de caso / Eclampsia as clinical presentation of gestational trophoblastic disease: case report

Introducción: La eclampsia es una complicación severa y poco frecuente del embarazo, apareciendo generalmente luego de las 34 semanas de edad gestacional. El diagnóstico de preeclampsia antes de las 20 semanas de edad gestacional se asocia con patología del trofoblasto. Presentación del caso: Paciente femenina de 18 años, 3 embarazos, 0 partos, 2 abortos, cursando embarazo de 14 semanas de edad gestacional, consulta por haber presentado síndrome convulsivo con crisis generalizadas de tipo tónico-clónicas y amaurosis posterior. Se sospecha síndrome de hipertensión endocraneana y se solicita resonancia magnética de encéfalo, que muestra múltiples lesiones córtico-subcorticales, sugiriendo síndrome de encefalopatía posterior reversible. Una ecografía obstétrica informa placenta aumentada de tamaño con múltiples imágenes econegativas con aspecto de panal de abeja, oligohidroamnios y feto con latidos positivos, sin anomalías anatómicas. La gonadotrofina coriónica humana fue de 11538440 U/L. Evoluciona con compromiso de conciencia y tres episodios de convulsión generalizada de tipo tónico-clónica con mala respuesta a diazepam y adecuada respuesta a sulfato de magnesio. Se pesquisa crisis hipertensiva y proteinuria de 24 horas de 8 gramos. Se decide interrupción del embarazo y manejo en Unidad de Paciente Crítico. Legrado aspirativo sin incidentes. La biopsia indica mola hidatidiforme parcial con feto sin malformaciones externas. Evolución favorable con negativización de gonadotrofina coriónica humana en controles posteriores. Discusión: El desarrollo de eclampsia antes de las 20 semanas es anecdótico con pocos casos reportados y su aparición debe hacer sospechar una patología del trofoblasto.

Introduction: Preeclampsia is a severe complication of pregnancy, usually appearing after 34 weeks of gestational age. The diagnosis of preeclampsia before 20 weeks of gestational age is associated with trophoblastic disease. Case report: Female patient, 18 years old, 3 pregnancies, 0 deliveries, 2 abortions, 14 weeks pregnant. Presents with generalized tonicclonic seizures and amaurosis. Clinical evaluation compatible with intracranial hypertension síndrome and magnetic resonance imaging of the brain is requested, showing multiple cortico-subcortical lesions, suggesting posterior reversible encephalopathy syndrome. Ultrasound evaluation informs increased size placenta, multiple echo-negativa images with honeycomb disposition, oligohydramnios and present fetal heartbeats. No fetal anatomic abnormalities. Human chorionic gonadotrophin level was 11538440 U/L. Clinical presentation evolves with impaired conscousness and three generalized tonic-clonic crisis, showing poor response to intravenous diazepam and appropriate response to magnesium sulfate. Hypertensive crisis develops and the result of 24 hour proteinuria is 8 grams. Due to mater nal risk pregnancy was interrupted and uterine aspirage was performed. Patient was managed in the Intensive Care Unit. Biopsy informed partial hydatidiform mole and fetus with no anatomical abnormalities. Clinical evolution was positive and human chorionic gonadotrophin level below detection during follow-up. Discussion: Development of eclapsia before 20 weeks of gestational age is anecdotal with few reported cases and could be indicative of gestational trophoblastic disease.

Mola invasiva / Invasive mole

La mola invasiva es poco frecuente y se caracteriza por la excesiva proliferación trofoblástica y penetración del trofoblasto dentro del miometrio, pero sin tendencia hacia la diseminación metastásica. El objetivo del trabajo es presentar un caso diagnosticado de neoplasia trofoblástica gestacional, tipo mola invasiva. Se realizaron estudios complementarios como: ecografía transabdominal, determinaciones de la fracción beta de la gonadotropina coriónica humana y una biopsia endometrial por legrado uterino. El resultado fue embarazo molar. Al ingreso le fue administrado metotrexato sistémico 25 mg intramuscular y ácido folínico un ámpula intramuscular de 15 mg diariamente, ambos durante cinco días. Posteriormente, a los 20 días se realizó histerectomía total abdominal sin anexectomía. La evolución clínica fue por consulta externa. Además, se realizó: radiografía de tórax, ultrasonografía de pelvis, dosificación de gonadotropina coriónica humana en su fracción beta, hemograma completo, tiempo de coagulación, sangramiento y transaminasa glutámico pirúvica evolutivas. En el manejo de la mola invasiva el tratamiento médico combinado con el quirúrgico fue efectivo y bien tolerado por la paciente.

Invasive mole is an infrequent condition characterized by excessive trophoblastic proliferation and trophoblast penetration into the myometrium, without a tendency to metastatic dissemination. The purpose of the study is to present a case diagnosed with gestational trophoblastic neoplasia of the invasive mole type. The following complementary tests were performed: transabdominal echography, human chorionic gonadotropin beta subunit determinations, and endometrial biopsy by uterine curettage. The result was molar pregnancy. Upon admission the patient was administered systemic methotrexate 25 mg intramuscularly, as well as an intramuscular ampoule of folinic acid 15 mg daily, both during five days. Total abdominal hysterectomy without anexectomy was performed 20 days later. Clinical evolution was followed up on an outpatient basis. The following tests were also performed: chest radiography, pelvic ultrasonography, human chorionic gonadotropin beta dosage, complete blood count, clotting time, bleeding and evolutive glutamic-pyruvic transaminase. During management of the invasive mole, the combination of clinical and surgical treatments proved effective and was well assimilated by the patient.

Complicações clínicas da gravidez molar / Clinical complications of hydatidiform mole

A gravidez molar, espectro benigno da doença trofoblástica gestacional, representa uma complicação obstétrica da primeira metade da gestação. De maneira geral, cursa com sintomatologia exuberante: hemorragia, útero aumento para a idade gestacional, cistose ovariana e pré-eclâmpsia precoce; chegando mesmo a graves situações clínicas de hipertireoidismo e insuficiência respiratória.Todavia, devido ao diagnóstico precoce da mola hidatiforme, ainda no primeiro trimestre, mercê da ultrassonografia, houve uma importante redução na ocorrência desses sintomas; contribuindo para que a condução desses casos excepcionais ficasse confinada aos Centros de Referência. É objetivo desse artigo apresentar ao obstetra brasileiro uma revisão das complicações clínicas da gravidez molar, atualizando-o no diagnóstico precoce e tratamento dessas condições clínicas que podem ser potencialmente ameaçadoras à vida da gestante e de seu concepto.(AU)

The molar pregnancy, in the benign gestational trophoblastic disease spectrum, represents an obstetric complication of first half of gestation. In general, runs with exuberant symptoms: bleeding, uterus increase for gestational age, ovarian cistose and early preeclampsia; even serious clinical situations of hyperthyroidism and respiratory failure. However, due to the early diagnosis of hydatidiform mole, still in the first trimester, through ultrasound, there was a significant reduction in the occurrence of these symptoms; contributing so that the conduct of these exceptional cases could be confined to the centers of reference. The purpose of this article is to present to the Brazilian obstetrician a review of clinical complications of molar pregnancy, updating it in the early diagnosis and treatment of clinical conditions that can be potentially threatening to the life of the pregnant woman and her fetus.(AU)

value of ultrasonography and serial B. HCG assay in the selection of cases of complete molar pregnancy for chemotherapy

This study included fifty-five patients with complete hydatidiform mole aiming to assess the value of U/S, transabdominal [TAS], transvaginal [TVS] and serial B HCG assay in the selection of cases of complete hydatidiform mole for the use of chemotherapy. All patients were diagnosed by ultrasonography and B HCG assay and managed by suction evacuation under continuous ultrasonic monitoring and then were followed up with serial B HCG assay and ultrasonography. The results concluded that the use of ultrasound, B HCG assay in conjunction with suction evacuation under continues US monitoring in the management of complete molar pregnancy is invaluable to select cases of persistent gestational trophoblastic disease for chemotherapy and helps together with careful follow up to give the standard care in such cases

Partial hydatidiform mole. a review of eight cases

This is a review of 8 cases of partial moles in Mosul, from 1979 to 1983. The 8 patients had partial moles associated with recent or prolonged intrauterine fetal death. They were diagnosed as missed abortion in 7 patients and as antepartum hemorrhage in 1. However, the final diagnosis was made macroscopically after spontaneous or operative evacuation of the uterus. The incidence of partial mole among complete hydatidiform moles was 5. 8% with a ratio of 1:17. Neither the clinical examination nor ultrasonography was helpful in the diagnosis of partial mole before evacuation of the uterus