Introduction
Ectopic pregnancy is a major cause of maternal morbidity, particularly when associated with rare conditions such as complete hydatidiform mole. This type of pregnancy poses a significant challenge to clinicians, requiring a deep understanding of pathological changes and abnormal physiological responses.(1) The occurrence of molar pregnancy in an ectopic site is extremely rare, with an estimated incidence of approximately 1.5 cases per million pregnancies and only 132 cases documented worldwide. This rarity underscores the need for thorough investigation and precise data collection to develop effective management strategies.(2)
These cases present complex diagnostic and therapeutic challenges due to the clinical overlap with other forms of ectopic pregnancies and the risk of severe complications, such as massive hemorrhage. This report presents a unique case of a complete hydatidiform mole in a tubal ectopic pregnancy, detailing the clinical progression, management approach, and the importance of intensive follow-up. The report also highlights the significance of early intervention and the role of multidisciplinary teamwork in ensuring optimal patient outcomes.(3)
Case Presentation
Patient Data
- Age: 28 years, female.
- Obstetric history: G3P3A0 (three pregnancies, three deliveries, no miscarriages).
- Presenting symptoms: Lower abdominal pain, light vaginal bleeding, and secondary amenorrhea.
Clinical Findings
- Blood pressure: Low (80/50 mmHg).
- Heart rate: Tachycardia (120 beats/min).
- Consciousness: The patient was alert and oriented.
Physical Examination
- Pelvic exam: Severe tenderness upon palpation in the pelvic area.
- Transvaginal ultrasound: Revealed an empty uterus, normal ovaries, and a 5-cm mass near the uterine fundus with a typical “snowstorm” appearance.(4)
- Free fluid: Presence of free fluid in the pouch of Douglas.
- β-hCG level: Elevated (10,350 IU/L).
Surgical and Therapeutic Management
Given the clinical suspicion of a ruptured ectopic pregnancy, emergency laparotomy was performed.
Intraoperative Findings
- Hemorrhage: Approximately 1.5 liters of clotted blood in the abdominal cavity.
- Mass: A vascular bleeding mass measuring 4–6 cm in the upper right uterine segment.
- Surgical intervention: Right salpingectomy along with removal of the affected segment of the uterus.
- Abdominal cavity: The cavity was thoroughly irrigated, and a drain was placed in the pouch of Douglas to prevent future infections.
- Blood transfusion: The patient received three units of blood (two intraoperatively and one six hours postoperatively) to compensate for blood loss and stabilize her condition.
Postoperative Follow-Up
Histopathological examination confirmed a complete hydatidiform mole at the ectopic site. The patient recovered quickly and was discharged after two days in good general condition.
Postoperative Findings
- β-hCG levels: Gradually decreased to 20 IU/L, along with the presence of a 5-cm lutein cyst in the left ovary, indicating regression without further complications.
- Follow-up plan: Weekly β-hCG monitoring until normalization, with emphasis on strict compliance to avoid recurrence or progression.
- Patient counseling: Advised to avoid pregnancy for at least six months to ensure stability and complete resolution of molar tissue.
Psychosocial Support
- Psychological care: Referred to a counselor for support to address potential anxiety and stress associated with this rare and severe condition.
- Family involvement: Educated family members about the patient’s condition to ensure a supportive environment during recovery.
Discussion
This case highlights the rarity of complete hydatidiform mole in a tubal ectopic pregnancy and the associated diagnostic and therapeutic challenges.
Pathophysiology and Diagnosis
A complete hydatidiform mole arises from abnormal trophoblastic cell proliferation with paternal genomic origin, a rare phenomenon in ectopic pregnancies. The diagnosis is particularly challenging due to significant clinical overlap between ectopic pregnancy and molar pregnancy. In this case, the typical ultrasound findings and elevated β-hCG levels played a crucial role in guiding prompt diagnosis and intervention.
Role of Ultrasound in Diagnosis
The “snowstorm” appearance on ultrasound is a hallmark feature of molar pregnancy.(4) This finding greatly reduced the risk of misdiagnosis. Additionally, the markedly elevated β-hCG levels further directed the clinical team toward timely and accurate surgical management.
Management and Treatment
- Surgical intervention: Emergency surgery was crucial to control hemorrhage and remove all trophoblastic tissue, thereby preventing complications such as gestational trophoblastic disease (GTD), which might require chemotherapy if not completely resolved.
- β-hCG monitoring: Weekly follow-up of β-hCG levels is critical to detect potential GTD and ensure complete recovery.
Preventive Measures and Long-term Follow-Up
- Future pregnancies: Avoidance of pregnancy for 6–12 months is essential to prevent complications and ensure complete resolution of molar tissue.
- Psychosocial care: Integrating family members into the treatment plan and providing psychological support are vital for comprehensive recovery.
Prognosis and Follow-Up
No evidence of GTD was observed in this case, with a gradual stabilization of β-hCG levels. The patient was advised to avoid pregnancy temporarily to ensure complete recovery.
Conclusion
This rare case underscores the critical importance of early diagnosis and prompt surgical intervention in ectopic pregnancies with complete hydatidiform mole. The case also emphasizes the necessity of meticulous follow-up to ensure full recovery and prevent future complications. Psychological and social support are integral to the holistic care of patients with such rare conditions. Long-term monitoring is essential to rule out recurrence and avoid chemotherapy-requiring complications.
Finally, this case highlights the need for continuous review and improvement of treatment protocols based on emerging data to minimize risks associated with ectopic molar pregnancies.
Acknowledgment:
This case was managed at Al-Noor Specialized Hospital for Maternity and Pediatrics, supported by Relief International. The surgical procedure was performed by Dr. Huda Al-Haj Hamidi, a resident in Obstetrics and Gynecology, under the supervision of specialists Dr. Ahlam Subha and Dr. Faten Tahan.
References
- Management of Gestational Trophoblastic Disease: Green-top Guideline No. 38 – June 2020. Vol. 128, BJOG: An International Journal of Obstetrics and Gynaecology. 2021.
- Athanasiou A, Féki A, Fruscalzo A, Guani B, Ben Ali N. Ruptured ectopic pregnancy as complete hydatidiform mole: Case report and review of the literature. Front Surg. 2022;9.
- Bruce S, Sorosky J. Gestational Trophoblastic Disease [Internet]. StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470267/
- Skandhan AKP. Snowstorm sign (complete hydatiform mole) | Radiology Reference Article | Radiopaedia.org [Internet]. 2023. Available from: https://radiopaedia.org/articles/snowstorm-sign-complete-hydatiform-mole-2