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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 107-109

Partial molar pregnancy at uncommon site as intramural molar ectopic pregnancy


Department of Pathology, Apollo Hospitals, Bilaspur, Chhattisgarh, India

Date of Web Publication5-Jul-2018

Correspondence Address:
Vandana Gite
Department of Pathology, Apollo Hospitals, Bilaspur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_28_18

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  Abstract 


Intramural partial molar ectopic pregnancy is among the rarest sites of molar changes, may mimic intramural myoma and seriously threaten maternal life. The diagnosis and treatment of this unusual site molar ectopic pregnancy present a clinical challenge. We report the case of a partial molar intramural ectopic pregnancy in a 44-year-old patient presented with multiple intramural myoma and confirmed on final histopathology examination.

Keywords: Intramural, partial mole, ectopic pregnancy, myoma


How to cite this article:
Gite V, Dhakane M. Partial molar pregnancy at uncommon site as intramural molar ectopic pregnancy. Apollo Med 2018;15:107-9

How to cite this URL:
Gite V, Dhakane M. Partial molar pregnancy at uncommon site as intramural molar ectopic pregnancy. Apollo Med [serial online] 2018 [cited 2022 May 22];15:107-9. Available from: https://www.apollomedicine.org/text.asp?2018/15/2/107/235995


  Introduction Top


Molar changes can occur at any site of an ectopic pregnancy. Intramural partial molar ectopic pregnancy is among the rarest sites of molar changes and consequently not often considered as a diagnostic possibility. The condition remains unknown to many clinicians and sonographers. Due to the adverse outcome that can occur, it is vital that it should be diagnosed as early as possible. It may mimic intramural myoma and seriously threaten maternal life. The diagnosis and treatment of this unusual site molar ectopic pregnancy present a clinical challenge. With the ever-increasing use of high-resolution ultrasound (USG) scanning, early diagnosis of the condition is now possible, provided that the condition is thought of.


  Case Report Top


A 44-year-old female was presented with lower abdominal pain and bleeding per vaginum and amenorrhea. Vaginal examination revealed enlarged uterus and slightly tender on movement. Transabdominal USG showed multiple enlarged uterus intramural fibroids and a large submucosal fibroid projecting into the endometrial cavity.

We received subtotal hysterectomy specimen measuring 9.5 cm × 9.0 cm × 5.0 cm along with the right and left  Fallopian tube More Details segment. On cut opening, endometrial cavity was identified with thickened endometrium. A gestational sac measuring 3.5 cm in diameter with fetus measuring 2.5 cm × 1.0 × cm × 1.0 cm [Figure 1] along with enlarged edematous villi invading the myometrium was identified along the left intramural portion. Myometrium also revealed multiple submucosal, intramural, and subserosal solid, whorled nodule with focal trabeculated areas. Subsequent microscopic examination [Figure 2]a and [Figure 2]b confirmed the intramural molar ectopic pregnancy suggestive of partial hydatidiform mole with fetal parts and exaggerated placental site reaction involving the myometrium along with leiomyomatosis and adenomyosis. Endometrium revealed irregular dilated secretory glands with Arias–Stella reaction and decidualized stroma.
Figure 1: Gross showing gestational sac measuring 3.5 cm in diameter with fetus measuring 2.5 cm × 1.0 cm × 1.0 cm along left intramural portion

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Figure 2: (a-c) Microscopically seen are enlarged oedematous villi invading the myometrium and trophoblastic proliferation

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  Discussion Top


Intramural molar pregnancy itself is a very rare condition and a challenging diagnosis to make. Few reported cases of molar changes in intramural pregnancy are also found in the literature.[1] Molar changes may even be found at any other site of an ectopic pregnancy such as tubal, corneal, cervical cesarean section scar, ovarian, and abdominal and carries a high risk of rupture with uncontrollable hemorrhage.[2] Its incidence increases at the extremes of reproductive age, with teenagers and perimenopausal women being most at risk.[3] Characteristically, women older than 35 years of age have a relative risk of 2.0, and women over 40 years of age have a 5–10-fold increase.[4]

Intramural implantation of molar ectopic pregnancy is among the rarest sites and is due to abnormal gametogenesis and fertilization. Intramural molar pregnancy was not initially suspected in our patient, and the condition was confused with degenerated fibroid. It can be also confused with pregnancy in a sacculation, diverticulum, or congenital uterine anomaly.[5] Its etiology remains unclear. Many hypotheses have been proposed to account for this lesion, including cesarean section,[6] microscopic sinus tracts associated with adenomyosis,[7],[8] invasion of the uterine wall by placenta accreta and subsequent growth of the fetus deep within the myometrium,in vitro fertilization and embryo transfer,[9],[10] or seral implantation of conceptus after external migration.[11] In our patient, the only identifiable risk factor was a previous dilation and curettage.

Accurate diagnosis of intramural molar ectopic pregnancy relies on a high index of suspicion as well as the availability of high-resolution transvaginal sonography, which allows accurate assessment of the location, gestational age, size, and viability of an ectopic pregnancy. Magnetic resonance imaging is also helpful in localizing the lesion. Detection rates are higher for complete compared to partial moles.[12] Histopathological examinations can determine the final diagnosis and requires that the gestational sac is located within the uterine wall, completely surrounded by myometrium and separated from the uterine cavity and fallopian tubes with strict criteria regarding morphologic abnormalities of molar pregnancy.

Treatment depends on when it is diagnosed. Patients with a history of previous uterine trauma should be observed closely. However, spontaneous can occur without any previous uterine surgery or intrauterine manipulation. Early diagnosis can prevent a life-threatening situation. Conservation of reproductive function with guided suction evacuation of the uterus and systemic neoadjuvant methotrexate chemotherapy is possible.[1] With uterine rupture, emergency hysterectomy is often necessary.[9] If discovered before rupture, conservative management can be considered, including surgical enucleation, injection of potassium chloride into the gestation, or systemic or local methotrexate injection.[9] Monitoring β-human chorionic gonadotropin titers is important, not only to diagnose persistent ectopic gestation but also to rule out the presence of malignant trophoblastic diseases.[13]

In general, after treatment for any molar pregnancy, patients should be advised to delay a new pregnancy as conception occurring too early could complicate the serologic picture or interfere with the spontaneous regression of any residual trophoblast.


  Conclusion Top


Intramural molar pregnancy itself is a very rare condition and can be confused with degenerated fibroid, pregnancy in a sacculation, diverticulum, or congenital uterine anomaly. Early diagnosis can prevent a life-threatening situation and conserve reproductive function. High-resolution transvaginal sonography or magnetic resonance imaging with histopathological examination of the conception products is the current gold standard for the diagnosis. The management varies depending on the type of intramural pregnancy, the gestational age, and severity of symptoms at presentation.

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.
Bhatia K, Bentick B. Intramural molar pregnancy: A case report. J Reprod Med 2004;49:689-92.  Back to cited text no. 1
[PUBMED]    
2.
Wu CF, Hsu CY, Chen CP. Ectopic molar pregnancy in a cesarean scar. Taiwan J Obstet Gynecol 2006;45:343-5.  Back to cited text no. 2
[PUBMED]    
3.
Bandy LC, Clarke-Pearson DL, Hammond CB. Malignant potential of gestational trophoblastic disease at the extreme ages of reproductive life. Obstet Gynecol 1984;64:395-9.  Back to cited text no. 3
[PUBMED]    
4.
Palmer JR. Advances in the epidemiology of gestational trophoblastic disease. J Reprod Med 1994;39:155-62.  Back to cited text no. 4
    
5.
Ong C, Su LL, Chia D, Choolani M, Biswas A. Sonographic diagnosis and successful medical management of an intramural ectopic pregnancy. J Clin Ultrasound 2010;38:320-4.  Back to cited text no. 5
    
6.
Ko JK, Wan HL, Ngu SF, Cheung VY, Ng EH. Cesarean scar molar pregnancy. Obstet Gynecol 2012;119:449-51.  Back to cited text no. 6
    
7.
Ginsburg KA, Quereshi F, Thomas M, Snowman B. Intramural ectopic pregnancy implanting in adenomyosis. Fertil Steril 1989;51:354-6.  Back to cited text no. 7
    
8.
Karakök M, Balat O, Sari I, Kocer NE, Erdogan R. Early diagnosed intramural ectopic pregnancy associated with adenomyosis: Report of an unusual case. Clin Exp Obstet Gynecol 2002;29:217-8.  Back to cited text no. 8
    
9.
Wang S, Dong Y, Meng X. Intramural ectopic pregnancy: Treatment using uterine artery embolization. J Minim Invasive Gynecol 2013;20:241-3.  Back to cited text no. 9
    
10.
Choi DH, Kwon H, Kim YS, Kim JH. Intramural pregnancy associated with adenomyosis after in vitro fertilization and embryo transfer: A case report. J Reprod Med 2009;54:255-8.  Back to cited text no. 10
    
11.
Hsieh YY, Chang CC, Tsai HD, Yeh LS, Hsu TY, Yang TC, et al. Intramural pregnancy with negative maternal serum beta-hCG. A case report. J Reprod Med 1998;43:468-70.  Back to cited text no. 11
    
12.
Fowler DJ, Lindsay I, Seckl MJ, Sebire NJ. Routine pre-evacuation ultrasound diagnosis of hydatidiform mole: Experience of more than 1000 cases from a regional referral center. Ultrasound Obstet Gynecol 2006;27:56-60.  Back to cited text no. 12
    
13.
Rotas M, Khulpateea N, Binder D. Gestational choriocarcinoma arising from a cornual ectopic pregnancy: A case report and review of the literature. Arch Gynecol Obstet 2007;276:645-7.  Back to cited text no. 13
    


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