A case of complete hydatidiform mole co-existing with a twin pregnancy after intra-uterine insemination

Objective

The aim of this study is to discuss the management of complete hydatidiform mole co-existing with a twin pregnancy after intra-uterine insemination which is clinically quite rare.

Case 

A 33-year-old, gravida 1 para 0 woman presented to our clinic; pregnancy following the intra-uterine insemination in another medical center with echogenic mass ultrasound finding which is more appropriate for mole hydatidiform. The first trimester ultrasound examination revealed a normal fetus and a large cystic echogenic mass in the uterine wall near the placenta. Fetal biometry was compatible with 12 weeks gestation and the echogenic cystic mass size was 4x5 cm at front of the uterine wall. The patient was asymptomatic. Her quantitative serum human chorionic gonadotropin was 1191602 mIU/ ml. After the two days, the control measurement of serum β-hCG was 911901 mIU/ml. The chest X-ray was evaluated normal. In magnetic resonance imaging, in the uterine cavity there were two gestational sac and a one live fetus with multicystic echogenic mass was demonstrated. Trophoblastic invasion was not differentiated in the MRI. No other pathology was observed radiologically in the other systems. At the perinatalogy council the patient was evaluated accompanied these findings and the pregnancy termination was decided. After the family’s approval, the pregnancy was terminated with dilatation and evacuation. The pathologic material’s volume had 600 cc which contained chorionic villi,desidua and gestational endometrium. The analysis of the vesicular tissue demonstrated a diploid (46XX) karyotype consistent with a complete mole. In postoperative period two weeks later, β-hCG measurement was 250 mIU/ml and 6 weeks later from the operation b-hCG level was 30 mIU/ml.

Conclusion

Today in the early period diagnosing the hydatidiform mole co-existing with a twin pregnancy is important. The ultrasound examination is preferred mostly. The continuation of pregnancy, there are also some maternal risks increased such as persistent trophoblastic disease, preeclampsia, spontaneous abortion or premature birth. The risk for persistent gestational trophoblastic disease of twin pregnancy with partial hydatidiform mole and complete hydatidiform mole has been reported to be 4-14 and 20%. In our case, she had a primary infertility diagnosis during the four years and we considered the maternal health firstly, decided to terminate pregnancy appropriately with the low risk of complication. The final pathologic diagnosis was a twin pregnancy with a complete mole. Approaching to the these patients in the postoperative period has not certain yet in the literaure. However Wee and Jauniaux recommend that an ultrasound examination and measure the  β-hCG level should be repeated twice a month.
The management and the pregnancy termination of this rare case should be planned at the tertiary treatment centres.

Keywords

Complete hydatidiform mole, twin pregnancy, termination.