///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Hydatidiform Mole with Co-Existing Live Fetus: A Case of Suspected Peripartum Emboli During Cesarean Section

Abstract Number: FCB-74
Abstract Type: Case Report Case Series

Sarah Rose Hall M.D.1 ; Jessica N Rock M.D.2; Elizabeth Ellinas M.D.3

Case:

A 27-year-old G4P2103 with a history of three prior cesarean sections (CS) had two early pregnancy ultrasounds (US) showing a singleton pregnancy. At 16 weeks gestation, vaginal bleeding (VB) prompted an addition US, showing a cystic molar mass sharing the same sac with a normally growing fetus, suspicious for a complete molar pregnancy with a coexisting viable fetus (CHMCF). Except for abnormally high hCG, chest X-ray and labs were normal. She declined an offer of pregnancy termination. Her antepartum course was notable for multiple episodes of VB occurring between 23-27 weeks gestation.

A repeat CS at 34 weeks and 1 day was performed with a single-shot spinal anesthetic technique. A 2150 g neonate with Apgars 9 and 9 was delivered 11 minutes after incision. During delivery of the placenta, copious amounts of hydropic villi were evacuated from the uterus. At 2-3 minutes and at 25 minutes after delivery, the patient complained of shortness of breath and difficulty speaking, followed by mild hypoxemia, hypotension, and tachycardia. Supportive management (not requiring intubation) ensued and her symptoms and vitals improved. Postoperatively, the patient stated her symptoms occurred abruptly and felt as though she could not speak, her “teeth hurt, and [her] whole body felt pressurized.”

Discussion:

CHMCF is extremely rare, with an estimated incidence of one in 22,000-100,000. In addition to an increased risk for maternal complications (preeclampsia, hyperthyroidism, hemorrhage), only 40-60% result in live births. Increased hCG levels are associated with poorer fetal outcomes and gestational trophoblastic neoplasia. It is unknown whether higher hCG is associated with maternal intrapartum embolic events. Self-limited, acute maternal respiratory distress arises in 3%-10% of molar pregnancies at the time of uterine evacuation. In a multicenter cohort of 72 cases of CHMCF, the only maternal death was caused by acute respiratory insufficiency during medical termination of pregnancy due to severe preeclampsia. There was a high suspicion for peripartum emboli—either amniotic fluid embolism (AFE) or trophoblastic embolism (TPE)—in our case. Most TPE happens in gestational trophoblastic disease, during CS or curettage. Like AFE, TPE is characterized by hypoxia, hypotension, and coagulopathy; treatment is supportive.

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Linn L, et al. Multiple pregnancies with CHMCF in N. and S. America: A retrospective multicenter cohort and literature review. Gynecol Oncology 2017; 145:88-95

Suksai M, et al. CHMCF: Predictors of live birth. Eur J OB Gyn and Repro Bio 2017; 212:1-8

Tews G, et al. Fatal trophoblastic embolism during cesarean section. Int J Gynaecol Obstet 2002; 76(2):179-80

Wang Q, et al. Acute trophoblastic PE during conservative treatment of placenta accreta: Case report & review of literature. Eur J Med Res 2015; 20:91

SOAP 2019