Case+1+Discussion

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Ultrasound description: - Location: uterus - Numerous discrete anechoic (cystic) spaces and central area of heterogeneous echotexture ("snowstorm appearance") - No embryonic or fetal structure. - No amniotic fluid

Dx: Molar Pregnancy (complete) Part of the spectrum of gestational trophoblastic neoplasia, molar pregnancies originate in the placenta and have potential to locally invade the uterus and metastasize. This maternal tumor is unique as it arises from gestational tissue, occurring after an aberrant fertilization. Complete moles are diploid and partial moles are triploid.

Regarding complete moles (as in our case here), they have a higher HCG count as well as higher potential for future malignancy. The marked elevation in HCG results in some of the clinical features such as ovarian enlargement due to multiple theca lutein cysts, hyperemesis gravidarum, early development of pre-eclampsia, and hyperthyroidism.

Interestingly, anecdotally many providers here in sub-Saharan Africa remark they have seen multiple molar pregnancies here. Limited studies do support higher incidence in Africa, as well as large scale studies demonstrating higher incidence in African-American women. Risk factors appear to be extremes of maternal Age ( 35, as in our case).

Vaginal bleeding, pelvic pressure, enlarged uterus (50% of cases of complete mole) are common presentations. If early pregnancy dating was more accessible here it would have been clear from an early stage that size was much larger than dates. Similarly, if we had access to quantitative HCG reports, we likely would have been tipped off by HCG > 100,000. But we do not have access to these diagnostcs, and therefore have to rely on the ultrasound as above.

Management:
 * Dilation and Curettage ** . Or just curettage evidently in the past as we have shockingly just received the first 5 sets of dilators this week as donation. We send all specimens down the hill to the central hospital for pathologic processing. Don’t forget anti-D immune globulin for those Rh-neg women.

But this is the easy part. Family medicine is all about the follow-up and in sub-Saharan Africa with no HCG quants this is a little tricky. In the US its been demonstrated that poor women have worse outcomes (higher rates of GTN) due to difficulties with follow-up.

ACOG recommends ** serial HCGs ** qweek until negative x 3, then q month x 6 months. Where we have no quants, a modified approach is necessary. Qual tests will be measured weekly (good ol fashioned urine dips) weekly until neg x 3 weeks with a q monthly quant sample that will be sent to the central laboratory. In the interim, ** contraception ** is critical so as not to confuse the picture with a possible subsequent pregnancy.

Prognostically 15-20 percent of complete mole pregnancies can be expected to go on to develop a form of GTN. Given the high rates, the importance of follow-up cannot be understated as earlier diagnosis of GTN is associated with improved outcomes. The village health worker (VHW) role in the community is crucial in such cases to accompany patients to their follow-up.

Lastly, it should be included the diagnosis of GTN: HCG levels plateu over 3 week period, HCG levels increased by >10% over 2 week period, or persistence of detectable HCG 6 months after D and C.