Journal of Medical Education & Research, Vol. 3, No.

2, July-Dec 2013

ISSN 2249-9660

Case Report

Invasive Mole
Amol M Valvi1, and Chandrakala Patil2 P.G Student1, Professor2, Department of Obstetrics and Gynecology MIMSR Medical College, Latur ___________________________________________________________________________

Abstract
We present the case of invasive mole, presenting as bleeding per vaginum with passing of grape like structure since 2 months. She diagnosed as a vesicular mole on ultrasonography and underwent suction and evacuation then after 8 days again started per-vaginal bleeding. Hysterectomy done confirmed the presence of invasive mole. Material & Method : Clinical data and literature review. Result: Patient was cured of all her symptoms. Conclusion: Surgical therapy (hysterectomy) performed coincident with the institution of the chemotherapy has shown the significantly reduces the duration of hospitalization and amount of chemotherapy used to achieve remission in this case. ___________________________________________________________________________ Key words: Gestational trophoblastic disease (GTD), Gestational trophoblastic neoplasia (GTN), Invasive mole (IM) Suction and evacuation (S&E), Total abdominal hysterectomy (TAH), Urine pregnancy test (UPT).

Introduction
The term gestational trophoblastic disease refers to a sprectum of pregnancy related placental tumor. Gestational trophoblastic disease is divided into molar and non-molar tumor. Address for correspondence: DR. AMOL M. VALVI, P.G Student, Department of Obstetrics and Gynecology MIMSR Medical College, Latur amol.valvi@yahoo.com Mob-9423182338
__________________________________________________________________________________ 56

Non-molar tumor are grouped as Gestational trophoblastic neaoplasia (GTN) (1). GTN are classified histologically into three distinct subgroups;choriocarcinomadestruens

Journal of Medical Education & Research, Vol. 3, No.2, July-Dec 2013 (invasive mole), choriocarcinoma, and placental site trophoblastic tumor (PSST) (2). Invasive mole follows approximately 10-15% of complete hydatiform mole. The prognosis for most cases of GTN characterized by by presence of wide spread of metastasis. IM is common manifestation of GTN characterized by presence of whole chorionic villi that accompany excessive trophoblastic overgrowth and invasion. This tissues penetrate deep into the myometrium sometime involving the peritoneum or vaginal vault. Such moles are locally invasive but generally lack the pronounced tendency to develop widespread metastases typical of choriocarcinoma. IM originates exclusively from complete or partial mole (3).

Valvi A. M. et al

Case Report
A 25yr old married ptP1L1A1 came in OPD with C/O per vaginal bleeding with passage of clots and grape like structre since two months. She visited to private practitioner one month back where they done ultrasonography and diagnosed as vesicular mole, she underwent suction and evacuation procedure. After 8 days of procedure she again started per vaginal bleeding. She came to our hospital, on examination her vitals were stable. On per abdominal examination uterus was just palpable and was corresponding to a gestational age of 12weeks size. On per speculum examination minimal bleeding was present. On bimanual examination uterus was bulky 12 to14 weeks gestation age no adnexal mass palpable. She was admitted

in our hospital, all investigations were done which were normal. Ultrasound done revealed multiple small cystic spaces within endometrium which was suggestive of Hydatiform mole. Serum -hCG done which was markedly raised >2, 00,000mIu/ml. suction and evacuation done again in our hospital but patient again complained of per-vaginal bleeding on day 4 of suction and evacuation. Ultrasound done again which revealed retained product of vesicles for that again S&E with check curettage done on day 7 and after that immediately ultrasound done, revealed heterogenous structure. Histopathological report of S&E came which was suggestive of partial mole. Serum -hCG done again on postoperative day 13 of S&E was 34860mIu/ml. patient discharged then came with follow-up on post-operative day 21 of S&E with serum -hCG 86000mIu/ml. Oncologist opinion taken and patient advised chemotherapy and if not relief then hysterectomy but patient was reluctant to chemotherapy and willing for hysterectomy, so that she again get admitted. Total abdominal hysterectomy with preservation of both ovaries done. Cut section of uterus revealed multiple grape like vesicles invading the endometrium (fig1). Post operatively Inj. Methotrexate 1mg/kg/day im is given on days 1, 3, 5, 7 four doses alternate day with inj. Folinic acid 0.1mg/kg im four doses on days 2, 4, 6, 8. Serum -hCG done on post-operative day 6 of total abdominal hysterectomy was 20889mIm/ml. histopathological examination report of uterus came which was suggestive of Invasive mole. Patient discharged on post operative day 9 of

__________________________________________________________________________________ 57

Journal of Medical Education & Research, Vol. 3, No.2, No. July-Dec 2013 3 total abdominal hysterectomy with followup on post operative operative day 13 of TAH with urine pregnancy test (UPT) which was weakly positive. Then again follow-up follow on post-operative operative day 21 of TAH with serum -hCG level 832mIu/ml. Patient again admitted and 2nd cycle of chemotherapy given i.einj methotrexate 1mg/kg/day im with inj. Folinic acid 0.1mg/kg/day alternate days. Patient discharged on post-operative operative day 36 of TAH and then again follow up on post-operative operative day 46 of TAH. UPT done which was weakly positive ve, then next follow-up post-operative operative day 54 of TAH with serum -hCG hCG level 8.29 mIu/ml. then patient followed up monthly for three months. Her serum -hCG hCG level gradually returned back to normal levels (fig 2), at each follow up visit enquired about relevant ant symptoms like irregular vaginal bleeding, persistent cough, breathlessness or hemoptysis. She had no side effects of chemotherapy and adhered to the follow up schedule.

Valvi A. M. et al

Patient cured from all her symptoms.

Fig 1. Cut section of uterus revealing multiple grape like vesicle.

250000 200000 200000 HCG 150000 SUBUNIT S IN 100000 MIU/ML 50000 0

86,000 34,860 20,889

Investigation
Complete hemogram, serum -hCG, pelvic ultrasound, chest x-ray, liver function test, kidney function test, histopathological examination report of suction &evacuation sample and uterus.

832 8.29 HCG SUBUNITS LEVELS GRADUALLY DECLINED

Fig2 Graph of - hCG levels gradually returned ned back to normal levels.

Treatment
Surgical therapy- suction &evacuation, & Total abdominal hysterectomy with bilateral preservation of ovaries. Medical therapy- Inj. Methotrexate 1mg/kg/day im alternate day with inj. Folinic acid 0.1mg/kg im four doses two cycle

Result

Fig 3.HPE report S/o invasive mole

__________________________________________________________________________________ 58

Journal of Medical Education & Research, Vol. 3, No.2, July-Dec 2013

Valvi A. M. et al

Discussion
GTN arises when the normal regulatory mechanism controlling the proliferation and invasiveness of trophoblastic tissue are lost. These are rare and constitute less than 1% of all gynecological malignancy. They are characterized by a distinct tumor marker hCG and have varying tendencies towards local invasion and distant metastasis (4). Vascular invasion and metastasis rarely occurs in Invasive mole (5).Myometrial invasion is difficult to document on pelvic ultrasound to demonstrate the invasion. Demonstration of vascular mass without evidence of fetal material on USG in the context of anelevated -hCG is highly suggestive of GTN (IM).

2. Amandeep k aanand, shashigupta, rajanigupta- invasive mole present as acute abdomen 3.Williamss gynecology gestational trophoblastic disease page 4. Moodley M, Tunkyi K, getational trophoblastic syndrome an audit of 112 patients. International J gynecolcancer2003; 13(2)234-39 5. Danforth obst&gyne 9thedtn, page 560566 6. Xiang y, yang X, Du J, Song H. the role of hysterectomy in gestational trophoblastic tumour

Conclusion
Although the development of effective chemotherapy has resulted in improved survival of the patients with GTD, hysterectomy remains an important adjunct in the treatment of the selected subset of patients (6). Surgical therapy (hysterectomy) performed coincident with the institution of the chemotherapy has shown the significantly reduces the duration of hospitalization and amount of chemotherapy used to achieve remission in this case.

References
1. Williamsobst 23rdeditn page 257-265

__________________________________________________________________________________ 59