Complete Molar Pregnancy in Posmenopausal Woman-a Case Report.

INTRODUCTION: Gestational trophoblastic desease (GTD) is disease typical for reproductive period of women and is extremly rare in postmenopausal period of woman's life. AIM: To present a rare case of mollar pregnancy in 57 years of age postmenopausal woman. CASE REPORT: A multiparous woman aged 57 years, and two yars after last menstrual bleeding, was admitted at Clinic, due to hyperplastic endometrium findings and moderate prolonged postmenopausal uterine bleeding. Due to clinical simptoms we performed diagnostic exploratice curettage. During that intervention heavy bleeding was developed resulting in spontaneous expulsion of tumorous mass wich macroscopic looked as a mollar tissue. Imediatelly after intervention level of β HCG was 193,057mlU/mL. Due to very high level of β HCG patient was taken to laparotomy and during the surgery dicision was made to perform total abdominal hysterectomy with bilateral adnexectomy. Eight day after surgery patient was discharged from Clinic in good condition. Hystopathological examination of material obtained by explorative curettage and uterus showed complete mollar pregnancy. Controlled level of β HCG was 1,996 mlU/mL fifth day after surgery.
CONCLUSION: Although molar pregnancy in postmenopausal period of woman's life is very rare disorder, because of potentialy heavy complications it is very important to recognise this disorder at time, to prevent delay of treatment.

INTRODUCTION

Gestational trophoblastic desease (GTD) generally occurs in women in the reproductive years of age. It is extremly rare in postmenopausal woman (1). It develops as a result of proliferation of cito- and sinciciotrophoblast. It is characterised by various degree of hyperplasia and dysplasia, hydropic degeneration of horionic vily, and desintegration of blood vesels. Mollar pregnancy is manifested in two gropus: partial which is less rare and complete mollar pregnancy (2). Disorders are larger in complete mollar pregnancy, with abscense of fetal tisue and its genetic material is, mostly, by duplication from fathers haploid set (46 xx).

Aim of this case report is to present a very rare case of mollar pregnancy in postmenopausal woman

CASE REPORT

A 57-year-old woman two years after last menstrual bleeding with no significant obstetric hystory. She had three normal births and four miscarriage. Her last menstrual bleeding was two years earlyer of day of admission to hospital wich was made because of prolonged moderate postmenopausal bleeding and sonographically suspicious heavy endometrial hyperplasia. On bimanual examination she had enlarged, softened uterus. Dicission was made to perform explorative curettage on department of one-day surgery. During intervention wich was made by general intravenous shorttime anaesthesia. During intervention, heavy bleeding was developed, resulting with spontaneous expulsion of tumorous mass sized 15x7 centimeters, wich macroscopically appeared as molar tissue (Figure 1).

Figure 1.

Macroscopic view of mollar tissue

Immediately after intervention β HCG and complete blood count (CBC) was asked for. β HCG level was 193,057 mlU/mL. CBC was in reference interval except plateles-96x109/L. RTG of lungs was without significance. Due to very high level of β HCG and suspicion of choriocarcinoma, next day patient was taken to laparotomy and during the surgery dicision was made to perform total abdominal hysterectomy with bilateral adnexetomy (Figure 2). Intraoperative finding was softened, enlarged uterus and no local spreeding of disease was identified during surgery. Postoperative recovery were with no significance. Serum β HCG level on fifth day after surgery was 1,996 mlU/mL. She was discharged on eight day after surgery

Figure 2.

Mollar tissue in uterine cavity (gross examination)

Hystopathology report was complete mollar pregnancy on both, the tumorous mass and the uterus.

DISCUSSION

Incidence of mollar pregnancy shows regional variations (1). The higest incidence is in east Asian countries with 1:120 pregnancies (2). Established risk factor for women aged over 40 years increases by 7,5 times (3,4). Tsukamto et al showed twenty cases of GTD in women aged more than 50 years, 25% were hydatiform mole, 40% were invasive mole and 25% choriocarcinoma (5). Identification of GTD in women over 50 years of age is difficult because menopause is expected, and the possibility of pregnancy is often overlooked or denied (6). Diagnosis is made by anamnesis, β HCG levles, gynecologic exam, and pelvic ultrasonography. The most sensitive diagnostic method for molar pregnancy is ultrasonography by caracteristic patern known as „snow storm“ as a result of hydropic degeneration in chorionic villi (7).

In our case differential diagnosis was choriocarcinoma because of very high level of β HCG and macroscopic view of mollar tissue after exploration of uterine cavity. Owing to the high rate (56.3%) of malignant sequelae after evacuation of molar tissue in women aged over 50 years, a primary hysterectomy for the treatment of hydatidiform mole in this age group is recommended (8). In view of postmenopausal status we performed total abdominal hysterectomy with bilateral adnexectomy.

CONCLUSION

Although, molar pregnancy in postmenopausal woman is very rare disorder, because of potential heavy complications, it is recommended that GTD should be included in differential diagnosis to prevent delay in treatment. Because of very high risk of postmolar malignant sequelae after suction curettage in postmenopausal women it is recommended to resolve GTD by total abdominal hysterectomy.