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Absent umbilical artery diastolic flow in a fetus with a partial mole at 18 weeks' gestation
Absent umbilical artery diastolic flow in a fetus with a partial mole at 18 weeks' gestation David M. Sherer, MD, J. Christopher Glantz, MD, Leon A. Metlay, MD, and Devereux N. Saller, Jr., MD
Rochester, New York We present a case in which Doppler velocimetry of the umbilical artery in a fetus with a partial mole at 18 weeks' gestation revealed absent diastolic flow. To the best of our knowledge, this is the first report of Doppler velocimetry of the umbilical artery in this rare condition. Increased placental resistance in this abnormal placenta may explain this finding. (AM J
OBSTET GYNECOL
1993;169:1167-8.)
Key words: Partial hydatidiform mole, Doppler velocimetry
Partial hydatidiform molar gestations are morphologically similar to complete moles but differ in that partial moles usually occur in conjunction with the presence of a fetus. Most histologically proved partial moles have been associated with abnormal karyotypes, typically triploidy. Rarely, fetuses with normal karyotypes representing diploid partial moles have been reported. [ Accounting for 0.00 I % to 0.0 I% of all pregnancies, the majority of partial molar gestations abort spontaneously in the first trimester. Sporadic cases may reach the second trimester and may appear as atypical preeclampsia. We report such a case with an abnormal Doppler velocimetry study of the umbilical artery
From the Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology and Pathology, Strong Memorial Hospuol, University of Rochester Srhool of Medicine and Dentistry. Received for publication May 26, 1993; revised [une 14, 1993; acceptedjune 29, 1993. Reprint requests: David M. Sherer, MD, Dnnsiou of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Strong Memoria! Hospital, University of Rochester School of Medicine and Dmtisti»; 601 Elmwood Ave., Box 8668, Rochester, NY 14642-8668. Copyright © 1993 hy Mosbv-Year Book, Inc. 0002-9378/93 $1.00 + .20 6/1/49707
thought to reflect increased resistance of the abnormal placenta.
Case report A 23-year-old woman, gravida 2, para I, rubella immune, Rh positive, was referred to labor and delivery at Strong Memorial Hospital at 18 weeks' gestation because of severe headache and marked weight gain gradually increasing over the 2 weeks before she was examined. Physical examination on admission revealed a young woman with edematous facies, blood pressure of 180/l15 mm Hg, fundal height of 19 em, and + 3 deep tendon reflexes. Laboratory results included hematocrit 46%, platelets 126,000 mm", albumin 2.1 gm/dl, blood urea nitrogen 17 mgldl, lactate dehydrogenase 225 lUlL (normal 100 to 190), aspartate aminotransferase 75 lUlL (normal 10 to 36), normal coagulation studies, and + 4 proteinuria. Ultrasonography confirmed a singleton vertex-presenting fetus with normal anatomy and amniotic fluid volume. The placenta appeared markedly enlarged, measuring 10 em in thickness throughout, with areas of mixed echogenicity and cystic changes (Fig. I, A). Doppler veloeimetry of the umbilical artery revealed absent forward diastolic flow (Fig. 1, B). Serum 13-subunit of human chorionic
Fig. 1. A, Ultrasonographic view of abnormal placenta. Note thickened placenta with cystic changes. B, Abnormal Doppler ve!ocimetry of umbilical artery. Note absent forward diastolic flow. 1167
1168 Sherer et al.
gonadotropin was 245,000 ml Uzrnl, and serum o-fetoprotein was 6.1 multiples of the median . Thyroid func tion tests confirmed that th e patient was euthyroid. The patient required multiple int ravenous boluses of 5 mg of hydralazine. Over th e first hours of her ho spi talizati on , oligu ria (with hourly output ranging between 5 and 10 ml) in sp ite of ad equate hydr at ion and an elevated cen tral venous presssure of 21 cm H 2 0 was docum ented. The condition was th ou ght to be consis tent with severe preeclampsia, possibly associated with a partial molar gestation. The maternal risks and the poor fetal prognosis were discussed with the patient, and evacuation termination was performed while she was under general anesthesia. Gross examination revealed multiple vesicular stru ctures within the placen tal tissue. Pathologic examination revealed a fra gmen ted immature fema le fetu s consistent with 18 wee ks' gestation with no apparent fetal a no ma lies. Histopathologic examination of the placenta reve aled ap propriate-forgestationa l-age villi. A well-p re served vesicular structure contained cisterns and had trophoblastic hyperplasia and con voluted borders, all features consisten t with a partial mole . Multiple cytogenetic samples from the fetus and placenta demonstrated a normal 46 ,XX karyotype . After the procedure the patient's condition gr ad ually improved, and she was discharged in good health 7 days after admission. Serum human chorion ic gonadotro pin level on discharge was 1138 mID/m!.
November 1993 Am J Obstet Gynecol
Comment
Histologically the pla centa of a partial molar gestation is characterized by molar villi int ermixing with seeming ly unaffected placental villi. Partial moles ha ve been associated with elevated m aternal seru m o-fetoprotein and human chorionic gonadotropin-B levels, findings that suggest abnormal pl acental fun ction . UItras on ographically the placenta may ap pea r bulky with multiple hypoechoic areas con sistent with vesicles. Variou s vascular placental pathologi c features have been reported in placentas complicated by abnormal fetal Doppler indices." The normal systolic/d iastolic ratio at 20 weeks is approximately 4. Absent forward d iastolic flow in the umbilical artery (Fig. 1, B) reflects mar kedly increased place ntal resistance, suggesting abnorma l pla cental vasculature in this partial molar gesta tion. To the best of our kn owledge, th is is th e first re port of Doppler velocimetry of the umbilical ar tery in association with this unusual pathologic entity. REFE RENCES
I . Feinberg RF, Lockwood CJ, Salafia C, Hobbins ]C. Sonograph ic diagn osis of a pregnan cy with a diffuse hydat idiform mole and coexistent 46,XX fetu s: a case report. A\\ J O BSTET GVNECOL 1988;72:4 85-8. 2. J au niau x E, Campbell S. Ultraso no gra phic assessment of placental abnormalities. A\1 J OIlSTET GVNECOL 1990 ;163: 1650-8.
Rochester, New York We present a case in which Doppler velocimetry of the umbilical artery in a fetus with a partial mole at 18 weeks' gestation revealed absent diastolic flow. To the best of our knowledge, this is the first report of Doppler velocimetry of the umbilical artery in this rare condition. Increased placental resistance in this abnormal placenta may explain this finding. (AM J
OBSTET GYNECOL
1993;169:1167-8.)
Key words: Partial hydatidiform mole, Doppler velocimetry
Partial hydatidiform molar gestations are morphologically similar to complete moles but differ in that partial moles usually occur in conjunction with the presence of a fetus. Most histologically proved partial moles have been associated with abnormal karyotypes, typically triploidy. Rarely, fetuses with normal karyotypes representing diploid partial moles have been reported. [ Accounting for 0.00 I % to 0.0 I% of all pregnancies, the majority of partial molar gestations abort spontaneously in the first trimester. Sporadic cases may reach the second trimester and may appear as atypical preeclampsia. We report such a case with an abnormal Doppler velocimetry study of the umbilical artery
From the Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology and Pathology, Strong Memorial Hospuol, University of Rochester Srhool of Medicine and Dentistry. Received for publication May 26, 1993; revised [une 14, 1993; acceptedjune 29, 1993. Reprint requests: David M. Sherer, MD, Dnnsiou of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Strong Memoria! Hospital, University of Rochester School of Medicine and Dmtisti»; 601 Elmwood Ave., Box 8668, Rochester, NY 14642-8668. Copyright © 1993 hy Mosbv-Year Book, Inc. 0002-9378/93 $1.00 + .20 6/1/49707
thought to reflect increased resistance of the abnormal placenta.
Case report A 23-year-old woman, gravida 2, para I, rubella immune, Rh positive, was referred to labor and delivery at Strong Memorial Hospital at 18 weeks' gestation because of severe headache and marked weight gain gradually increasing over the 2 weeks before she was examined. Physical examination on admission revealed a young woman with edematous facies, blood pressure of 180/l15 mm Hg, fundal height of 19 em, and + 3 deep tendon reflexes. Laboratory results included hematocrit 46%, platelets 126,000 mm", albumin 2.1 gm/dl, blood urea nitrogen 17 mgldl, lactate dehydrogenase 225 lUlL (normal 100 to 190), aspartate aminotransferase 75 lUlL (normal 10 to 36), normal coagulation studies, and + 4 proteinuria. Ultrasonography confirmed a singleton vertex-presenting fetus with normal anatomy and amniotic fluid volume. The placenta appeared markedly enlarged, measuring 10 em in thickness throughout, with areas of mixed echogenicity and cystic changes (Fig. I, A). Doppler veloeimetry of the umbilical artery revealed absent forward diastolic flow (Fig. 1, B). Serum 13-subunit of human chorionic
Fig. 1. A, Ultrasonographic view of abnormal placenta. Note thickened placenta with cystic changes. B, Abnormal Doppler ve!ocimetry of umbilical artery. Note absent forward diastolic flow. 1167
1168 Sherer et al.
gonadotropin was 245,000 ml Uzrnl, and serum o-fetoprotein was 6.1 multiples of the median . Thyroid func tion tests confirmed that th e patient was euthyroid. The patient required multiple int ravenous boluses of 5 mg of hydralazine. Over th e first hours of her ho spi talizati on , oligu ria (with hourly output ranging between 5 and 10 ml) in sp ite of ad equate hydr at ion and an elevated cen tral venous presssure of 21 cm H 2 0 was docum ented. The condition was th ou ght to be consis tent with severe preeclampsia, possibly associated with a partial molar gestation. The maternal risks and the poor fetal prognosis were discussed with the patient, and evacuation termination was performed while she was under general anesthesia. Gross examination revealed multiple vesicular stru ctures within the placen tal tissue. Pathologic examination revealed a fra gmen ted immature fema le fetu s consistent with 18 wee ks' gestation with no apparent fetal a no ma lies. Histopathologic examination of the placenta reve aled ap propriate-forgestationa l-age villi. A well-p re served vesicular structure contained cisterns and had trophoblastic hyperplasia and con voluted borders, all features consisten t with a partial mole . Multiple cytogenetic samples from the fetus and placenta demonstrated a normal 46 ,XX karyotype . After the procedure the patient's condition gr ad ually improved, and she was discharged in good health 7 days after admission. Serum human chorion ic gonadotro pin level on discharge was 1138 mID/m!.
November 1993 Am J Obstet Gynecol
Comment
Histologically the pla centa of a partial molar gestation is characterized by molar villi int ermixing with seeming ly unaffected placental villi. Partial moles ha ve been associated with elevated m aternal seru m o-fetoprotein and human chorionic gonadotropin-B levels, findings that suggest abnormal pl acental fun ction . UItras on ographically the placenta may ap pea r bulky with multiple hypoechoic areas con sistent with vesicles. Variou s vascular placental pathologi c features have been reported in placentas complicated by abnormal fetal Doppler indices." The normal systolic/d iastolic ratio at 20 weeks is approximately 4. Absent forward d iastolic flow in the umbilical artery (Fig. 1, B) reflects mar kedly increased place ntal resistance, suggesting abnorma l pla cental vasculature in this partial molar gesta tion. To the best of our kn owledge, th is is th e first re port of Doppler velocimetry of the umbilical ar tery in association with this unusual pathologic entity. REFE RENCES
I . Feinberg RF, Lockwood CJ, Salafia C, Hobbins ]C. Sonograph ic diagn osis of a pregnan cy with a diffuse hydat idiform mole and coexistent 46,XX fetu s: a case report. A\\ J O BSTET GVNECOL 1988;72:4 85-8. 2. J au niau x E, Campbell S. Ultraso no gra phic assessment of placental abnormalities. A\1 J OIlSTET GVNECOL 1990 ;163: 1650-8.