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Hydatidiform mole and toxemia of pregnancy
HYDATIDIFORM With
MOLE
Unusual
AND
Late Development
TOXEMIA of Lutein
OF
PREGNANCY
Cyst
JAMES K. QUIGLEY, M.D., ROCHESTER,N.Y. (From
the Obstetrical
Department
of the Rochester
General
Hospital)
T
HE rccrnt publication of a caw of hydatid mole complicated by towmia of pregnancy and the unusual beharior of the complicat,ing lutein cyst in a patient. wcentl:- seen by mr prompts thv reporting of this casr.
Mrs. F. P. was a 29.year-old woman with a history of one previous full-trwn pregnancy. Her last menstrual period had begun on October 29 and I SBX hPr in consultation on February 27. For five woks she had had nausea and vomiting of moderat,c: severity and during this time had had constant vaginal bleeding, varying from spotting to the saturation of a small pad daily. On c>xnmination the uterus was larger than the wlculatc~d dat.? of pregnancy woultl warrant. Thr tentative diagnosis was swrre anrlmia, toxemia of pregnancy, and the possibility of hydatidiform mole. On admission hc,r lernperaturewas 98.3” F., pulse 116, blooll pressure lfZO/lOO, red blood count 2.6 million, with a hemoglobin of 63 per cent. The blood smear suggrsted “anemia of a pernicious typo probably on :t tosrmia basis. ” T7rirmlysis shovel 4 plus all)uminuria with fine and coarse ,granular casts. During the nwt two she complained of headache. Permission was sought to (‘a% of hytlatid mole. The of religious belief, refused critical. She was dull and h~twrrrl 140 and 160.
days
the patient rapidly became ~vorsc, jaundice appwred ant1 The icteric index was 30 and thr nonprotein nitrogen 35. empty the uterus because of the conriction that this was a family, still thinking that the patient was pregnant and becauw this permission until March 3 when her condition had become apathetic anI1 markedly dyspneic with a thready pulse ranging
She was taken to thus delivery room, the partially dilated cwvix and vagina were tightly time as though the patient’s condition would emptying the utrrus. Within thirty minutes wmoved and a No. 4 Voorhees hydrostatic bag 911 hemorrhage ceasetl, contractions started, 3 :10 P.IVI. March 4 the bag and a hydatid mass The uterus was ruretted and packed. Microscopic ,1 large tion. nas no tvidence
examination of the tissue shelved the chorionic villi with cystic part of the dwirlual tissue and nmny chorionic villi were necrotic, of malignancy. The diagnosis was hydatid mole.
The improvement twelve hours she was I,l%ter. HII! rwrivwl I1 tlir red blood rount orb Llarc~lr I”..I to the
membranes were ruptured, and the soft and packed with gauze. It did not seem at the permit of any more radical method of she had bled through the pack, which was introduced through the cervix and inflated. and a second transfusion was given. At the size of a large grapefruit were expelled. dcgenerabut there
in the patient’s condition was dramatic and immediate. Within retaining fluids by mouth ant1 was alert and said sh(a felt wry mu(~h two niow transfusions. This improvement wntinuetl and on Xawll She \vas diwhargril was 3.3 millirm anti the hwnoplohin 70 per cwt.
On April 7. or about five ofi0~. looking rnu~~h lwtter
weeks than
following the expulsion \rh(bn shv lrft the hospital 1059
of but
the molt,, she rcport~~d complaining of 1owc1
1060
QUIGLEY
Am. J. Obst. & Gynec. November, 1957
abdominal discomfort and a slight bloo~l~ spotting. An abllominal and vaginnl examin:ttion disclosed a soft movable mass in front of the utwus, the size of a. 3 months’ pregnnncy. The cervix was soft, and patulous and tlww was a nlncosa~~gui~~co~~s diwharyr. A Zondek-Friedman test I\:LS done with thrw rabbits. The first, which revived IO CC. of urine, showed a morlcratc~ly positive rc~a(~tion. I IOWCT~T, Ilot the swond rahtbil injrctptl with 4 C.C. and the third \\hich rewivcll 1 rx. WPI’D nqative. The tliagnosi8 was lutc,in ovarian cyst of rapid growth \vit,h no wiilencc of c+horiont~pithelioma. On April 8 a curcttagc an11 a conservatiw oophoreetomp ww duw, with some ovarian tissue left on the afl’~~ct
Comment Crowcll’ reported toxemia in 4 cases out of 15 of hydatidiform mole, or 26.7 per cent. In 3 the toxemia was severe. Chesley, Cosgrove, and Preece’! collected 35 cases and added one of their own of probable or alleged eclampsia associated with hydatidiform mole, with 5 deaths, or a 14 per cent mortality rate. Die.ckman$ found toxemia in 3 of 30 cases of hydatid mole, while Page’ report,ed toxemia in 10 out of 30 moles. In a very large series of 85 cases of hydatid mole, Acosta-Sison’ of the clinic of the University of the Philippines cited 31 cases with symptoms of toxemia. Mueller and Lapp’$ case was unusual in that the eclampsia occurred one week after the mole was passed. Chorionepithelioma followed in this cast and the patient was alive and well two years after complete hysterectomy. Several observers noted that the toxemia was severe only in the cases where the uterus had reached t,he height of the umbilicus or beyond, or after amenorrhea of from 4 to 7 months. The tendency toward the development of lutein ovarian cysts following hydatid mole has been noted before, but most observers have said that these regressed after the. removal of the mole. In the case here reported, however, the cyst increased rapidly in size after the uterus was emptied with the chorionic gonadotrophic hormone falling. Two interesting facts emerge from this review of the literature: First, hydat,idiform mole occurs more frequently than has been c&mated in the past. The blargarct Hague group, Cheslcy, Cosgrove, and Preecc, reported 1 case in 1.32 I pre,gnancics, Mueller and T~app from Kings Counly in l~rooklpn a similar proportion o-f 1 in 1,349. Cr~well gave: au incidence of 1 in ?‘%!I deliveries and from the Philippines one clinic reported 55 casesof hydatidiform mole with no note of the total number of obstetrical cases,which must have been enormous. The second fact is that toxemia not only is a common accompaniment of mole but it may be fatal.
;:;$;zv;J
USE
OF
HYDATIDIFORM
MOI,E
AND
TOXEMIA
OF
PREGNANCY
lfl(jl
Summary 1. A case of hydatidiform molt is rcportcd with toxemia so severe as to threaten life. 2. The case was charactcrizc~d by tllc unusual development of a large lutein cyst, rather 6han its regression, after passage of the mole. Refsrences 1. 2. 3. 4. 5.
Cibelli, Ludwig J.: New York J. Med. 56: 2567, 1956. Crowell, J. A.: North Carolina M. J. 16: 11, 1955. Chesley, L. C., Cosgrove, 8. A., and Preece, J.: AM. J. OBST. & GYNEC. 52: 311, 1946. Page, Ernest W.: AM. J. OBST. & GYXEC. 37: 291, 1939. Dieckmann, W. J.: The Toxemia5 of Pregnancy, St. Louis, 1952, The C. V. Mosby Company, p. 497. 6. Mueller, C. W., and Lapp, W. A. : AK J. OBST. & GYNEC. 58: 133, 1.949. 7. Acosta-Sison, Honoria: Ai% J. OBST. Bc GYNEC. 71: 1279, 1956. 2390
ELMWOOD
AVENUE
MOLE
Unusual
AND
Late Development
TOXEMIA of Lutein
OF
PREGNANCY
Cyst
JAMES K. QUIGLEY, M.D., ROCHESTER,N.Y. (From
the Obstetrical
Department
of the Rochester
General
Hospital)
T
HE rccrnt publication of a caw of hydatid mole complicated by towmia of pregnancy and the unusual beharior of the complicat,ing lutein cyst in a patient. wcentl:- seen by mr prompts thv reporting of this casr.
Mrs. F. P. was a 29.year-old woman with a history of one previous full-trwn pregnancy. Her last menstrual period had begun on October 29 and I SBX hPr in consultation on February 27. For five woks she had had nausea and vomiting of moderat,c: severity and during this time had had constant vaginal bleeding, varying from spotting to the saturation of a small pad daily. On c>xnmination the uterus was larger than the wlculatc~d dat.? of pregnancy woultl warrant. Thr tentative diagnosis was swrre anrlmia, toxemia of pregnancy, and the possibility of hydatidiform mole. On admission hc,r lernperaturewas 98.3” F., pulse 116, blooll pressure lfZO/lOO, red blood count 2.6 million, with a hemoglobin of 63 per cent. The blood smear suggrsted “anemia of a pernicious typo probably on :t tosrmia basis. ” T7rirmlysis shovel 4 plus all)uminuria with fine and coarse ,granular casts. During the nwt two she complained of headache. Permission was sought to (‘a% of hytlatid mole. The of religious belief, refused critical. She was dull and h~twrrrl 140 and 160.
days
the patient rapidly became ~vorsc, jaundice appwred ant1 The icteric index was 30 and thr nonprotein nitrogen 35. empty the uterus because of the conriction that this was a family, still thinking that the patient was pregnant and becauw this permission until March 3 when her condition had become apathetic anI1 markedly dyspneic with a thready pulse ranging
She was taken to thus delivery room, the partially dilated cwvix and vagina were tightly time as though the patient’s condition would emptying the utrrus. Within thirty minutes wmoved and a No. 4 Voorhees hydrostatic bag 911 hemorrhage ceasetl, contractions started, 3 :10 P.IVI. March 4 the bag and a hydatid mass The uterus was ruretted and packed. Microscopic ,1 large tion. nas no tvidence
examination of the tissue shelved the chorionic villi with cystic part of the dwirlual tissue and nmny chorionic villi were necrotic, of malignancy. The diagnosis was hydatid mole.
The improvement twelve hours she was I,l%ter. HII! rwrivwl I1 tlir red blood rount orb Llarc~lr I”..I to the
membranes were ruptured, and the soft and packed with gauze. It did not seem at the permit of any more radical method of she had bled through the pack, which was introduced through the cervix and inflated. and a second transfusion was given. At the size of a large grapefruit were expelled. dcgenerabut there
in the patient’s condition was dramatic and immediate. Within retaining fluids by mouth ant1 was alert and said sh(a felt wry mu(~h two niow transfusions. This improvement wntinuetl and on Xawll She \vas diwhargril was 3.3 millirm anti the hwnoplohin 70 per cwt.
On April 7. or about five ofi0~. looking rnu~~h lwtter
weeks than
following the expulsion \rh(bn shv lrft the hospital 1059
of but
the molt,, she rcport~~d complaining of 1owc1
1060
QUIGLEY
Am. J. Obst. & Gynec. November, 1957
abdominal discomfort and a slight bloo~l~ spotting. An abllominal and vaginnl examin:ttion disclosed a soft movable mass in front of the utwus, the size of a. 3 months’ pregnnncy. The cervix was soft, and patulous and tlww was a nlncosa~~gui~~co~~s diwharyr. A Zondek-Friedman test I\:LS done with thrw rabbits. The first, which revived IO CC. of urine, showed a morlcratc~ly positive rc~a(~tion. I IOWCT~T, Ilot the swond rahtbil injrctptl with 4 C.C. and the third \\hich rewivcll 1 rx. WPI’D nqative. The tliagnosi8 was lutc,in ovarian cyst of rapid growth \vit,h no wiilencc of c+horiont~pithelioma. On April 8 a curcttagc an11 a conservatiw oophoreetomp ww duw, with some ovarian tissue left on the afl’~~ct
Comment Crowcll’ reported toxemia in 4 cases out of 15 of hydatidiform mole, or 26.7 per cent. In 3 the toxemia was severe. Chesley, Cosgrove, and Preece’! collected 35 cases and added one of their own of probable or alleged eclampsia associated with hydatidiform mole, with 5 deaths, or a 14 per cent mortality rate. Die.ckman$ found toxemia in 3 of 30 cases of hydatid mole, while Page’ report,ed toxemia in 10 out of 30 moles. In a very large series of 85 cases of hydatid mole, Acosta-Sison’ of the clinic of the University of the Philippines cited 31 cases with symptoms of toxemia. Mueller and Lapp’$ case was unusual in that the eclampsia occurred one week after the mole was passed. Chorionepithelioma followed in this cast and the patient was alive and well two years after complete hysterectomy. Several observers noted that the toxemia was severe only in the cases where the uterus had reached t,he height of the umbilicus or beyond, or after amenorrhea of from 4 to 7 months. The tendency toward the development of lutein ovarian cysts following hydatid mole has been noted before, but most observers have said that these regressed after the. removal of the mole. In the case here reported, however, the cyst increased rapidly in size after the uterus was emptied with the chorionic gonadotrophic hormone falling. Two interesting facts emerge from this review of the literature: First, hydat,idiform mole occurs more frequently than has been c&mated in the past. The blargarct Hague group, Cheslcy, Cosgrove, and Preecc, reported 1 case in 1.32 I pre,gnancics, Mueller and T~app from Kings Counly in l~rooklpn a similar proportion o-f 1 in 1,349. Cr~well gave: au incidence of 1 in ?‘%!I deliveries and from the Philippines one clinic reported 55 casesof hydatidiform mole with no note of the total number of obstetrical cases,which must have been enormous. The second fact is that toxemia not only is a common accompaniment of mole but it may be fatal.
;:;$;zv;J
USE
OF
HYDATIDIFORM
MOI,E
AND
TOXEMIA
OF
PREGNANCY
lfl(jl
Summary 1. A case of hydatidiform molt is rcportcd with toxemia so severe as to threaten life. 2. The case was charactcrizc~d by tllc unusual development of a large lutein cyst, rather 6han its regression, after passage of the mole. Refsrences 1. 2. 3. 4. 5.
Cibelli, Ludwig J.: New York J. Med. 56: 2567, 1956. Crowell, J. A.: North Carolina M. J. 16: 11, 1955. Chesley, L. C., Cosgrove, 8. A., and Preece, J.: AM. J. OBST. & GYNEC. 52: 311, 1946. Page, Ernest W.: AM. J. OBST. & GYXEC. 37: 291, 1939. Dieckmann, W. J.: The Toxemia5 of Pregnancy, St. Louis, 1952, The C. V. Mosby Company, p. 497. 6. Mueller, C. W., and Lapp, W. A. : AK J. OBST. & GYNEC. 58: 133, 1.949. 7. Acosta-Sison, Honoria: Ai% J. OBST. Bc GYNEC. 71: 1279, 1956. 2390
ELMWOOD
AVENUE