Images in Radiology - Complete Hydatidiform Mole With Live Pregnancy In A Twin Gestation

A 29-year-old primigravida, 22 weeks of gestation, complained of abdominal lump, pain in the abdomen, episodes of vasovagal attacks, headache and intermittent episodes of spotting. On physical examination she was normotensive and fundal height was 20 cm. Two big firm masses were palpable in the lumbar regions bilaterally. The foetal heartbeats were ausculated normally. Antenatal ultrasound examination revealed a live foetus, which had measurements consistent with 22 weeks of gestation. The placenta was anterior in location and showed grade I maturity, without any focal lesion. Another markedly enlarged mass, separate from the anterior normal placenta, with small cystic areas and increased echogenicity was seen along the posterior uterine wall, typically showing "snow storm" appearance. These changes were consistent with hydatidiform molar changes most probably in the second placenta (Figure 1). Two large extrauterine, predominantly cystic masses were also seen in the lumbar regions bilaterally near the fundus of the uterus. They were showing multiple cystic areas within it and measured approximately 15 X 15 cm in size. These were suggestive of theca lutein cysts in both enlarged ovaries in association with the hydatidiform mole (Figure 2). Serum titre of beta-HCG at 22 weeks was 1,20,000 mIU/ml. Chest x-ray, thyroid and liver function tests were normal. Repeat ultrasound at 24 weeks revealed exacerbation of placentomegaly and onset of polyhydramnios. The symptoms continued to increase and the patient underwent spontaneous delivery at 28 weeks of gestation and delivered a baby with weight of 1450 grams. The normal placenta was delivered within 15 minutes after birth and the abnormal posterior placenta was removed subsequently using surgical approach. The histopathology of the abnormal posterior placenta revealed hydatidiform (grapelike, cystic) degeneration of chorionic villi with inadequate vascularisation and abnormal, excessive proliferation of placental trophoblasts. Karyotype of the baby's white cells and mole revealed normal 46-XX chromosomal patterns. Mother's chest radiograph, abdomino-pelvic sonography and serum CA-125 marker study done post partum did not reveal any abnormality. She was not give any chemotherapy.