This is a 25-year-old primigravida mother whose gestational age from a reliable last normal menstrual period was 29 weeks and 6 days. She came for an antenatal care follow-up after she was referred from a private clinic with the diagnosis of second trimester pregnancy and coexisting molar pregnancy at 26 weeks of pregnancy, which was her first visit. She had no aneuploidy screening or genetic testing. She had symptoms of excessive vomiting and nausea in the first trimester and early in the second trimester; otherwise, she had no history of vaginal bleeding, headache, abnormal body movement, or raised blood pressure, and she had no self-history or family history of diagnosed chronic medical or surgical illness. On her second visit, she was evaluated and diagnosed with the same assessment as the private clinic at 27 weeks and 5 days, and she was appointed to have regular follow-ups both at our hospital and the private clinic every 2 weeks. On her current presentation, she was diagnosed with hyperthyroidism in addition to the above diagnosis, for which she was admitted to the hospital after she presented for her routine follow-up. Except for palpitation, she had no symptoms or danger signs of pregnancy in her current presentation.
Upon arrival, the physical examination revealed a blood pressure of 120/70, a pulse rate of 108, a respiratory rate of 18, and temperature = 36.5 C The thyroid gland size was normal, with no nodules, and on obstetric abdominal palpations, the fundal height was 32 weeks, with a longitudinally lie, cephalic presentation, and a fetal heartbeat of 144. And also, no uterine contraction was detected, and on genitourinary examination, there was no vaginal bleeding, and the cervix was closed, posterior, and firm.
On ultrasound evaluation, the findings were as follows: twin intrauterine pregnancy, one normal and the other molar. The normal twin was cephalic, with a positive fetal heartbeat and no gross anomaly, an average gestational age of 29 weeks and 4 days, and an estimated fetal weight of 1200 g. The placenta was fundal and posterior. The biophysical profile findings were adequate amniotic fluid volume with intact acute variables, and the Doppler study was normal. There was a 13 x 7 cm echo complex mass anteriorly with a diffusely cystic and snowstorm appearance (Figures 1 and 2). The twin peak (lambda sign) and a thick inter-twin membrane are also seen.
Laboratory investigation results were as follows: on complete blood count (white blood cells = 6500 cells/muL, hematocrit = 35.8%, and platelet = 236,000/muL), thyroid function tests (thyroid-stimulating hormone (TSH) = 0.19 mIU/L, free T3 = 8.21 nmol/L, free T4 = 275 nmol/L), liver function test (serum glutamic-oxaloacetic transaminase = 24 IU/L, serum glutamic-pyruvic transaminase = 19 IU/L), renal function test (creatinine = 0.8 mg/dL), serum electrolytes are in a normal range, blood group and Rh is O positive, hepatitis B surface antigen = negative, venereal disease research laboratory = negative, hepatitis C antibody = negative, urinalysis = unremarkable, and serum beta-hCG was 88,387.21 mIU/mL.
She was diagnosed with an early preterm twin pregnancy in which normal fetus coexists with molar + hyperthyroidism based on the clinical presentations, ultrasound findings, and laboratory results. Following a thorough explanation of the risks of developing complications related to a molar pregnancy, she was admitted to the obstetric ward with the aforementioned diagnosis for inpatient management.
She received two courses of dexamethasone 6 mg intramuscularly twice a day (BID) for 2 days for lung maturity, as well as propylthiouracil 100 mg per os (PO) BID, propranolol 10 mg PO BID, and was followed with antepartum fetal surveillance with maternal kick count, a biweekly biophysical profile, and a fetal Doppler study. The Doppler study of the normal fetus was done, and all the results were normal throughout the follow-up period. Serum beta-hCG done after 2 weeks of admission, and it was 94,387 mIU/mL. A thyroid function test was also done every 2 weeks (once antepartum after the initial presentation and twice postpartum), and it was in the normal target range, which is TSH suppressed and free T4 in the upper range of normal during antepartum and in the normal target range postpartum after 7 days and 2 weeks. She had improved from hyperthyroidism clinically as well as by biochemical tests, and the antithyroid drug was continued at the same dose.
On the 22nd post-admission day, at 33 weeks of gestation, she started having labor. Then, she underwent a cesarean section (C-section) for an indication of twin pregnancy molar coexisting with an alive fetus in labor, resulting in the delivery of a 1700-g female neonate who was alive and had APGAR scores of 8 and 9 at the first and fifth minutes, respectively. The fetus' cord and placenta were healthy. The other finding was an excessive vesicular mass, which is distinct from a normal placenta and membrane (Figure 3).
The woman had a smooth postoperative period; except the neonate was admitted to the neonatal ICU with the diagnosis of preterm + low birthweight + respiratory distress syndrome, and after being treated for the above diagnosis and worked up for congenital hypothyroidism (thyroid function tests were in the normal range in the first week and 2 weeks after the discharge), both the mother and neonate were improved and discharged on the fifth postoperative day.
After the operation, the sample was sent for histopathology, and the results showed hydrophilic villi with a circumferential proliferation of trophoblasts (Figure 4). The index was a complete mole, whereas the second placenta showed a normal placenta. The chest X-ray done postpartum was normal, and following 3 months, post-molar surveillance demonstrated a normal pattern of serum beta-hCG decrease, which was then negative until 6 months of monthly monitoring.