ectopic molar pregnancy is a rare occurrence and consequently not often considered as a diagnostic possibility . in this article , an attempt was made to stress on the need for histopathological examination and follow up of every case of ectopic pregnancy .
a 30-year - old gravida 4 , para 3 , pregnant woman with a 7-week history of amenorrhea attended hospital with abdominal pain . per vaginal examination revealed a tender left adnexal mass measuring 4x4 cm and on ultrasonography there was a live fetus corresponding to a 7-week and 6 days gestation with free fluid in the pelvic cavity .
laparotomy , revealed a ruptured left tubal ectopic pregnancy and histopathological examination was suggestive of a molar pregnancy .
clinical diagnosis of a molar pregnancy is difficult but histopathology is the gold standard for diagnosis .
the incidence of partial or complete hydatidiform mole is approximately 1 in 500 to 1 in 1000 pregnancies ( 1 ) .
its malignant potential is similar to that of an intrauterine molar pregnancy ( 2 ) .
molar changes could be either partial or complete and the treatment is surgical combined with chemotherapy .
follow - up is usually done by serial serum human chorionic gonadotropin ( -hcg ) titrations .
although ultrasonography is useful in the diagnosis of uterine molar pregnancies , there is a chance of missing this diagnosis in cases of an ectopic molar pregnancy .
a 30-year - old female patient , gravida 4 , para 3 , was admitted to north eastern indira gandhi regional institute of health and medical sciences ( neigrihms ) , shillong , india with a 7-week history of amenorrhea followed by an episode of mild bleeding per vaginum .
she also had abdominal pain 1 week prior to the presentation . on examination , her vital signs were stable with no pallor or edema
. per abdominal examination revealed tenderness over the left iliac fossa , without any guarding or rigidity .
per vaginal examination showed a normal - sized uterus and a tender left adnexal mass measuring 4x4 cm .
her hemoglobin concentration was 8.6% gr / dl and the urine pregnancy test was positive .
trans - abdominal ultrasonography confirmed the finding of a left tubo - ovarian mass denoting a live fetus corresponding to 7 weeks and 6 days of gestation with free fluid in the pelvic cavity .
however , such hemodynamically stable patients could have been managed by laparoscopy in the presence of the required facility and expertise . during the operation ,
hemoperitonium was found with a normal uterus , an intact right - sided fallopian tube and a ruptured left tubal ectopic pregnancy .
gross examination showed grey brown tissue , measuring 6x4x2 cm with moles ranging in size from 1 to 3 mm and a fetus corresponding to 6 to 7 weeks of gestation ( figure 1 ) .
ruptured tube showing fetus and placental tissue with molar changes on histological examination , there were chorionic villi showing circumferential trophoblastic proliferation , hydropic changes and karyorrhexis . based on these findings ,
the possibility of a molar pregnancy was thought and serum -hcg level determination was asked .
postoperatively , on the day of surgery , serum -hcg was 5308 miu / ml . her post - operative period was otherwise unevenful , but she was followed up by weekly serum -hcg measurements .
the tests showed a decreasing trend and turned negative at the end of the 6th week .
barrier contraception was advised for at least 1 year during which she was also on regular follow - ups .
clinically , tubal molar pregnancy mimics normal tubal ectopic pregnancy and , therefore , makes the diagnosis difficult ( 3 ) .
however , provisional diagnosis is made during surgery and histopathological examination can determine the final diagnosis .
conservative fertility - sparing management was found successful in a reported case of cervical molar pregnancy ( 5 ) .
rupture of the horn does not usually take place until the twelfth week of gestation but , when it does , there is nearly always severe bleeding which makes the condition extremely dangerous .
reported cases of molar changes in ovarian pregnancy are also found in the literature ( 8) .
molar ectopic pregnancy becomes even more difficult to diagnose when it occurs in heterotopic pregnancies , where the patient may present with shock , weeks after evacuation of the intrauterine pregnancy ( 9 ) .
although extremely rare , an extra - uterine molar pregnancy should form part of the differential diagnoses in cases of intra - uterine pregnancy complicated by the presence of a pelvic mass , vascularity and high levels of serum -hcg ( 10 ) .
monitoring -hcg titers following conservative management of suspected ectopic pregnancies is important , not only to diagnose persistent ectopic gestation , but also to rule out the presence of malignant trophoblastic diseases ( 11 ) .
the current trend in the treatment of ectopic pregnancies is through conservative surgery and monitoring of -hcg titers to avoid missing a choriocarcinoma developing in an ectopic gestation , even though this is a very rare condition ( 12 ) .
mediastinal metastasis of choriocarcinomas following ectopic pregnancies cause dyspnoea , pleural effusion and thoracic pain ( 13 ) .
one extensive study on routine pre - evacuation ultrasound diagnosis of hydatidiform mole suggests that ultrasonography identifies less than 50% of hydatidiform moles .
detection rates are , however , higher for complete compared to partial moles , and improve even further after the 14 week of gestation ( 14 )
. histopathological examination of conception products remains the current gold standard for the diagnosis of gestational trophoblastic neoplasia .
there is also a possibility of over - diagnosis by histological examination , especially in early ectopic tubal pregnancies , due to a more florid extra - villous trophoblastic proliferation compared with evacuated uterine products of conception ( 1 ) .
extra caution should be taken to strictly apply the morphological criteria of circumferential trophoblastic proliferation , hydropic changes , scalloped villi and stromal karyorrhexis for diagnosis ( 15 ) .
ectopic molar pregnancy is a rare condition , which can occur at any place in the pelvic cavity . invasive
. however , ultrasonography might not be able to fully diagnose ectopic molar pregnancies , leaving histopathological examination of the conception products the current gold standard for the diagnosis .
 introductionectopic molar pregnancy is a rare occurrence and consequently not often considered as a diagnostic possibility . in this article , an attempt was made to stress on the need for histopathological examination and follow up of every case of ectopic pregnancy . 
 this was substantiated with the help of a case report.case presentationa 30-year - old gravida 4 , para 3 , pregnant woman with a 7-week history of amenorrhea attended hospital with abdominal pain 
 . per vaginal examination revealed a tender left adnexal mass measuring 4x4 cm and on ultrasonography there was a live fetus corresponding to a 7-week and 6 days gestation with free fluid in the pelvic cavity . 
 laparotomy , revealed a ruptured left tubal ectopic pregnancy and histopathological examination was suggestive of a molar pregnancy.conclusionalthough rare , molar changes can occur at any site of an ectopic pregnancy . 
 clinical diagnosis of a molar pregnancy is difficult but histopathology is the gold standard for diagnosis . 
Introduction
Case Presentation
Conclusion
Introduction
Case Presentation
Discussion
Conclusion