Ovary hyperstimulation syndrome accompanying molar pregnancy: case report and review of the literature

Multidisciplinary perioperative management in dilatation and evacuation for a giant hydatidiform mole: A case report

Gestational trophoblastic disease (GTD) is an abnormal pregnancy caused by the placenta, which can potentially metastasise. Suction evacuation is recommended for diagnosis and treatment, and dilatation and evacuation (D&E) is usually performed under intravenous anaesthesia due to the short operation time and minimal blood loss. We refer to the guidelines produced by the Japan Society of Obstetrics and Gynaecology (JSOG), and acknowledge that practices vary globally. However, to the best of our knowledge, there is no evidence on perioperative management and arrangements in D&E required for managing giant hydatidiform moles, such as preventing massive haemorrhage, respiratory dysfunction with a pathogenesis like ovarian hyperstimulation syndrome (OHSS), or intensive care needs. This case report describes perioperative considerations for managing a giant hydatidiform mole using D&E in a uterus enlarged to the third-trimester pregnancy size. A 28-year-old multiparous woman was clinically diagnosed with a hydatidiform mole after a spontaneous miscarriage due to abnormal genital bleeding, systemic oedema, and abdominal distention. Ultrasound and computed tomography showed a ballooning uterus with a third-trimester pregnancy size, a robust intrauterine mass, and ascites. Serum hCG levels were extremely high (>3,000,000 mIU/mL), confirming the clinical diagnosis of a hydatidiform mole. Emergency D&E was safely performed under multidisciplinary perioperative management, with careful preparation and support. This is a rare experience-based case report and valuable documentation detailing multidisciplinary perioperative management under general anaesthesia. To the best of our knowledge, this is the first report describing the considerations, details, and innovations required in the perioperative management of giant hydatidiform moles using D&E.

Ovarian Hyperstimulation Syndrome Complicating Spontaneous Molar Pregnancy: A Case Report and Review of the Literature

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is traditionally associated with fertility treatments and results in elevated human chorionic gonadotropin (βhCG) levels and fluid shifts to extravascular compartments. Rarely, spontaneous pregnancies with significant βhCG elevations, such as molar pregnancies, can give rise to OHSS.

CASE

A 24-year-old woman was diagnosed as having a molar pregnancy at approximately 12 weeks gestation following spontaneous conception. Her initial βhCG was over 1 million IU/L. There was no evidence of metastatic disease. She underwent an uncomplicated dilation and curettage. Three days later, she presented with chest pain, shortness of breath, and abdominal discomfort. Massively enlarged ovaries were identified with bilateral pleural effusions requiring repeated thoracentesis.

CONCLUSION

This case demonstrates rare sequelae of molar pregnancy. Treatment is mainly supportive, and close observation is required to manage complications. In patients with extremely elevated βhCG levels, clinicians must remain vigilant for signs suggesting OHSS, even following evacuation of the uterus.

Spontaneous Ovarian Hyperstimulation Syndrome in a Partial Molar Pregnancy With Early Onset Severe Pre-eclampsia at 15 Weeks Gestation

Ovarian hyperstimulation syndrome is a well-known entity in assisted reproductive technology. However, it is unusual for this entity to occur without any medications that stimulate follicle stimulating hormone. Herein, we describe a case where a partial molar pregnancy with high human chorionic gonadotropin promiscuously activated follicle stimulating hormone receptors has resulted in spontaneous ovarian hyperstimulation syndrome. There are only eight other cases documented per our literature search of ovarian hyperstimulation syndrome in molar gestations, and this is the third report in partial molar gestation. In our case, it is an unique development of severe early onset pre-eclampsia in the second trimester. Our goal is to discuss the nuances in management of this entity as well as to add the available body of research on this subject.

Ovarian hyperstimulation syndrome following surgical removal of a complete hydatidiform mole: a case report

Background

Generally, ovarian hyperstimulation syndrome develops after superovulation caused by ovulation-inducing drugs in infertile patients. However, ovarian hyperstimulation syndrome associated with natural pregnancy is rare, and most cases of ovarian hyperstimulation syndrome have been associated with a hydatidiform mole.

Case presentation

We describe a case of a 16-year-old Japanese girl with a complete hydatidiform mole. The patient was referred for intensive examination and treatment of the hydatidiform mole and underwent surgical removal of the hydatidiform mole at 9 weeks, 5 days of gestation. Histopathological examination revealed a complete hydatidiform mole. The patient’s blood human chorionic gonadotropin level decreased from 980,823 IU/L to 44,815 IU/L on postoperative day 4, and it was below the cutoff level on postoperative day 64. Transvaginal ultrasonography on postoperative day 7 revealed a multilocular cyst measuring 82 × 43 mm in the right ovary and a multilocular cyst measuring 66 × 50 mm in the left ovary. Both ovarian cysts enlarged further. Magnetic resonance imaging on postoperative day 24 revealed that the right multilocular ovarian cyst had enlarged to 10 × 12 cm and that the left multilocular ovarian cyst had enlarged to 25 × 11 cm. Blood examination showed an elevated estradiol level as high as 3482 pg/ml. We diagnosed the patient with bilateral giant multilocular cysts accompanied by ovarian hyperstimulation syndrome because of the rapid increase in the size of the cysts. The patient complained of mild abdominal bloating; however, symptoms such as nausea, vomiting, dyspnea, and abdominal pain were not observed. Therefore, we chose spontaneous observation in the outpatient clinic. The cysts gradually decreased and disappeared on postoperative day 242.

Conclusion

Physicians should be aware that ovarian cysts can occur and can increase rapidly after abortion of a hydatidiform mole. However, the ovarian cyst can return to its original size spontaneously even if it becomes huge.

A Comparison of the Clinical Presentation of Ovarian Hyperstimulation Syndrome in a Partial Molar Pregnancy Case Versus a Fertility Treatment Case

Ovarian hyperstimulation syndrome (OHSS) is ovarian enlargement secondary to hormones overstimulating ovarian growth. It can be associated with a spectrum of other clinical findings, including ascites, hemoconcentration, hypercoagulability, and electrolyte imbalances. OHSS most commonly occurs as a complication of treatment with in vitro fertilization medications, such as human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone agonists. OHSS has infrequently been reported to be caused by high hCG levels in complete, partial, or invasive molar pregnancies. The classic signs and symptoms of OHSS include nausea, vomiting, bloating, abdominal pain, tachycardia, tachypnea, and dyspnea. Further positive diagnostic studies for OHSS include enlarged ovaries, ascites, hemoconcentration, hyponatremia, hyperkalemia, and oliguria. OHSS due to molar pregnancies is extremely rare. Suziki et al. performed a literature review in 2014 and describe the eight ever-reported molar pregnancy-associated OHSS cases, three of which were partial molar pregnancies. We present a two-case comparison that first examines an exceptionally rare OHSS case presentation of a 19-year-old female with a partial molar pregnancy that was also complicated by hCG-induced thyrotoxicosis. Following this, we discuss a case of the more classic presentation of OHSS caused by fertility treatments. This case report is of novel interest because we present a case comparison that emphasizes a rare, paradoxical association between OHSS and dilation-evacuation procedures that is important for physicians to be aware of - OHSS is not an adverse event of molar pregnancies that can be eliminated by declining hCG levels after a dilation and evacuation procedure; rather, in a molar pregnancy, OHSS occurs after the dilation and evacuation.

Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction

Over the past 40 years since the first in vitro fertilization was performed, both the role of assisted reproductive technology (ART) in establishing viable pregnancy as well as the available treatment options have expanded enormously. Annually in the USA, nearly 2% of pregnancies now employ some form of ART assistance, with in vitro fertilization (IVF) being the most commonly utilized methodology. Both maternal and fetal risks are elevated in ART pregnancies, the latter including adverse outcome due to both increased gestational number as well as advanced maternal age. Maternal risks may be divided into locoregional and systemic complications. Adverse pelvic complications include those relating to gamete harvesting and transfer, ovarian hyperstimulation, the sequela of ectopic and heterotopic pregnancies, as well as ovarian torsion, all of which are elevated in the ART cohort. Ovarian hyperstimulation syndrome is the most commonly encountered complication, with both systemic and pelvic features relating to increased vascular permeability, hemoconcentration, and ascites. While life-threatening cases are relatively rare, moderate and severe manifestations may occur in up to 10% of ART cycles and, as such, are a not infrequent cause for ER visitation. Familiarity with the clinical and imaging manifestations of ART complications as well as their prognostic implications will facilitate a timely diagnosis and assist the interpreting radiologist in best expediting appropriate clinical care. In this article, we will briefly discuss the current methodology of ART then present an imaging-based multimodality review of the potentially encountered adverse maternal sequela, highlighting key diagnostic features and differential considerations as well as potential prognostic implications.

Placental mesenchymal dysplasia associated with spontaneous ovarian hyperstimulation syndrome

Placental mesenchymal dysplasia (PMD) is a rare disorder of unknown aetiology characterised by placentomegaly, serpiginous surface blood vessels and large cystic villi. Although a mimic of molar pregnancies and other entities, it can be distinguished from them by its association with intrauterine growth restriction or death of a relatively normal fetus and its characteristic histopathology. We report the case of a 20-year-old primigravida who presented at 16 weeks with heavy clotty vaginal bleeding and subsequent miscarriage. The placenta was grossly abnormal and resembled a partial molar pregnancy. PMD was confirmed by microscopic examination. Postmiscarriage, ultrasound revealed enlarged and multicystic ovaries similar to those seen in ovarian hyperstimulation syndrome (OHSS), which returned to normal a few weeks after miscarriage. This is the first report of PMD associated with OHSS, and we hypothesise that the most likely pathogenesis is ovarian stimulation from PMD-derived vascular endothelial growth factor.

Suspected ovarian molar pregnancy after assisted reproductive technology conception: a diagnostic challenge

A 32-year-old patient with primary infertility received in vitro fertilisation (IVF) therapy. Four weeks later she developed intermittent left iliac fossa pain. Transvaginal ultrasound showed an empty uterus and an adnexal mass adjacent to the right ovary. Serum β-human chronic gonadotropin was 33,492 IU/L. At laparoscopy a mass attached to right ovary, suggestive of a right ovarian ectopic pregnancy, was excised. Histological examination confirmed an ovarian ectopic gestation, but noted enlarged chorionic villi and trophoblastic atypia, which raised the suspicion of molar pregnancy. Subsequent p57 immunohistochemistry and DNA ploidy studies excluded a mole, however. Cases of suspected molar disease in ectopic pregnancy present a diagnostic challenge for both clinicians and histopathologists, and establishing a definitive diagnosis may be difficult.