Two cases of hydatidiform degeneration of the placenta with fetal abnormality and triploid chromosome constitution

Maternal complications in molecularly confirmed diandric and digynic triploid pregnancies: single institution experience and literature review

Objectives

Assessment of the maternal complications in molecularly confirmed diandric and digynic triploid pregnancies.

Methods

Sonographic features, biochemical results, and clinical presentation were analyzed. Beta-hCG level was controlled after diandric triploidy.

Results

The study included nine diandric and twelve digynic triploid pregnancies at the mean gestational age at diagnosis of 14.9 and 18.0 weeks, respectively (p = 0.0391). Mean value of total-hCG was 979 703.6 U/ml in diandric cases and 5 455.4 U/ml in digynic ones (p < 0.000). Maternal complications occurred in 88.9% of diandric triploid pregnancies, including: thecalutein cysts (44.4%), hyperemesis gravidarum (44.4%), symptomatic hyperthyreosis (33.3%), early onset gestational hypertension (22.2%) and vaginal bleeding (11.1%). No case of proteinuria, preeclampsia or HELLP syndrome was observed. Only maternal complication observed in digynic triploidy was vaginal bleeding (50.0%). The mean time of beta-hCG normalization after diandric triploid pregnancies was 84 days (range 11–142 days). No case of gestational trophoblastic neoplasia (GTN) was observed.

Conclusions

Maternal complications (except for vaginal bleeding) are associated with diandric triploidy. The relatively low incidence of hypertensive maternal complications and their less severe course in our cohort may be attributed to the earlier prenatal diagnosis. The frequency of GTN after diandric triploidy may be lower than previously reported.

Pre-eclampsia and trisomy 13: a possible association

Pregnancies of fourteen women who gave birth to babies with trisomy 13 were studied retrospectively for evidence of pre-eclampsia, with twenty-eight controls matched for age and parity. Of the five nulliparous women who subsequently gave birth to a baby with trisomy 13 all had had severe pre-eclampsia, compared with none of the control group. The records of eleven women whose first babies had had trisomy 18 (four) or trisomy 21 (seven) were also studied with appropriate controls and none of these pregnancies had been complicated by pre-eclampsia. Development of pre-eclampsia may be influenced by a gene or genes on fetal chromosome 13.

Analysis of gross anatomical variations in human triploidy

Three cases of human triploidy were dissected in detail to determine whether or not there are any specific patterns of morphologic variation associated with this form of polyploidy. No specific constellations of anatomic variation were observed. However, each body did have a greater than normal number of variations among muscles that tend to be variable in the normal population. Two bodies showed a marked increase in the size of the thigh muscles, two bodies had eyeballs that were larger than normal, and two bodies had anomalous attachments of the extraocular muscles. The sample size is not large enough to draw any specific conclusions concerning the pathogenesis of these variations. However, the findings do suggest that careful examination of additional specimens will be of value in providing further information about the genotype/phenotype relationships in human triploidy.

Morphologic anomalies in triploid liveborn fetuses

Analysis of the morphologic features of 43 complete and 11 mosaic triploid infants delivered at or after 22 weeks of gestation revealed, in addition to well-delineated gross features, a number of new or previously little emphasized histopathologic features. These included testicular Leydig cell hyperplasia, increased levels of hematopoiesis, and ovarian, adrenal, and pulmonary hypoplasia. Some of these findings appeared to be linked to partial hydatidiform mole replacing the normal placenta, which was present in about 70 per cent of the triploid cases. It is important to recognize the breadth of the triploidy spectrum, which ranges from near normalcy to multisystem involvement, and to pay special attention to the placenta. The importance of correct morphologic diagnosis of triploidy is stressed in view of the fact that its occurrence apparently does not prejudice the future reproductive performance of the parents.

Twin pregnancy with complete hydatidiform mole (46,XX) and fetus (46,XY): genetic origin proved by analysis of chromosome polymorphisms

In a case of complete hydatidiform mole with fetus the genetic origins were defined by the use of chromosomal polymorphisms. The fetus had a normal 46,XY karyotype with evidence of the presence of both maternal and paternal chromosomes. The mole was 46,XX and of androgenetic origin. There was no evidence of a maternal contribution, and duplication of paternal chromosomes was shown. In such atypical molar pregnancies examining genetic polymorphisms yields much more information than do sex chromosome studies and karyotyping, particularly in confirming the diagnosis and defining the origin and aetiology of the condition.

Further observations on the sonographic spectrum of gestational trophoblastic disease

Sonograms of 27 patients with gestational trophoblastic disease were evaluated and categorized to newer concepts regarding the pathology and pathogenesis of this disorder. The patients were assigned to the following subgroups: 1) classical or complete mole; 2) partial or incomplete mole; 3) coexistent mole and fetus; 4) hydropic degeneration of the placenta; 5) locally invasive mole; and 6) metastatic trophoblastic disease, including choriocarcinoma. The utility of this categorization and of ultrasound in the diagnosis and subsequent management of these patients is presented.

Triploidy in human abortions

Seven triploid embryos and fetuses, six spontaneously aborted and one resulting from pregnancy interruption are described. A wide range of malformations, from amorphous, nodular embryos, to apparently normal phenotypes were observed. The degree of hydatid degeneration in the placentae ranged from minimal to severe. In several cases large, atypical cells were present in the villous stroma. There was no apparent correlation between the degree of placental lesion and fetal malformations. It is suggested that termination of triploid pregnancies is determined more by the degree of placental damage rather than the severity and type of fetal anomalies.

Cell ploidy in molar placental disease

Molar diseases of the placenta is associated with cystic change in the villi. The cysts may be from 5-20+ mm in diameter. This disease has been described in association with triploid and diploid cell lines and with and without an accompanying embryo or fetus. It may be followed by malignant change and invasive chorio-carcinoma. In order to investigate the association between cell ploidy, embryonic development and subsequent malignancy, a detailed study of 30 conceptuses with molar disease was made, with the accompanying maternal history and follow-up. The cell ploidy was determined by measurement of nuclei by a cytoscan light microscope connected to a computer program as has been previously described. Diploid cell lines were not found with embryonic or fetal development. Triploid cell lines were always associated with an embryo or fetus. Triploidy is not associated with hyperplastic changes in the trophoblast. These results are presented and discussed.

The syndromes of hydatidiform mole. I. Cytogenetic and morphologic correlations

Cytogenetic and morphologic analysis of 23 hydatidiform moles allowed the division into at least two syndromes: (1) the syndrome of complete (classical) mole is without an ascertainable embryo/fetus, gives a diploid karyotype, and manifests a progressive fluid engorgement of the villi as well as a gross, haphazardly distributed trophoblastic hyperplasia; (2) the syndrome of partial (incomplete) mole has an ascertainable fetus (alive or dead), gives a triploid karyotype, and exhibits a slowly progressing hydatidiform swelling in the presence of functioning villous capillaries that spares many villi; trophoblastic immaturity is constant and focal hyperplasia is inconspicuous but present. A single case of diploid mole with unusual morphologic features, complete with a fetus, may herald yet another syndrome. Human chorionic gonadotropin levels were initially high in practically all cases. There was no malignant trophoblastic disease in this small series, but a plea is made that partial moles be followed carefully in order to establish their relation to choriocarcinoma.

Ocular findings in triploidy

We studied the abnormal ocular and systemic findings in one case of true triploidy and two cases of triploid mosaicism. A liveborn triploid child 69,XXY, had abnormalities including cebocephaly, a single midline nostril, incomplete cleft palate, transverse palmar creases, partial syndactyly, and ambiguous genitalia. Ocular abnormalities included hypotelorism, blepharophimosis, microcornia, iris coloboma, cataract, persistent hyaloid vasculature, retinal dysplasia, and optic atrophy. A 16-year-old girl with triploid mosaicism had congenital left facial and body hemiatrophy, both growth and mental retardation, left-sided grand mal seizures, incontinentia pigmenti of both legs, partial syndactyly, and generalized weakness. Results of her ocular examination were within normal limits. A 13-year-old boy with triploid mosaicism exhibited both growth and mental retardation, truncal obesity, and required a brace to support his back. Ocular findings included synophrys, bilateral blepharoptosis, and abnormal results of Schirmer tear test. Studies indicate a wide spectrum of ocular and systemic abnormalities occur that are presumably associated with the chromosome error.

Clinical details, cytogenic studies,and cellular physiology of a 69, XXX fetus, with comments on the biological effect of triploidy in man

A triploid fetus, 69, XXX, aborted spontaneously at 26 weeks' gestation. It had multiple abnormalities including syndactyly of the hands and feet single palmar creases, hypoplasia of the adrenals and ovaries, hypertrophy of thigh muscles, and abnormalities of the brain. The placenta was large and showed hydatidiform degeneration. The pregnancy had been complicated by acute dyspnoea, pre-eclampsia, and postpartum haemorrhage. Detailed cytogenetic studies, using banding and fluorescence techniques, were performed on fetus and parents. Meiotic studies were made on the fetal ovaries. Muscle cell differentiation and electrophysiological relationships of cultured skin fibriblasts were examined in an attempt to study the way in which the extra haploid set of chromosomes exerts its effect on the phenotype. The antenatal diagnosis of late triploidy is discussed. The finding that 25 per cent of late triploids have spina bifida is further evidence that meningomyelocele has a genetic component and strongly suggests that this results from chromosomal imbalance or a regulatory gene disturbance.

Immunogenetic factors in aetiology of pre-eclampsia/eclampsia (gestosis)

The evidence that genetic and immunogenetic influences operate in the causation of pre-eclampsia/eclampsia (gestosis) is reviewed. The problems of definitive diagnosis are discussed along with the possibility of a multifactorial aetiology. The difficulties of differentiating trigger and effector mechanisms are also considered. It is concluded that there is evidence for a predisposition, probably genetic, operating in some cases, an immunogenetic mechanism in others, and chromosomal factors in a small group.

Pathomorphological changes in an early spontaneous abortus with triploidy (69, XXX)

Triploid (69,XXX) spontaneous abortus with a gestational age of 14--15 weeks (anatomical age of the embryo was 6 weeks) was analyzed macro- and microscopically. There were hydatidiform swelling and cystic degeneration of the villi, without proliferatio of the trophoblast of cells, aplasia of one umbilical artery. The embryo had the following anomalies: cranial and caudal hypoplasia; aplasia of the facial structures (aprosopia), ocular vesicles, nasal stalk, extremity buds, somites, upper jaw, hyoid and pharyngeal arches, esophagus; trachea, Rathke's pouch and oropharyngeal cavity; encephalocele, focal anomalous rudiments of cartilage in the chordamesoderm, atresia of the stomodeal foramen and persistance of the lenticular placode.

A diploid-triploid human mosaic with cytogenetic evidence of double fertilization

The karyotype 46,XX/69,XXY was found in a 13-year-old mentally subnormal patient with club feet, strabismus, eunuchoid habitus, small penis, midscrotal urethrovaginal opening, small descended left testis, and small undescended right testis; no ovarian tissue could be found at laparotomy. Triploid:diploid cell ratios were 60:40 and 4:96 in skin fibroblasts and curculating lymphocytes, respectively. In the triploid line, two of the no. 13 chromosomes had unusually large satellites and one of the no. 22 chromosomes had a brightly fluorescent zone on its short arms. The patient's father was heterozygous for both these autosomal markers; the mother carried neither marker. This, together with the single Y, indicated that the extra haploid set was derived from the father. Of several possible mechanisms, we favor the suggestion that double fertilization occurred; one sperm nucleus immediately fused with the egg nucleus producing the diploid line; the second sperm nucleus was incorporated later into one of the two cells resulting from the first division of the zygote, producing the triploid line.

[Triploidy as a cause of midtrimester gestosis(author's transl)]

The authors report a case of triploidy in a prematurely born child. The pregnancy was complicated by severe toxemia beginning during the second trimester and terminating in preeclampsia leading to cesarian section in the 33th week of gestation. The externally female child was underweight, hypotonic and asphyctic and died shortly after birth. She exhibited a complex brain malformation including excessive hydrocephaly, cebocephaly and aplasia of the piturary gland, and multiple dysmorphic signs. Autopsy revealed hypoplasia and dysplasia of the adrenal glands; no uterus, tubes and ovaries were present, but no testes were found. The placenta showed localized hydatidiform degeneration and was relatively large. The karyotype was 69,XXY, and with the aid of fluorescence markers, paternal origin of the additional haploid chromosome set was demonstrated. Typical findings in pregnancies with fetal triploidy are discussed and the possibility of prenatal diagnosis of triploidy by chromosome analysis in cultivated amniotic fluid cells is pointed out.

Three further cases of triploidy in man surviving to birth

Three triploid infants, two male (69,XXY) and one female (69,XXX) all of which survived beyond 35 weeks' gestation are described. One was stillborn due to a difficult delivery, the other two survived for a few hours only. Two were of relatively low birth weight, the other was normal. There was no evidence of mosaicism in the tissue examined.

In keeping with previously reported triploid infants they showed a variety of abnormalities. From a total of 13 cases now reported the more frequent associated anomalies are low set ears, coloboma of the iris, syndactyly of the hands, a single palmar crease, abnormal male genitalia in XXY individuals, polycystic kidney, and congenital heart defect. The most common anomaly, however, is hydatidiform degeneration of a large placenta.