Partial molar pregnancy with severe pre-eclampsia at 19 weeks' gestation

A 28-year-old primigravida presented to the early pregnancy assessment unit for a dating scan because of a history of irregular periods as a result of polycystic ovaries. She had slight bleeding per vaginum and some abdominal discomfort. An ultrasound examination confirmed a singleton viable fetus corresponding to 8 weeks’ gestation. An area of sub-chorionic bleed was noticed. At 12 weeks, she attended for a nuchal scan at a Fetal Medicine Centre. Ultrasound examination revealed a live fetus slightly smaller than her dates by previous scan. The crown rump length was 45.4 mm, equivalent to 11 weeks’ gestation and nuchal thickness1⁄4 1.0 mm. The placenta appeared large and bright with cystic changes suggestive of molar changes. Her age-related risk for trisomy was estimated as 1:733. Her serum free bHCG was 214.70 IU/l, equivalent to 5.2301 MOM and serum PAPPA was 1.823, equivalent to 0.667 MOM. The adjusted trisomy risk was 1:201. The high level of bHCG supported the diagnosis of partial mole despite the normal nuchal translucency. She was counselled regarding a possible risk of fetal chromosomal abnormality associated with partial mole and elected to have a chorion villus sampling. The karyotype was normal. At 14 weeks, a repeat ultrasound revealed restricted fetal growth. A detailed anomaly scan showed an exomphalos which showed bowel contents. There was an area of retroplacental haematoma and the placenta showed cystic changes as before. The amniotic fluid volume was normal. At 17 weeks, she attended for review. Her blood pressure was 140/90 mmHg. She was asymptomatic and had no proteinuria. Ultrasound examination still showed some growth restriction of fetus but the amniotic fluid volume was normal. The placental changes were similar to the previous examination. Blood pressure measurement and urinalysis was recommended and she was advised to report to the hospital if symptomatic. At 19 weeks, she was referred to the Day Unit with a blood pressure of 163/100 mmHg and 5 g proteinuria. She had symptoms of headache, visual disturbances, itchy rash and pedal oedema. On examination, she was hyperreflexic and very shaky and anxious. Uterine fundal height corresponded to 28 weeks. She was admitted for close monitoring and treatment. Her haemoglobin was 10.2 g/dl. All other blood results were within normal limits. Her blood pressure was not controlled on oral antihypertensives and her general condition was deteriorating. A decision to terminate the pregnancy was made after a detailed discussion with the couple about the problems of continuing the pregnancy in her present fulminating pre-eclamptic state. Termination of pregnancy was commenced with gemeprost and subsequent oxytocin infusion. She was started on hydralazine and magnesium sulphate regimes.Because of concern about hercondition she was transferred to the intensive care unit. She had reduced urine output and heavy blood loss requiring blood transfusion. After delivery, the fetus and placenta were sent for post-mortem examination. The placental histology confirmed a partial mole with an area of mosaicism. She recovered well post-delivery and was discharged home on oral antihypertensives. She was monitored carefully with bHCG levels which have steadily reduced to normal levels. Discussion