Accepted Manuscript

Title: Hysteroscopic Management of Partial Hydatidiform Mole. a Novel

Approach of an Old Disease.

Author: Alejandro Gonzalez, Luis Alonso, Laura Nieto, Jose Carugno

PII: S1553-4650(18)30186-9
DOI: https://doi.org/10.1016/j.jmig.2018.04.001
Reference: JMIG 3479

To appear in: The Journal of Minimally Invasive Gynecology

Received date: 4-3-2018

Revised date: 28-3-2018
Accepted date: 1-4-2018

Please cite this article as: Alejandro Gonzalez, Luis Alonso, Laura Nieto, Jose Carugno,
Hysteroscopic Management of Partial Hydatidiform Mole. a Novel Approach of an Old Disease.,
The Journal of Minimally Invasive Gynecology (2018),
https://doi.org/10.1016/j.jmig.2018.04.001.

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Images in Gynecologic Surgery

Hysteroscopic management of Partial Hydatidiform Mole. A novel approach of an old disease.

Gonzalez, Alejandro MD, PhD1; Alonso, Luis MD2; Nieto, Laura MD 3; Carugno, Jose MD FACOG4

1. Hospital Naval Pedro Mallo, Buenos Aires, Argentina

2. Centro Gutenberg, Malaga, Spain
3. Hospital Universitario Reina Sofia, Cordoba, Spain
4. University of Miami, Miami, Florida, USA

Corresponding author: Jose Carugno MD. Department of Obstetrics and Gynecology, University
of Miami. Miller School of Medicine. 1321 NW 14th Street Suite 201. Miami, FL 33136
e-mail: jac209@med.miami.edu

Disclosure Statement: The authors declare that they have no conflicts of interest and nothing to
disclose.

Keywords: Hysteroscopy, Molar pregnancy

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 Gestational trophoblastic disease (GTD) is a spectrum of neoplastic conditions derived from
the placenta.(1) It occurs in 2/1000 women of reproductive age. Most hydatiform moles are
benign although a small amount may persist as invasive moles. (2) Partial hydatidiform moles
exhibit chorionic villi with focal edema and scalopping stromal trophoblastic inclusions as well
as focal trophoblastic hyperplasia. Progress in surgical endoscopic technology, with improved
visualization and the use of energy have enable hysteroscopic surgeons to efficiently treat
pregnancy related conditions. (3) The gold standard for evacuation of hydatiform mole is
suction curettage. (4) However, with the noted advancements in hysteroscopic technology,
applying this technology as a treatment option of patients with gestational trophoblastic
disease, is now a possibility. Moreover, hysteroscopy with direct visualization of the uterine
cavity offers the advantage of ensuring the evacuation of the entire amount of molar tissue
with little to no damage of the endometrium, and minimizing the chance of complication
resulting from suction curettage which is a blind procedure with risk of retained products of
conception, uterine perforation or creation of a false passage.(3, 5, 6)
We present a case of a 35-year-old primigravida who presented at 8 weeks of amenorrhea
complaining of vaginal bleeding. Transvaginal ultrasound revealed the absence of gestational
sac with the presence of a heterogeneous structure containing cystic spaces within the
endometrial cavity. Baseline serum human chorionic gonadropin (hCG) was 115535 mIU/ml.
Chest x-ray was normal. Molar pregnancy was suspected. Patient underwent hysteroscopic
resection of products of conception using a continuous flow monopolar 45-degree
resectoscope (Karl Storz, Tüttlingen, Germany) The procedure was performed without
complications using Glycine 1.5% as distention media infused by fluid management system,
monopolar energy at 60 Watts, with a fluid deficit of 180 ml and estimated blood loss of 20 cc.
Direct visualization of the cavity allowed complete excision of the uterine content with
insignificant damage to the myometrium. (Figures 1. B-D)
The pathology reported chorionic villi with focal edema and focal throphoblastic hyperplasia
confirming the diagnosis of partial hydatidiform molar gestation. (Figure 1. E) After the
procedure, the patient was placed on oral contraceptives and serum bHCG level were followed
weekly after the procedure decreasing to 5674 at one week, then becoming negative 7 weeks
after the procedure. The patient resumed normal menstruations 5 weeks after the procedure
and was placed on oral contraceptives as per patient desire. A diagnostic hysteroscopy
performed 3 months after the procedure revealed a normal uterine cavity without the presence
of intrauterine adhesions. Prior to submission for publication, the local IRB at Hospital Naval
Pedro Mallo was consulted and granted IRB exemption.

References

1. Lurain JR. Gestational trophoblastic disease I: epidemiology, pathology, clinical

presentation and diagnosis of gestational trophoblastic disease, and management of
hydatidiform mole. Am J Obstet Gynecol. 2010;203(6):531-9.
2. Shanbhogue AK, Lalwani N, Menias CO. Gestational trophoblastic disease. Radiol Clin
North Am. 2013;51(6):1023-34.

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3. Perez-Medina T, Sancho-Sauco J, Rios M, Pereira A, Argila N, Cabezas E, et al.
Hysteroscopy in pregnancy-related conditions: descriptive analysis in 273 patients. J Minim
Invasive Gynecol. 2014;21(3):417-25.
4. Berkowitz RS, Goldstein DP. Current advances in the management of gestational
trophoblastic disease. Gynecol Oncol. 2013;128(1):3-5.
5. Ayala Yáñez R, Briones Landa C, Anaya Coeto H, Leroy López L. [Diagnosis of molar
pregnancy by hysteroscopy]. Ginecologia y obstetricia de Mexico. 2012;80(8):540-4.
6. Di Spiezio Sardo A, Bettocchi S, Coppola C, Greco E, Camporiale AL, Granata M, et al.
Hysteroscopic identification of hydatidiform mole. J Minim Invasive Gynecol. 2009;16(4):408-9.

Figures

Figure 1.
A. Hysteroscopic view of chorionic villi with focal edema
B. Panoramic view of the empty endometrial cavity after the procedure. Note the minimal
damage to the myometrium
C. Pathology. High magnification Hematoxylin-eosin stain. Note the atypical trophoblastic
proliferation (long arrow) and chorionic villi with and without central cystic formation
with prominent acellular central space (short arrows)

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FigureAJPG.jpg

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FigureBJPG.jpg

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FigureC.JPG

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