Ovarian molar pregnancy

A 29-year-old Chinese woman was admitted following a sudden onset of lower abdominal pain with associated vomiting and dysuria. She denied a history of dizziness, shoulder tip pain, vaginal bleeding or bowel symptoms. She gave a history of 6 weeks amenorrhoea other than a minimal 1 day bleed, 2 weeks prior to admission. She had been trying to conceive and had a positive home pregnancy test. Her medical history included a laparotomy for ectopic pregnancy 8 years previously, in China, then a vaginal delivery after an uncomplicated pregnancy 2 years ago. On examination, she was haemodynamically stable. A midline laparotomy scar was noted. She had lower abdominal tenderness but no peritonism; bilateral adnexal tenderness but no masses or cervical excitation. A urine pregnancy test was positive, serum HCG 3,584 IU/l and haemoglobin 12.6 g/dl. Pelvic ultrasound scan revealed a left adnexal cystic mass measuring 446 416 34 mm with a trace of free fluid in the Pouch of Douglas but no intrauterine pregnancy. The patient was initially managed conservatively. Serum HCG levels doubled every 48 hours rose to 8,970 IU/l, then 13,700 IU/l. Repeat pelvic ultrasound scan continued to show no evidence of an intrauterine pregnancy. The left adnexal mass had increased in size to 726 71662 mm. Serum HCG was now 38,513 IU/l with a haemoglobin of 12.4 g/dl. An exploratory laparotomy was performed for suspected left tubal ectopic pregnancy. Intraoperative findings included a haemoperitoneum of approximately 1 litre. The majority of the left fallopian tube was absent due to a previous ectopic pregnancy, but that portion present was adherent to the ovary which was enlarged to 86 46 3 cm. A site of rupture was identified on the ovary, consistent with a ruptured left ovarian ectopic pregnancy. Left salpingo-oophorectomy was performed. The procedure was complicated by bowel injury; two small serosal tears were repaired following division of dense bowel adhesions. The patient had an uneventful recovery and was discharged on day 4 postoperatively. Serum HCG levels 1 week and 3 weeks postoperatively were 651 IU/l and 39 IU/l, respectively. Histological examination revealed a complete hydatidiform mole in the context of an ovarian ectopic pregnancy. The diagnosis was confirmed by the supra-regional Trophoblastic Disease Centre in Sheffield, where the patient was subsequently followed-up. Urine HCG levels remained negative.