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Mrs. LPS, aged 31 years, married for 4 ½ years came to
us on 11/7/2005 for primary infertility. She was a known
case of poly cystic ovarian syndrome with menstrual
cycles only on induction. Her ultrasound and
diagnostic hysterolaparoscopy revealed a normal uterus
with enlarged sclero cystic ovaries and bilateral patent
tubes. The husband’s semen analysis was also normal.
The patient conceived in the first cycle of clomiphene
citrate therapy with IUI. Her b-HCG level on the 32nd
day was 3026.4mIU/ml (4/9/2006). The first
transvaginal sonographic examination on the 40th day
revealed triplet pregnancy. This underwent a natural
reduction to twins at 7-8 weeks of gestation. During her
routine antenatal scan with us at 11-12 weeks of
gestation, there was a suspicion of a coexistent molar
pregnancy with bilateral enlarged theca lutein cysts and
she was referred to Mediscan (centre for sonology and
fetal therapy) for a second opinion. They confirmed the
presence of twin viable fetuses with molar pregnancy
(Trichorionic Triamniotic triplets) in the third sac.
Due to a unfortunate previous experience with
termination of ICSI twin pregnancy owing to
complications, published in our newsletter earlier, we
were anxious not to lose the otherwise normal appearing
and viable twin pregnancy.
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Her initial blood investigations were all normal and
she did not have any history of hyperemesis or
bleeding per vaginum as was with our previous case.
At a follow up scan at 16 weeks it was noted that a
separate cleavage plane existed between the
placenta of fetus A and the mole and so it was
confirmed to be a molar degeneration of the Fetus C.
Thus we opted to continue the pregnancy until any
expected complications arose. She then underwent
stringent monitoring and regular antenatal check up.
At 30 weeks of gestation both fetuses were found to
have asymmetric growth restriction with normal
doppler study and a gradual increase in the volume
of molar pregnancy as well. She was already on
prophylactic therapy of antioxidants and amino acid
infusion to combat it. She underwent an elective
caesarean section on 19/03/2007 at 34 weeks of
pregnancy owing to increasing volume of mole and
fetal doppler changes, and delivered a boy and girl
weighing 1.36kg and 1.24kg respectively.
Intraoperatively there was no complication with
regards to bleeding or evacuation of the molar
products. Both mother and babies did well on
discharge. The patient was followed up after
delivery and her b-HCG values consistently
reduced and was less than 1.0mIU/ml after 3 months
of child birth.
In this case we did not have to perform any genetic
testing of the coexisting viable fetuses as the mole
was a separate entity by itself (trichorionic
triamniotic). Literature review reports several cases
of multiple gestation with molar pregnancies and
varied outcomes. The dilemma with regards to
termination may be overcome by careful analysis of
the patient's physical condition, presence of known
complications such as hyperemesis, thyrotoxicosis,
hemorrhage and development of pregnancy induced
hypertension. Serial ultrasound monitoring itself
not only clinches diagnosis but also gives a volume
of information on disease progression. |
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