Gestational trophoblastic neoplasia mimicking ruptured ectopic pregnancy: A case report

Abstract

Rationale: Gestational trophoblastic neoplasia (GTN) refers to the hydatidiform mole tissue that invades the myometrium or even penetrates the uterine wall to the broad ligament or abdominal cavity, and a few have distant metastases through blood transport. According to the World Health Organization[1] 2020 (5th edition) classification lists an erosive hydatidiform mole as a borderline or biologically behavioral uncertain tumor, it continues to be clinically classified as a malignancy and combined with choriocarcinoma as a GTN. The clinical manifestations of GTN include amenorrhea, abnormal vaginal bleeding, and increased serum human chorionic gonadotropin level, which are also common clinical features of ectopic pregnancy. The diagnosis of typical GTN is not difficult. However, some patients with atypical clinical manifestations and a lack of specificity in their B-ultrasound images are easy to misdiagnose, especially when the lesions are located in special parts outside the uterus and lack specific imaging features.

Patient concerns: A 41-year-old woman who presented 3 months after having an abortion with severe abdominal pain that lasted 15 hours.

Diagnoses: CT showed massive blood accumulation in the abdominal cavity and the pelvic cavity. Uterine lesions? Transvaginal uterine ultrasound reveals: a right intrauterine mixed mass (approximately 83 * 66 mm mixed echo mass), a possible pregnancy, and a rupture pregnancy (right pregnancy). abdominal effusion (large) and clots, maximum front and rear diameters of 95 mm, pelvic effusion, and about 20 mm deep. HCG levels in the blood were 17,452 IU/L and hemoglobin levels were 81 g/L. Admission diagnosis: Abdominal pain investigation: ectopic pregnancy? Bleeding shock.

Interventions: Laparoscopy and laparotomy followed by hysterectomy, treated by chemotherapy.

Outcomes: Hysterectomy was required due to intraoperative hemostasis difficulties, and the patient lost her uterus forever.

Lessons: Continued reporting of these cases are important so that the gynecologists are aware about the possibility of ruptured invasive mole and it should be kept as a differential diagnosis in all the pregnant women presents with acute onset lower abdominal pain.

Figure 1.

Ultrasound: Mixed mass on the right side of uterus, considering the possibility of ectopic pregnancy rupture, massive fluid accumulation in the pelvic cavity.

Figure 2.

The right lateral wall of the uterus was obviously enlarged and uplifted near the uterine horn. The surface was filled with purplish blue earthworm shape. The scope was approximately 6*3cm. Rupture was visible on the surface, there were several blister-like tissues of varying sizes of the rupture, and there was active bleeding.

Figure 3.

Uterus + right adnexa + left fallopian tube.

Figure 4.

Excessive proliferation of trophoblast cells, visible infiltration of syncytial trophoblast cells and intermediate trophoblast cells into the uterine muscle layer, and invasion of the right adnexa, along with vascular invasion, and no invasion of the left fallopian tube (HE × 100).